Coeliac disease is a common digestive condition where a person has an adverse reaction to gluten.
Eating foods containing gluten can trigger a range of symptoms, such as:
- diarrhoea – which may be particularly unpleasant smelling
- bloating and flatulence (passing wind)
- abdominal pain
- weight loss
- feeling tired all the time – as a result of malnutrition (not getting enough nutrients from food)
- children not growing at the expected rate
Symptoms can range from mild to severe.
Read more about the symptoms of coeliac disease.
What causes coeliac disease?
Coeliac disease is what is known as an autoimmune condition. This is where the immune system – the body’s defence against infection – mistakenly attacks healthy tissue.
Coeliac disease isn’t an allergy or an intolerance to gluten.
In cases of coeliac disease, the immune system mistakes substances found inside gluten as a threat to the body and attacks them.
This damages the surface of the small bowel (intestines), disrupting the body’s ability to absorb nutrients from food.
Exactly what causes the immune system to act in this way is still not entirely clear, although a combination of a person’s genetic make-up and the environment appear to play a part.
Read more about the causes of coeliac disease.
Gluten is a protein found in three types of cereal:
Gluten is found in any food that contains the above cereals, including:
- breakfast cereals
- most types of bread
- certain types of sauces
- some types of ready meals
In addition, most beers are made from barley.
Treating coeliac disease
There is no cure for coeliac disease, but switching to a gluten-free diet should help control symptoms and prevent long term consequences of the disease.
Even if symptoms are mild or non-existent it is still recommended to change your diet, as continuing to eat gluten can lead to serious complications (see below).
It is important to make sure your gluten-free diet is healthy and balanced. An increase in the range of available gluten-free foods in recent years has made it possible to eat both a healthy and varied gluten-free diet.
Read more about the treatment of coeliac disease.
Currently, screening for coeliac disease is not routinely carried out in England.
It is usually only recommended for people at an increased risk of developing the condition, such as those with a family history of the disease. It is recommended that first-degree relatives (parents, brothers, sisters and children) of people with coeliac disease are screened.
See diagnosing coeliac disease for more information about who should be screened for coeliac disease.
Complications of coeliac disease only tend to affect people who continue to eat gluten, or who have yet to be diagnosed with the condition (which can be a common problem in milder cases.)
Potential long-term complications include:
- osteoporosis (weakening of the bones)
- anaemia – lack of red blood cells which can cause breathlessness, tiredness and lack of energy
Less common and more serious complications include those affecting pregnancy, such as low birth weight, and some types of cancers, such as bowel cancer.
Read more about the complications of coeliac disease.
Who is affected
Coeliac disease is a common condition that affects approximately 1 in every 100 people in the UK. However, some experts think this may be an underestimate as milder cases may go undiagnosed or misdiagnosed as other digestive conditions, such as irritable bowel syndrome (IBS).
Reported cases of coeliac disease are two to three times higher in women than men and can develop at any age, although symptoms are most likely to develop:
- during early childhood – between 8-12 months old (though it may take several years before a correct diagnosis is made)
- in later adulthood – between the ages of 40 and 60 years
Symptoms of coeliac disease can range from mild to severe.
Recognise the symptoms:
- mild abdominal (stomach) pain
- occasional changes in bowel habit, such as episodes of mild diarrhoea or constipation
- anaemia (tiredness, breathlessness and an irregular heartbeat, caused by a lack of iron in the blood)
- loss of appetite
- weight loss
- tingling and numbness in your hands and feet (peripheral neuropathy)
- vomiting (usually only affects children)
- alopecia (loss of hair) usually only affects adults
The symptoms are often intermittent (they stop and then start again), and sometimes appear unrelated to your diet and digestive symptoms.
Mild cases of coeliac disease may not cause any noticeable symptoms and the condition is often only detected during testing for another condition. However, treatment is recommended as complications can still occur in these cases.
Severe coeliac disease
Symptoms of severe coeliac disease include:
- diarrhoea, which can often suddenly occur during the night, resulting in bowel incontinence(loss of bowel control)
- weight loss
- stomach cramps
- muscle spasms
- swelling of your hands, feet, arms and legs, caused by a build-up of fluid (oedema)
Your stools (faeces or ‘poo’) may also contain abnormally high levels of fat (steatorrhoea), which can make them foul smelling, greasy and frothy. They may also be difficult to flush down the toilet.
If coeliac disease is untreated, being unable to digest food in the normal way could cause you to becomemalnourished, making you feel tired and lacking in energy.
Malnutrition in children can lead to failure to grow at the expected rate, both in terms of weight and height, and in older children a delayed puberty.
Diagnosing coeliac disease
Routine screening for coeliac disease is not recommended unless you have symptoms or are at an increased risk of developing them.
In 2009, the National Institute for Health and Clinical Excellence (NICE) issued guidance about when testing for coeliac disease should be carried out. The guidance recommended testing for adults or children with the following signs or symptoms:
- long-term (chronic) diarrhoea or repeated and regular episodes of diarrhoea
- persistent or unexplained gastrointestinal symptoms (such as feeling sick and being sick)
- fatigue (feeling tired all the time)
- recurring abdominal pain
- cramping or bloating
- sudden or unexplained weight loss
- unexplained anaemia
- failure to thrive in infants/toddlers
Testing is also recommended if you have the following conditions:
- type 1 diabetes
- irritable bowel syndrome (IBS)
- underactive thyroid or overactive thyroid glands
- dermatitis herpetiformis (a skin condition that causes blistering)
In some circumstances, testing may also be recommended if you have any of the following conditions:
- Addison’s disease, a condition where the immune system attacks certain glands in the body
- Down’s syndrome, a genetic condition that causes abnormal physical and mental development
- lymphoma, a type of cancer
- bone diseases, such as rickets (a condition that causes softening and weakening of the bones)
- persistent or unexplained constipation
- repeated miscarriages
- Sjogren’s syndrome, a condition where the immune system attacks the tear and saliva glands
- Turner syndrome, a genetic condition that only affects women and causes infertility and delayed growth
- unexplained infertility
Screening for coeliac disease involves a two stage process:
- blood tests – to help identify people who may have coeliac disease
- a biopsy – to confirm the diagnosis
These procedures are described in more detail below-
Your GP will take a blood sample and test it for antibodies usually present in the bloodstream of people with coeliac disease. You should not be avoiding gluten in your diet when the blood test is done as this could lead to an inaccurate result.
If coeliac disease antibodies are found in your blood, your GP will refer you for a biopsy of your gut.
However, it is sometimes possible to have coeliac disease and not have these antibodies in your blood. So if you continue to have coeliac disease-like symptoms, despite having a negative blood test, your GP may still recommend you have a biopsy.
A biopsy is carried out in hospital, usually by a gastroenterologist (a specialist in treating conditions of the stomach and intestines). A biopsy can help confirm a diagnosis of coeliac disease.
If you need to have a biopsy, an endoscope (a thin, flexible tube with a light) will be inserted into your mouth and gently passed down to your small intestine.
Before the procedure, you will be given a local anaesthetic to numb your throat or a sedative to help you relax.
The gastroenterologist will pass a tiny biopsy tool through the endoscope to take samples of the lining of your small intestine. The sample will then be examined under a microscope for signs of coeliac disease.
Tests after diagnosis
If you are diagnosed with coeliac disease, you may also have other tests to assess how the condition has affected you so far.
You may have further blood tests to check levels of iron and other vitamins and minerals in your blood. This will help determine whether coeliac disease has led to you developing anaemia (a lack of iron in your blood) due to poor digestion.
If you appear to have dermatitis herpetiformis (an itchy rash that is also caused by gluten intolerance), you may have a skin biopsy to confirm it.
This is carried out under local anaesthetic where a small skin sample is taken from the area so it can be examined under a microscopic.
In some cases of coeliac disease, a DEXA scan may also be recommended. A DEXA scan is a type of X-ray that measures bone density. It may be necessary if your GP thinks that your condition may have started to thin your bones. In coeliac disease, a lack of nutrients caused by poor digestion, can make bones weak and brittle (osteoporosis). This is not a test for arthritis and only looks at bone density to see if you are at risk of bone fractures as you get older.
Coeliac disease is usually treated by simply excluding foods that contain gluten from your diet.
This prevents damage to the lining of your intestines (gut) that is caused by gluten, and the associated symptoms, such as diarrhoea and stomach pain.
If you have coeliac disease, you must give up all sources of gluten for life because eating foods that contain it will cause your symptoms to return and cause long-term damage to your health. This may sound daunting, but your GP can give you help and advice about ways to manage your diet.
Your symptoms should improve considerably within weeks of starting a gluten-free diet. However, it may take up to two years for your digestive system to heal completely. You will also need to return to your GP for regular check-ups.
A gluten-free diet
When you are first diagnosed with coeliac disease, you will be referred to a dietitian to help you adjust to your new diet without gluten. They can also ensure that your diet is balanced and contains all the nutrients you need.
If you have coeliac disease, you will no longer be able to eat foods that contain wheat (farina, graham flour, semolina, durum, cous cous and spelt), barley or rye.
Even if you only consume a small amount of gluten, such as a spoonfull of pasta, you may have very unpleasant intestinal symptoms. If you keep consuming gluten regularly, you will also be at greater risk of osteoporosisand cancer in later life.
As a protein, gluten is not essential to your diet and can be replaced by other foods. Many gluten-free alternatives are widely available in supermarkets and health food shops, including pasta, pizza bases and bread. A range of gluten-free foods is also available on prescription.
Many basic foods – such as meat, vegetables, cheese, potatoes and rice – are naturally free from gluten so you can still include them in your diet. Your dietitian can help you identify which foods are safe to eat and which are not. If you are unsure, use the lists below as a general guide.
Foods containing gluten (unsafe to eat)
If you have coeliac disease, do not eat the following, unless they are labelled as gluten-free versions:
- biscuits or crackers
- cakes and pastries
- gravies and sauces
It is important to always check the labels of the foods you buy. Many foods – particularly those that are processed – contain gluten in additives, such as malt flavouring and modified food starch.
Gluten may also be found in some non-food products, including lipstick, postage stamps and some types of medication.
Cross-contamination can occur if gluten-free foods and foods that contain gluten are prepared together or served with the same utensils.
Gluten-free foods (safe to eat)
If you have coeliac disease, you can eat the following foods, which naturally do not contain gluten:
- most dairy products, such as cheese, butter and milk
- fruit and vegetables
- meat and fish (although not breaded or battered)
- gluten-free flours, including rice, corn, soy and potato
By law, food labelled as ‘gluten free’ can contain no more than 20 parts per million (ppm) of gluten.
For most people these trace amounts of gluten will not cause any problem. However, there are a minority of people with coeliac disease who are unable to tolerate even trace amounts of gluten, and require a diet completely free from cereals.
For more information see the ‘Codex standard for gluten’ on the Coeliac UK website.
The Coeliac UK website also contains information and advice about living with the condition, including gluten-free recipes.
Oats do not contain gluten, but many people with coeliac disease avoid eating them because they can become contaminated with other cereals that do contain gluten.
If, after discussing this with your health professional, you want to include oats in your diet, check that the oats are pure and that there is no possibility that contamination could have occurred.
It is recommended that you should avoid eating oats until your gluten-free diet has taken full effect and your symptoms have been resolved. Once you are symptom free, gradually reintroduce oats into your diet. If you develop symptoms again, stop eating oats.
Advice on feeding your baby
Do not introduce gluten into your baby’s diet before it is six months old. Breast milk is naturally gluten free and all infant milk formulas are too.
If you have coeliac disease, Coeliac UK recommends that gluten-containing foods be introduced gradually when a child is six months old, and the situation carefully monitored.
As well as eliminating foods that contain gluten from your diet, a number of other treatments are available for coeliac disease. These are described below.
In some people, coeliac disease can cause the spleen to work less effectively, making you more vulnerable to infection.
Therefore, you may need to have extra vaccinations, including:
- flu (influenza) jab
- HIB/MenC vaccine, which protects againstsepsis (blood poisoning), pneumonia andmeningitis (an infection of the lining of the brain)
- pneumococcal vaccine, which protects against infections caused by the Streptococcus pneumoniae bacterium
However, if your spleen is unaffected by coeliac disease, these vaccinations are not usually necessary.
As well as cutting gluten out of your diet, your GP or dietitian may also recommend that you take vitamin and mineral supplements, at least for the first six months after your diagnosis.
This will ensure that you get all the nutrients you need while your digestive system repairs itself. Taking supplements can also help correct any deficiencies, such as anaemia (a lack of iron in the blood).
If you have dermatitis herpetiformis, also known as DH (an itchy rash that can be caused by gluten intolerance), cutting gluten out of your diet should clear it up. However, sometimes it can take longer for a gluten-free diet to clear the rash than it does to control your other symptoms, such as diarrhoea and stomach pain.
If this is the case, you may be prescribed medication to speed up the healing time of the rash. It is likely that this will be a medicine called Dapsone, which is usually taken orally (in tablet form) twice a day.
You may need to take medication for up to two years to control your dermatitis herpetiformis. After this time, you should have been following a gluten-free diet long enough for the rash to be controlled without the need for medication.