Ask The Doctor
Dr. Brian Schwender is an American Board Certified physician in both Internal Medicine and Gastroenterology & Hepatology and is thrilled to be active in the Singapore Celiac community. He has been practicing medicine since 2003 in the United States before moving his family to Singapore in 2014. While in Singapore, he was a Consultant working and teaching in both Gastroenterology and Hepatology, at Singapore General Hospital until joining Tucker Medical in the summer of 2017.
My DNA test showed tendency for Celiac Disease. I had persistent diarrhea, which is much better after starting a gluten free diet. Is that enough evidence to say that I have Celiac Disease?
Unfortunately, no. Up to 30-40% of Caucasians carry the HLA-DQ2 and/or HLA-DQ8 genes but only up to 2-3% of them will actually have Celiac Disease. If you are positive for HLA-DQ2 you are 5 times more likely to develop Celiac Disease but it doesn’t guarantee that you have Celiac Disease or develop it over time. If you do not have either one of these genes you are unlikely to have Celiac Disease which makes this genetic test good to rule out this condition. Approximately 95% of patients with Celiac Disease will be positive for HLA-DQ2 and the other 5% will have HLA-DQ8.
Are skin rashes common in patients with Celiac Disease?
Rashes are not uncommon in patients with Celiac Disease. Dematitis Herpetiformis (DH) is an irregular rash that forms both blister like vesicles and associated with patchy red spots. They can be itchy and sometime painful. More commonly this rash can be seen on the elbows, back side of forearms, knees, scalp, back and buttocks.
DH can be seen in up to 25% of Celiac Disease patients and can also be seen with other autoimmune diseases such as Type I Diabetes. Usually when one adheres to a strict gluten free diet these rashes will ultimately resolve within a few weeks.
Do I need to take Vitamin Supplements if I have Celiac Disease?
Unless you have deficiencies in certain micronutrients you do not need to take vitamin supplements. Anyone with Celiac Disease should be checked for deficiencies in such micro and macronutrients such as Iron, Calcium, Zinc, Magnesium, Copper, Fat Soluble Vitamins (A,D,E,K) as well as Vitamin B12 and Folic Acid. If one is found to have a vitamin or mineral deficiency they should receive supplements until the deficiency has resolved as well as being strictly gluten free to treat their underlying Celiac Disease.
I’ve been strictly adherent to a gluten free diet since my original diagnosis in 2003. I’ve had about 3 upper endoscopies since then. Do I need to have repeat upper endoscopies with duodenal biopsies on a more regular basis, or are there any other tests that can be done to make sure everything is all ok?
Currently there is no strict guidelines to advise patients on how often they should have surveillance endoscopies to check on the status of their Celiac Disease. Doctors should follow up with our patient who have Celiac Disease on a routine basis in the office to perform a proper physical exam to look for signs of active disease or malnutrition or vitamin/mineral malabsorption.
A simple blood test to check for antibodies that target certain components of the gluten protein molecule can be performed. If one is adherent to a strict gluten free diet, these antibodies should eventually diminish to normal levels and typically rise when getting exposed to gluten in their diets. These antibody tests are Anti TTG IgA, Anti EMA IgA and Anti DGP IgA/IgG.
Basic blood work to evaluate for vitamin or mineral deficiencies should also be performed periodically to monitor for signs of malabsorption or malnutrition. Bone Mineral Density testing should be done at baseline and periodically to monitor one’s bone strength (to rule out osteopenia or osteoporosis). Exam intervals can range greatly depending on how active one’s symptoms are. Once someone is on a very stable and strict gluten free diet and they are clinically doing well, yearly physical exams with labs can be implemented.
I wonder if I should get tested for Celiac? I tested for allergies and gluten is one of them, on far end of severely allergic. I intend to be gluten-free anyway and I don’t believe in taking pharmaceuticals so I will not take pills. Are there any other benefits of testing?
I am not sure if the testing that you had done was gluten sensitivity testing or true gluten allergy testing. Many times, gluten sensitivity and gluten allergy are used interchangeably but they are two completely different conditions. Gluten allergy is a true allergy in which someone would develop an allergic/immune response to ingested gluten or contact with gluten. The allergic reaction can occur within minutes after ingestion or contact with gluten and results in an itchy, red, slightly raised rash throughout the body called hives or can be more severe with throat/tongue swelling called angioedema which can be life threatening. Food sensitivity testing with IgG antibodies to certain foods is not considered true allergy testing (as allergic immune responses are usually IgE mediated). Typically, gluten allergies tend to affect young children and they usually outgrow these allergies by young adulthood.
To answer whether one should be tested or not: It all depends if you are having on going symptoms that could be associated with Celiac Disease or have other risk factors putting you at increased risk of celiac disease (such as personal or family history of autoimmune diseases such as Type 1 Diabetes, Hashimoto’s Thyroiditis, Autoimmune Adrenal Gland Disorders).
As of now there are no medications that are used to treat Celiac Disease. The only known and effective therapy is to be on a strict gluten free diet. The benefit of testing is to know if you truly have Celiac Disease which if not diagnosed and/or treated properly can lead to an increased risk of malabsorption/malnutrition, infertility, osteoporosis or brittle bones, and intestinal malignancy such as lymphoma.
Besides the medical conditions that I have just mentioned, there are significant social and financial implications for patients with Celiac Disease because of having to be on a strict gluten free diet. This is why I think it’s really important to have a proper diagnosis, as people who may be Non-Celiac Gluten Sensitive or Intolerant may not have to be as strict about cross contamination of gluten and don’t carry the same risks of intestinal malignancy as does someone with Celiac Disease.
I am a newly discovered celiac sufferer. My naturopath tells me that there are gluten digesting enzymes you can buy. He says I can take 2-3 capsules before a meal. I eat out a lot so get lots of cross-contamination. I have seen Gluten Rescue and Gluten Defense pills for sale in a vitamin shop. I just bought a couple of bottles so can’t wait to try. Will this help me?
For now, the only scientifically proven treatment for Celiac Disease is to be on a strict gluten free diet to allow one’s intestinal lining regenerate and heal from prior exposure to gluten containing products. Although digestive enzymes sound very interesting with respect to patients with Celiac Disease, research has shown that these digestive enzymes are not effective in rendering ingested gluten non-immunogenic.
These digestive enzymes may help break down the gluten protein molecule but they do not digest the components of gluten that drive the inflammatory process in the intestines (reference: Janssen, George, Chantal Christis, Yvonne Kooy-Winkelaar, Luppo Edens, Drew Smith, Peter Van Veelen, and Frits Koning. “Ineffective Degradation of Immunogenic Gluten Epitopes by Currently Available Digestive Enzyme Supplements.” Plos One 10.1371 (2015): CrossMark.). For people who are just Non-Celiac Gluten Sensitive these supplements may have a role but for Celiac Disease sufferers I would stay clear of these digestive enzymes.
Please see the link to the Celiac Disease Foundation regarding digestive enzymes: Study Demonstrates Current Enzyme Supplements for Celiac Disease are Ineffective
I have recently found out I am allergic to gluten and dairy and have been told I should be tested for Celiac. I have been following a low carb diet for over 2 years and haven’t eaten bread pasta wheat etc for that time except for the very rare occasion. I haven’t been gluten free but assume my intake of gluten would be pretty low given I mainly eat fresh unprocessed food. May be a silly question but has anyone been in a similar situation and tested positive for celiac without doing a gluten challenge? I really want to get to the bottom of my issues but hesitant to eat wheat and gluten again.
Overtime, being on a gluten free diet will lead to a decrease in the blood antibodies that we check for Celiac Disease in people (Anti TTG IgA, Anti EMA IgA, Anti DGP IgA/IgG). Within 6-12months these antibodies can diminish to normal levels and as you can imagine if we use these blood antibody tests as an initial screening test for celiac disease on someone who is gluten free for some time they can be low and appear normal. From biopsied tissue (mainly of the small intestines or duodenum) the Celiac Disease related inflammation and injury can take longer to resolve on a gluten free diet (1-2 years).
Yes, I have seen people who are on a low gluten diet test positive for Celiac Disease with elevated antibodies and/or endoscopic biopsy findings. It really depends on how much gluten you are exposure to. A typical gluten challenge involves consuming at least 10 grams of gluten per day for 6 or more weeks under monitoring from a physician. (This is the equivalent of having 2-3 slices of bread per day). Gluten is also found in other foods besides breads and pasta such as Soy Sauce.
Genetic testing can be done in cases where one is on a low or gluten free diet and is concerned about re-challenging with gluten. This is a blood test to check for the presence of HLA-DQ2 or HLA-DQ8 genetic markers which are present in patients that have Celiac Disease. This test can be useful to rule out Celiac Disease as if one doesn’t carry any of these genetic markers it’s unlikely that they have Celiac Disease.
However, if they do carry one of these genetic traits, it does not confirm that they have Celiac Disease as up to 30-40% of Caucasians can carry HLA-DQ2 genetic markers but only a small percentage of them actually have Celiac Disease. I would strongly suggest that you seek medical advice from a qualified medical practitioner who had a strong understanding of Celiac Disease diagnostic testing to help you with identifying whether you have Celiac Disease or not.
I suspect I’m slightly intolerant to gluten but is there a scientific way this can be tested? Is anyone aware of a definite link between gluten and eczema?
At this point there no reliable scientific way to check for gluten sensitivity using biomarkers or blood testing. The easiest way to check for whether you are intolerant to gluten or not is to eliminate gluten from your diet for a period of time and then re-introducing gluten to see how you respond. Before doing this, I would recommend consulting with your physician to make sure that you don’t need to be screened for Celiac Disease first as once you go on a gluten free diet your abilities to diagnose Celiac Disease diminishes.
It is known that gluten exposure in some can result in certain rashes. In people who suffer from Celiac Disease, gluten exposure can result in a very itchy/pimply/blistering rash on the arms/hands and trunk called Dermatitis Herpetiformis which can be seen in up to 25% of Celiac Disease Sufferers. Yes, eczema or atopic dermatitis has been seen in Celiac Disease suffers as well as Non-Celiac Gluten Sensitive patients. Typically, these rashes to improve or resolve when going on a gluten free diet. If they do not resolve, one should seek medical attention and possible dermatologist consultation.
Do you have a question you would like to ask? Dr. Schwender can be reached at:
Tucker Medical Pte Ltd
8 Sinaran Drive, Suite 04-01
Novena Specialist Center
Tel +65 6659 6918