Gluten-sensitive enteropathy associated conditions
Editor-In-Chief: C. Michael Gibson, M.S., M.D. 
Template:Gluten sensitivity GSE has a wide variety of associated condition(GSEA), however the key symptoms are typically restricted to the bowel and associated tissues. These include irritable bowel disease, eosinophilic gastroenteritis, villous atrophy(CD), crypt hyperplasia(CD), all of the common symptoms are discussed on the Coeliac Disease. The focus of this article is on assorted autoimmunities or allergic-like responses (IgE or IgA, IgG) markedly increased in GSE many which persist on a strict GF diet, and thus become independent of coeliac disease after triggering.
Ambiguities with other conditions has resulted because the clinical manifestations of celiac incidences that fall below clinical detection can still promote secondary allergic responses and secondary autoimmune diseases. The frequency in western societies is typically around 0.5 to 1%, but the detection rate are typically 10-fold lower. However, the association with other, secondary, diseases remains largely idiopathic and sporadic to coeliac disease. With such low co-occurrence frequencies, statisticians are unable to provide linkage. Overall, however, the incidence of autoimmune diseases not directly linked to GSE in GSE patients is higher than the general population, thus these diseases deserve our attention.
GSEA blood disorders
Avitaminosis. Maladsorption in GSE can results in decline of fat soluble vitamins and vitamin B, as well as maladsorption of essential fatty acids. This can cause a wide variety of secondary problems. hypocalcinemia is also associated with GSE. . In treated GSE, the restrictions on diet as well as reduced absorption as a result of prolonged damage may result in post treatment deficiencies.
- Vitamin A - Poor adsorption of vitamin A has been seen in coeliac disease. and it has been suggested that GSE associated cancers of the esophagus may be related to vitamin A deficiency 
- Folic acid deficiency - Folic acid deficiency is believe to be primary to the following secondary conditions:
- Megaloblastic anemia
- Calcification of brain channels - Epilepsy, Dementia, Visual Manifestations.
- B-6 deficiency. Vitamin B-6 deficiency can result in neuropathies and increases in pain sensitivity. may explain some of the peripheral neuropathies, pain and depression associated with GSE.
- B-12 deficiency
- Vitamin D deficiency. Vitamin D deficiency can result in osteopenia and osteoporosis
- Vitamin K - Coeliac disease has been identified in patients with a pattern of bleeding which treatment of vitamin K increased levels of prothrombin.
- Vitamin E - deficiency of vitamin E can lead to CNS problems  and possibly associated with myopathy
Mineral deficiencies. GSE is associated with the following mineral deficiencies:
- Calcium - Hypocalcemia  causing Oesteopenia
- Magnesium - hypomagnesemia , may lead to parathyroid abnormalities.
- Iron - Iron deficiency anemia
- Phosphorous - hypophosphatemia , causing Oesteopenia
- Zinc - Zinc deficiencies  are believed to be associated with increased risk of Esophagus Carcinoma
- Copper - deficiency 
- Selenium - deficiency  - Selenium and Zinc deficiences may play a role increasing risk of cancer.. Selenium deficiency may also be an aggravating factor for autoimmune hyperthyroidism (Graves disease).
Megaloblastic anemia (MA) is associated with GSE and is believed to be the result of B-12 and folate deficiency.  In GSE, is appears to be associated with the IgA-less phenotype.. Unlike other forms of megaloblastic anemia, GSEA MA is not a form of autoimmune gastritis.
Pernicious anemia(PA). pernicious anemia is associated with GSE and is believed and results primarily from maladsorbtion phenomena.
Iron-deficiency anemia. Iron-deficiency anemia (IDA) may be the only symptom for CD , detected in subclinical CD and is accompanied by a decrease in serum ferritin levels. This can cause addition problems (see: symptoms of IDA and certain conditions like such as Paterson-Brown Kelly (Plummer-Vinson).  Whereas IDA is corrected on GF diet, refractory disease or gluten-sensitive malignacies can cause persistent IDA.
Thromboembolism is a well-described complication of IBD, with a clinical incidence of up to 6% and a three-fold higher risk of disease,  and the Factor V Leiden mutation further increases the risk of venous thrombosis . Recent studies describe the co-occurrence between coeliac disease, in which IBD is common in venous thrombosis. 
A study of patients with dermatitis herpetiformis or coeliac disease revealed significantly more gluten in the blood than controls.  This increases the risk of asthma, anaphylaxis and dermatological conditions.
Triticeae glutens are the primary cause of dermatitis herpetiformis(DH). Epidermal transglutaminase (eTG) is related to tTG and is the autoantigen of DH. It appears that all DH patients have or are susceptible on wheat ingestion to CD. Within CD DH is relatively rare or underdiagnosed with about 5% of patients having DH. Aphthous stomatitis is a common mouth lesion found with celiac disease.
Atopy, urticaria, eczema
Chronic urticaria has been seen in a few cases of CD.  and are likely the result of fortuitous allergies to wheat, or allergies secondary to GSE. Atopy disorders have been found to be more common in celiacs and in first degree relatives. . Celiac disease is associated with a number of epidermal conditions including Psoriasis 
Prurigo nodularis. Prurigo nodularis has been identified with coeliac diease. . Rothmund-Thomson syndrome. Rothmund-Thomson syndrome, or poikiloderma congenitale, is a rare disorder, generally attributed to mutations of the RECQL4 helicase gene on 8q24 with features that include photosensitivity and poikilodermatous skin changes, etc and has been reported in one celiac patient.
GSE has been found to be associated with alopecia areata (patchy baldness)  whereas regrowth did not necessarily occur on a gluten free diet. 
GSEA Endocrine disorders
[Section under construction] Grave's Disease, Hashimoto's thyroiditis. Grave's disease and Hashimoto's thryroiditis are greatly increased in patients with CD.  Grave's disease is an autoimmune hyperthyroidism, as GSE is a potentiator for autoimmune disease, but GD is more commonly found and avitaminosis of selenium and other minerals may be a factor in this increase.
Type 1 (Juvenile onset). The incidence of juvenile Type 1 Diabetes (T1D) is about 1:500 in the U.S. population, and is the result of autoimmune damage to the Islets of Langerhans cells in the pancreas. The level of adult onset T1D plus ambiguous T1D/T2D is unknown. It is unclear how large a role Triticeae has in T1D which also shows stong linkage to DQ2.5 and DQ8. Childhood (male) Type 1 diabetes increases the risk for GSE and vice versa and it now appears that GSE precedes T1D in many cases  and an active search for coeliac disease in early juvenile diabetes patients revealed that GF diet resulted in some improvements.  A high frequency of diabetes patients have anti-transglutaminase antibodies along with increased levels of gluten specific T-cells in T1D patients. From an evolutionary point of view it is difficult to explain the high association of T1D and DQ2.5 given negatively selective nature of the disease in NW European population given the number of studies suggesting that the "Super B8" haplotypes has been under positive selection, and appears to be the most characteristic HLA type in NW Europeans indicating an advanced natural history of the haplotype. A T. aesitivum storage globulin, Glb-1 (locus), was identified that is similar to the hypersensitizing peanut protein Ara h 1 and other known plant hypersensitizing proteins. Antibodies to this protein correlated with levels of lymphocyte infiltration into Islet regions of the pancreas. Gastrointestinal viruses may play a role.  
Studies from Sweden suggest that persons with Coeliac disease are 11 times more likely to have Addison's disease (primary adrenal insufficiency) relative to the normal population.
GSE can result in high risk pregnancies and infertility. Some infertile women have GSE and iron deficiency anemia  others have zinc deficiency  and birth defects may be attributed to folic acid deficiencies. It has also been found to be a rare cause of amenorrhea.
GSEA Gastrointestinal diseases
While GI disease is one of the major symptoms of GSE which is characterized by increased levels of IgA/IgG to food proteins, many conditions like chronic constipation and irritable bowel disease persist after GF diet. Some of this may be due to persistent undetected food allergies, increased sensitivity of the damaged gut, or problems masked by GSE itself.
Irritable bowel (IBS)
In diarrhea dominant IB is a common symptom of GSE, increased celiac disease-associated serum IgG was found in treated and untreated CD patients. The IgG was most common in untreated patients with more active DQ2 expression which dropped on GF diet.. Some irritable bowel can be the result of other food intolerances, such as casien intolerance, lactose intolerance, or intolerances to non-dextrose sugars in other foods. It can also be result of overgrowth of yeast or bacteria as a result of excesses of unadsorbed nutrients. IB may not resolve on GF diet and may become more severe in rare cases because it may not have initially been directly linked to gluten consumption.
Inflammatory bowel disease (IBD)
A recent study of Irritable bowel disease and Coeliac disease found that anti-tTG was increased in Irritable bowel disease although most cases were not clinical CD. IBD was increased 10 fold in coeliac disease. Irritable bowel disease consists of Crohn's disease, ulcerative colitis and microscopic colitis.
Gastroesophageal reflux disease
Gastroesophageal reflux disease (GERD) is the indirect result of many factors and some autoimmune diseases like schleroderma. GSE can cause inflammation and delayed gastric emptying, which can persist through most of the sleeping hours causing GERD. GSE is associated with an increase of food allergies, in some patients this can cause diarrhea, but in others constipation. In some patients, food allergies and GERD are an apparent symptom of GSE, but these allergies and GERD often persist on a GF diet. While GERD associated with GSE can be treated with acid blockers, it is most effectively treated with proper eating habits and elimination diet. The more powerful acid blockers (omeprazole, esomeprezole) can interfere with calcium adsorption and can aggravated preexisting hypocalcaemia and Hypomagnesemia which are more common GSE
A high proportion of children in Italy who were diagnose with eosinophilic oesophagitis were found to have coeliac disease.  All patients appeared to improve on either a gluten-free or allergen free diet.
Diseases of the pancreas, gall bladder, bile duct
Primary biliary cirrhosis. CD is prevalent in primary biliary cirrhosis (PBC). In PBC anti-mitochondrial antibodies are directed toward 3 mitochondrial autoantigens (pyruvate dehydrogenase, oxoglutarate dehydrogenase,branched-chain alpha-keto acid dehydrogenase), 2 or more nuclear proteins (nucleoporin 210kDa, nucleoporin 62kDa, centromere protein, and sp100), and 57% of acute liver failure patients have anti-transglutaminase antibodies.
cholangitis. CD also found at higher than expected frequencies in autoimmune cholangitis and primary sclerosing cholangitis.. CD is frequently linked to pancreatitis but also to papillary stenosis and, in India, tropical calcific pancreatitis appears also to be associated with CD.
Neuropathies tend to be associated with late onset celiac disease. Dementia and ataxia appear to be more common. A recent study of children with neuropathies revealed no increase of CD in early onset neuropathies.. While there are many studies linking CD to various neuropathies such as migraine, encephalopathy, chorea, brain stem dysfunction, myelopathy, mononeuritis multiplex, Guillain-Barre-like syndrome, antiganglioside-positive neuropathy with antibodies. Strong associations remain largely unconfirmed in epidemiologic studies. A recent study looking for changes in the physiology of the brain found regional cerebral hypoperfusion in 73% of untreated CD The calcification of channels at the surface of the brain appear to be a leading phenomena associated with Migrane, Visual, Auditory, Schizophrenia, Epilepsy, Dementia. The problem is that while these are found increased in GSE the cause of these calcifications is unclear and this may extend beyond GSE to other immunological or allergic phenomena. A recent study in Sweden of 14,000 GSE patients revealed no association of CD with multiple sclerosis, Parkinson's disease, Alzheimer's disease, hereditary ataxia, ataxia(the symptom), Huntington's disease, myasthenia gravis, or spinal muscular atrophy, but prior polyneuropathy was associated with subsequent CD.
Peripheral neuropathies are greatly increased in people who have GSE. In clinical CD there is on obvious reason, Avitaminosis and the inability to adsorb essential fatty acids and vitamins can lead to nervous system problems, including sensitivity of the peripheral nervous system. In addition to these problems there are a number or rare autoimmune conditions, secondary autoimmunities, such as fibromyalgia that are more frequent in GSE than in the normal population. Gulliane-Barre syndrome is associated with peripheral neuropathies, and it has been found that anti-ganglioside autoantibodies take part in the binding to axons and schwann cells. Antibodies to these gangliosides have been found elevated in coeliac disease
A sizable fraction of individuals who have gluten-sensitive ataxia have signs of GSE (either CD or elevated intraepitheal lymphocytes) and ataxia is a common symptom in GSE. Studies of clinically undefinable ataxia generally had higher proportion of late onset gait ataxia, mild upper limb symptoms, and evidence of peripheral neuropathy, questions were raised about the specificity of testing and false positives. Patients with ataxia and CD have antibodies that react with Purkinje fibers but is restricted to the anti-gliadin IgA/IgG. A recent Swedish study of 14,000 registered celiacs showed no association of GSE with Ataxia.
Some cases of autism may be linked to cross-reactive allergic response to wheat but these primarily appear to be as a result of milk. A subset of wheat-sensitive autism and autistic spectrum disorders (ASD) appear to be linked to GSE. Some of the influences may be indirect. Pyridoxine (vitamin B6), Long-chain omega-3 fatty acids, magnesium, benefit large number of ASD cases. Vitamins A, B3, C, folic acid, calcium, zinc, cod-liver oil, and digestive enzymes, also offer some benefit.. One of the core features of CD, to a lessor degree GSE, is malabsorption and the benefit of nutrient replacement (essential fatty acids, vitamins, minerals) parallels the above findings, suggesting a large link between autism and CD may be indirect result of malabsorption. However the methodological approach may show a benefit less than implied in these studies.
Epilepsy has been noticed in a sampling of Coeliac Disease patients. One prime example is calcium channel obstruction in the brain and dementia. There is a growing body of evidence suggesting that subclinical cases in older adults will typically progress toward dementia, a large number of studies in Italy and Spain have documented earlier onset cases, though the autoimmune condition is not known, folic acid malabsorption may be the cause.
Visual and Auditory disturbances
According to recent studies calcifications of channels seen in dementia can also occur in specific brain areas such as the visual complex in the occipital lobe. Such calcium channel blockages can cause visual problems or partial field hallucinations (Paroxysmal visual manifestations). . Other papers show a link between migrane, visual aura and cerebral calcifications. Disturbances may be followed by convulsions and associated with gastrointestinal phenomena.
White matter leasions
Ten (of 75) young patients had neurologic findings such as febrile seizures, single generalized seizures, mild ataxia, and muscular hypotonia with retarded motor development, but magnetic resonance imaging detected unilateral and bilateral T2-hyperintensive white-matter lesions in 15 patients (20%)
Depression in GSE has several causes, in the more severe CD depression can be the result of lower vitamin adsorption and essential fatty acid adsorption (see section on autism). Depression and Anger may also be the result of lower quality of life issues as a result of gluten-free diet. Depression appears to persist on gluten free diet in a sizable fraction of GSE. . Elevated anger has been noted also with GSE.
Anxiety is a common feature of GSE, treatment on a gluten-free diet is effective at reducing anxiety, some aspect of which may be due to maladsorption phenomena and cytokine activity (i.e. constant stress). More resolution of anxiety is expected on gluten free diet.
Fibromyalgia was found in 9% of adult patients relative to 0.03% in the general population with a link common to IBD. Concurrent IBS is found in 30% to 70%. Small intestinal bacterial overgrowth is associated is common with a transient response to antimicrobial therapy.
Chronic fatigue associated with GSE is a systemic disorder, however there are neurological components that are especially manifest in blood deficiencies like avitaminosis, amineralosis and anemia. Reduced iron and the lack of vitamins folate, B6, B12 and maladsorption of essential fatty acids can cause depression and chronic fatigue. Anti-gliadin antibodies correlate with higher risk for chronic-fatique when no clinical finding of CD is present.. While fatigue is reduced on gluten-free diet, bouts of depression can become worse. 
GSEA Connective tissue disorders
Some instance of arthritis with small bowel villous atrophy have been found to resolve on gluten free diet, and anti-connective tissue antibodies have been found in increased levels in celiac disease. Anti-rheumatoid factor antibodies are also increased. In addition, cross-reactive anti-beef-collagen antibodies (IgG) may explain some rheumatoid arthritis (RA) incidences. Although the presence of anti-beef collagen antibodies does not necessarily lead to RA, the RA association with Triticeae consumption is secondary to GSE and involves DRB1*0401/4 linkages to DQ8 and is debatable. In one instance rhuematoid arthritis was tied directly to refractory disease.
Still's disease (AOSD) is a rheumatic disorder of unknown etiology characterized by a triad of fever, polyarthritis and evanescent rash. An idiopathic case has been reported with celiac disease.
Some myopathies may be the indirect result of maladsorption of fat soluble vitamins such as vitamin E.
Dermatomyositis is associated with CD in children and more recently established in adults
glomerulonephritis.Celiac disease is associated with immune complex glomerulonephritis. 
IgA Nephropathy. Anti-gliadin IgA antibodies are found also more commonly in patients with IgA Nephropathy. The paper finds a link between GSE and IgA Nephropathy, but not between CD and Nephropathy.
Hyperoxaluria. Calcium oxolate correlates with severity of fat maladsorption in celiac disease.
There are two predominant cancers associated with coeliac disease. Cancer of the esophagus and lymphoproliferative diseases such as gluten-sensitive enteropathy associated T-cell lymphoma.. For non-EATL cancers it is though the mineralemias such as zinc and selenium may play a role in increasing risk..
CD is associated with two grades of disease linked precancerous states. This condition is known as refractory celiac disease (RCD), defined as malabsorption due to gluten-related enteropathy (villous atrophy or elevated intraepitheal lymphocytes) after initial or subsequent failure of a strict gluten-free diet (usually 1 year) and after exclusion of any disorder mimicking coeliac disease.
- RCD 1 involves precancerous tissues in which transformed T-cells continue to produce a response even though gluten is no longer present. The stage is fairly treatable (azathioprine, prednisone) if caught early and infrequently produces lymphoma.. Elemental diet (proteins digested to amino acids) seems to be an effective alternative diet, indicating other proteins are stimulating the IEL. 5 year viability is high when treated. DQ representation is similar to non-RCD celiacs.
- RCD 2 involves neoplastic tissues that the lack of surface expression of usual T-cell markers.
- Increased expression of:
- Intracytoplasmic CD3e
- Surface CD103
- Decreased expression of:
- Increased expression of:
- Clonal T-cell expansion in RCD 2 is not manageable with steroids (see: RCD 1) and sometimes manageable with chemotherapeutic drugs, however, more aggressive therapies seem more affective. A high percentage of RCD 2 patients spontaneously develope lymphoma, the 5 year survival rate is markedly lower than RCD1 but higher than lymphoma. DQ2.5/DQ2 individuals are more frequently found.
Causes of RCD.
- Coeliac disease
- Age at CD/GSE diagnosis - most people are over the age of 50 when first diagnosed at RCD
- Length of latency - The length of time, often unknown in which the person is GSE+.
- Severity - The severity of the microscopic destruction appears to be a factor, and genetics appears now to play a role.
- Genetics - For RCD 2 and EATL, genetics plays large role DQ2.5/DQ2+ individuals are over-represented in the patient set.
GSE increases the risk of cancers of specific types  Among these certain Enteropathy-Associated T-cell Lymphoma is the most common neoplasm and cancers of the intestinal tract are of greatest risk, approximately 5 fold higher than normal. Sixty percent of individuals with gluten-sensitive enteropathy associated T-cell lymphoma were homozygotes for DQ2, whereas only 25% of celiac disease patients and 2.1% of controls are homozygotes for DQ2, these studies indicate that homozygotes of associated DQ types can increase the severity of the disease. GS-EATL is always associated with clinical CD.
Squamous carcinoma of the esophagus is more prevalent in coeliac disease . The increased prevalence may be secondary to GERD that results from chronic delayed gastric emptying. Other studies implicate the maladsorption of vitamin A and zinc as a result of multi-vitamin and mineral deficiencies seen in Coeliac disease.
Adenocarinoma of the bowel has been associated with coeliac disease.
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