Celiac disease is characterized by inflammation of the upper small intestine in response to dietary gluten. Feighery emphasizes in a clinical review article that celiac disease may be much more common than previously realized and may now be diagnosed in adults more often than in children.

The endomysial antibody test has led to improvements in the diagnosis of celiac disease. Current data from population-based studies suggest that the prevalence of celiac disease is approximately one case in 200 persons, compared with a previously cited prevalence of one case in 1,000 persons. Only a minority of affected persons have symptoms. The peak incidence in adults is in the fifth decade, and the female-to-male ratio is 3:1.

Minimal or atypical symptoms occur in many patients, especially those presenting with the disease in adulthood. Severe symptoms are most common in young children. A fulminant form, characterized by diarrhea, failure to thrive, abdominal distention and vomiting, occurs in children younger than two years of age. The median age at the time of diagnosis in children is four years, and loss of appetite is a common symptom. Adults may present with abdominal bloating, diarrhea, dyspepsia or oral ulceration. Patients may also have manifestations of malabsorption, such as anemia or osteoporosis. The skin condition dermatitis herpetiformis is classically associated with celiac disease.

Formerly, the classic diagnostic approach was to obtain a series of intestinal biopsies: before treatment, after dietary withdrawal of gluten and, finally, following a challenge with gluten. Such a series of biopsies is now rarely performed. The development of the serum endomysial antibody test has changed the method of diagnosis. Some authorities now consider a positive endomysial antibody test plus clinical improvement following withdrawal of gluten sufficient evidence for the diagnosis of celiac disease. A biopsy, however, is still frequently performed to confirm the diagnosis.

Treatment of celiac disease requires withdrawal of dietary gluten. Wheat, barley and rye products should not be ingested. Recent studies show that oats do not damage the mucosa in celiac disease. Dietitians and patient support groups can be useful resources for helping the patient identify gluten-containing foods and for encouraging compliance. Serial antigliadin or antiendomysial antibody tests can be used to monitor the patient's adherence to a gluten-free diet. Although symptoms may resolve quickly, mucosal recovery can take months or years. Patients may require supplements of specific nutrients such as iron, folic acid and calcium.

Failure to implement a gluten-free diet or a lack of response to treatment may lead to the two major complications of celiac disease: osteoporosis and malignancy. Cancer of the small intestine, esophagus and pharynx is associated with celiac disease. The classic malignancy associated with the disease is lymphoma of the small intestine.

editor's note: Sometimes our understanding of specific conditions changes dramatically. Celiac disease is now considered a common, underdiagnosed condition that affects adults as well as children. We have observed for years some patients who develop significant gastrointestinal symptoms in response to adding bran and cereal to their diets after taking our advice to increase their fiber intake. Do such patients have celiac disease? Similarly, do many of the patients thought to have irritable bowel syndrome actually have celiac disease? As this new thinking on celiac disease becomes more widely known, an increased demand for the antibody screening tests can be anticipated, followed by a boom in the public's interest in gluten-free foods. In the future, will gluten rival cholesterol as the principal nutritional public enemy?—a.d.w.