By Geoff Barnett

Freelance Medical Writer and Editor

About 10,000 years ago, our hunter-gatherer forebears began to realise that hunting animals, birds and fish, and gathering plants, fruit and fungi were not the only ways of supporting life. They discovered that by settling in one place for long enough they could sow, harvest and store crops of cereals like wheat. One consequence of this neolithic revolution was rudimentary civilization; another was that people who couldn't tolerate wheat in their diet became ill with what today we know as coeliac disease. Explore more of the fascinating historical background at Hunters, Fishers and Gatherers and subsequent sections.

Known by a variety of synonyms, including non-tropical sprue, coeliac sprue, gluten intolerance enteropathy and gluten sensitive enteropathy, coeliac disease was first described in the second century AD by the Greek physician, Aretaeus of Cappadocia. Read his definition of a coeliac [patient] and find out how long it took before fundamental discoveries were made in the diagnosis and treatment of the disease at the illuminating The History of the Coeliac Condition.

Coeliac Disease, expertly summarised in this recent BMJ clinical review article, is a chronic inflammatory disorder of the lining of the small intestine resulting from ingestion of the protein gluten,(1) commonly found in wheat, rye, barley and possibly oats.(2) In genetically susceptible individuals, gluten causes an immune reaction leading to inflammation and atrophy of the mucosa of the small intestine and consequent malabsorption of nutrients. Small Intestine - Pathology clearly demonstrates micrographically the difference in appearance between villi in coeliac disease and those of a normal intestine; and high quality endoscopic images comparing duodenal mucosa in coeliac disease with that of a normal individual can be found at High Resolution Images: Duodenal Mucosa in Coeliac Disease. You can also watch a 50-second endoscopic videoclip - provided you're prepared to wait for the download.

The loss of functioning villi results in a wide range of clinical manifestations that are protean in nature and vary markedly with the age of the patient, duration and extent of the disease, and presence of extraintestinal pathological conditions - several reports indicating that almost 50% of newly diagnosed patients do not present with gastrointestinal symptoms. Thus, there is no typical coeliac: some patients, especially adults, are asymptomatic or have atypical or minimal symptoms; others may present with one or more symptoms, including diarrhoea or constipation, anaemia, weight loss or osteoporosis. Accordingly, coeliac disease can be difficult to diagnose and is frequently underdiagnosed, particularly in the US - a subject capably expounded at Detecting Celiac Disease in Your Patients. Note in particular the reference to the skin disorder, dermatitis herpetiformis, also caused by gluten intolerance and currently regarded as a variant of coeliac disease. Characteristically presenting as extremely itchy grouped vesicles, often on red plaques, the symptoms were graphically described by one sufferer as 'like rolling in stinging nettles naked with a severe sunburn, then wrapping yourself in a wool blanket filled with ants and fleas' Go to The Dermatitis Herpetiformis Online Community to read a recently published authoritative overview of this distressing condition. Then, to see thumbnail images that, when enlarged, carry tabulated annotations, click on Images for the Diagnosis 'Dermatitis Herpetiformis Duhring'.

An intriguing aspect of coeliac disease is its association with other autoimmune conditions of which type 1 diabetes mellitus and thyroid disease are perhaps the most common - one source estimating that as many as one in 20 insulin-dependent diabetics may have coeliac disease. These and other diseases are listed and amplified through links at Coeliac Com under Related Disorders.

Until the late 1900s coeliac disease was considered a comparatively uncommon condition, with prevalence rates of 1 in 1,000 or lower. But the recent development of sensitive serological tests, scientifically discussed at Serodiagnosis of Celiac Disease, indicates that the prevalence is much higher, affecting roughly 1 in 100-500 of the European and US population, and as such is one of the commonest genetically based diseases. The Epidemiology of CD, starting on page 4 of the Gastroenterology article Current Approaches to Diagnosis and Treatment of Celiac Disease: An Evolving Spectrum, provides detailed epidemiological statistics and a revealing country-by-country table that compares prevalence based on clinical diagnosis with that from screening.

The only treatment for coeliac disease is the strict adherence of a gluten-free diet for life, perhaps supplemented initially with vitamins or mineral supplements. For most people, following this diet will stop symptoms, heal existing intestinal damage and prevent further harm. Improvements often begin within days of starting the diet and the small intestine is usually completely healed within 3-6 months, perhaps up to 2 years for older patients. A gluten-free diet involves avoiding all foods containing wheat, rye, barley and possibly oats - in other words most grain, pasta, cereal and many processed foods. Despite these restrictions, coeliacs can eat a well-balanced diet with a variety of foods, including bread and pasta. For example, instead of wheat flour, potato, rice, soy or bean flour may be used, and gluten-free bread, pasta and other products are available from specialist suppliers. Wheat Free Zone provides a wealth of diet- and life-oriented links for those that have to live their lives gluten-free. And members of Coeliac UK, an independent registered charity that has been supporting coeliacs in the UK since 1968, can purchase The Gluten-free Food & Drink Directory containing information on 12,000 gluten-free products arranged by manufacturer and major retailers. Don't overlook the ingenuity of the attractively designed Flash-enhanced home page.

Future directions in coeliac disease research were agreed at the 9th International Symposium on Celiac Disease held in Baltimore, USA in 2000. The direct link to the relevant paper seems unreliable, so go to Celiac Disease: The Past, the Present, the Future (the first in the list) and then click on Full Page Image to get there indirectly. Under Future you'll see that the six research priorities include such diverse objectives as developing a vaccine against the disease and engineering gluten-free grains. The increasing realisation that coeliac disease is more common and geographically more widespread than originally thought has provided additional impetus to these exciting and challenging multidisciplinary initiatives. The prognosis for correctly diagnosed and treated coeliac disease is already excellent; the future holds even more promise.

(1) By definition gluten is found only in wheat, though the term is commonly used to refer to any grain protein harmful to sensitive populations. Gluten comprises several proteins, the two main classes being called gliadins and glutenins. For further elaboration go to What is Gluten? What is Gliadin?

(2) The place of oats in a gluten-free diet has been debated for several years, but there is growing evidence to suggest that the grain can form part of a gluten-free diet in some individuals. A paper on this issue has recently been published by the Coeliac Societies' Medical Advisory Council and is summarised at Guidelines on Coeliac Disease & Oats.

Do you have any comments on this article? Please contact Geoff directly at geoff@healthcare-edit.demon.co.uk.

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