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Effects of CD
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"Classic" CD is what most medical students are taught about.  It is
characterized by diarrhea, steatorrhea (smelly, floating, pasty, fatty
stools), weight loss, abdominal bloating or distention, and flatulence
(farting [yes, he really did say that--ed.]).
 
Dr. Murray showed a lovely slide depicting steatorrhea, but warned
that you can't identify it just from its appearance; it is the smell
that distinguishes it.  There is nothing that smells quite like
steatorrhea.  (Dr. Murray admitted that he sometimes has trouble
keeping nurses in his clinic because he does frequently collect stool
samples, which they find rather "challenging".)  Steatorrhea (fat in
the stool) was thought to be synonymous with CD.  In fact, CD has also
been called idiopathic steatorrhea, which refers specifically to this
particular symptom.  So it was thought that if you didn't have this
symptom, you didn't have CD.  Nothing could be further from the truth;
Dr. Murray says fewer than a third of his celiac patients have ever
produced this sort of stool.
 
What are the consequences of the damage to the small intestine?
 
  *  Anemia, particularly iron-deficiency anemia or folate-deficiency
     anemia.  Why these two types (there are other types of anemia)?
     Because iron and folic acid are absorbed in the first part of the
     small intestine, which is also the part that is most affected by
     CD.
 
  *  Hypocalcimia (low calcium level).  This happens for two reasons:
     1) You are deficient in Vitamin D, a fat-soluble vitamin.  Fat
     mostly passes through the intestine into the stool, and carries
     the fat-soluble vitamins with it.  2) If there is severe damage
     throughout the small intestine, then calcium is not going to be
     absorbed well.
 
  *  Other fat-soluble vitamin deficiencies:  Vitamin E, which can be
     related to nerve damage; Vitamin A, which can cause night
     blindness; and Vitamin K, which is for blood clotting (lack of
     Vitamin K can lead to nosebleeds, easy bruising, or easy
     bleeding).
 
Dr. Murray then showed a few pictures of a young woman who is one of
his more unusual celiac patients:  She was extremely obese.  She was
an inpatient at the hospital on the psychiatry floor (which is
interesting in itself).  She had complained of nighttime abdominal
pain.  The most common cause of this symptom is a regular duodenal
ulcer, but medication to treat an ulcer wasn't working so the
gastrointestinal (GI) department was consulted.  They performed an
endoscopy, expecting to find an ulcer.  They also did a biopsy because
that is Dr. Murray's habit whenever he does an endoscopy.  They were
surprised to find active CD.  Her symptoms were chronic constipation
(she had diarrhea as a child), malodorous flatus (smelly gas), had
gained 200 lbs.  in the preceding four years, and practiced
lactose-avoidance.  Being overweight and constipated, she was just
about the exact opposite of what most people would conceive of as the
typical celiac.  She had completely normal serum chemistries.  Routine
blood tests were normal; there was no clue to the physician suggesting
CD.  Yet the biopsy showed completely flattened villi and an
antiendomysial antibody test came back positive.  She had a good
clinical response to a gluten-free (GF) diet which included some
weight loss.
 
The degree or type of symptoms that a person with CD presents with
does NOT depend on the severity of the disease where you take the
biopsy.  In CD the damage starts in the intestine just after the
stomach and works its way down.  The small intestine is about 26 feet
long and has a tremendous ability to compensate.  So if the damage is
mostly near the stomach (which is where biopsies are done) then you
may never have diarrhea; the rest of the small intestine can
compensate and absorb all the liquid and food that passes by the first
few damaged feet.
 
When somebody presents with severe diarrhea and wasting, that means
most of the small intestine is damaged and it is not able to
compensate for the damage closer to the stomach.  So it is the amount
of the small intestine that is damaged which determines the symptoms.
If you have all of the small intestine damaged you'll have diarrhea
and weight loss.  If only a small portion of the small intestine is
damaged, you may have pain, bloating, and discomfort after eating but
not diarrhea.
 
Dr. Murray discussed some of the different types of presentations
that they see at the University of Iowa:
 
  *  Iron-deficiency anemia.  At the University of Iowa this is the
     most common symptom other than diarrhea.
 
  *  Lactose intolerance.  This is a very common cause of diarrhea in
     certain populations, including people of African and Asian
     descent.  In these populations lactose intolerance is genetically
     predetermined.  Something happens in the lining of their
     intestine at a certain age that makes them unable to break down
     lactose.  (Lactose is milk sugar.  It has nothing to do with the
     fat content of the milk.)  In Caucasians this genetically
     predetermined lactose intolerance is not very common, occurring
     in less than 5% of the population.  So when a Caucasian complains
     of lactose intolerance Dr. Murray looks for damage to the small
     intestine as a possible cause.
 
  *  Constipation.  About 20% of Dr. Murray's celiac patients present
     with constipation instead of diarrhea.
 
  *  "Nutritionally-compensated".  In other words, they are not skinny
     and have never been skinny.
 
  *  Osteopenia.  This refers to weak, thin bones.
 
  *  Chronic fatigue.  This is a very common symptom in untreated
     celiacs.
 
  *  Arthralgias.  These are joint aches or pains.
 
  *  Brittle diabetes.  [This is a form of Type I diabetes that is
     difficult to control--Dr. Alexander.]
 
  *  Short stature.  Many people with CD are short.  Untreated CD can
     cause malabsorption of nutrients.  Lack of nutrition in turn can
     cause short stature in children, in which they fail to follow a
     normal growth curve.  Of course there are also many tall celiacs.
     But if you are a celiac and you have a child that isn't growing,
     even if there are no GI symptoms you should consider CD as one of
     the possible causes.
 
  *  Neurological disorders.  There are some associated neurological
     disorders.  Thankfully these are fairly rare.
 
  *  Dental enamel defects.  This is a problem when CD is otherwise
     silent in children during the time when their permanent teeth are
     developing.  What happens is the enamel (the hard coating on your
     teeth) does not develop properly.  With no enamel, your teeth
     wear down and you get cavities very quickly.  Dr. Murray has
     seen terrible dental loss in 20-year-old celiacs, where they've
     lost an entire mouthful of teeth.  This is not as much of a
     problem in the United States as it is in other countries, where
     dental care is not as frequent and aggressive.  If dental enamel
     defects are detected, you can't really regrow it because it has
     never developed.  But now there are new dental bonding techniques
     where they can put special films over the tooth to protect the
     defective area.
 
As we see, CD can present in its "classic" form with multiple symptoms
such as steatorrhea, weight loss, typical blood test abnormalities,
and a flat biopsy.  But perhaps more often it presents in an
"atypical" form with only one symptom such as anemia or bone problems.
In atypical cases the biopsies are not always flat; there may be
varying degrees of damage.