Modern view on the diagnosis and treatment of celiac enteropathy in young children. Symptoms of celiac disease in adults. Diagnosis of the disease celiac enteropathy

Hi all! I am glad to welcome you again to my page. And I would like to begin our communication with the question: how often do you suffer? intestinal problems? Surely each of you often has indigestion, problems with stool, flatulence and bloating, belching? Did you know that all these phenomena are also direct symptoms of celiac disease? This is probably the first time you’ve even heard this word. Today I invite you to talk about diseases such as celiac disease or celiac enteropathy, what it is and how to deal with it, you will learn on my blog.

Celiac enteropathy, popularly called flour disease, is an autoimmune inflammatory disease small intestine. The disease appears as a result of a reaction to gluten, a protein found in cereal crops.

In other words, celiac enteropathy is an individual intolerance to gluten, an allergy to products made from wheat, barley, oats, and rye. As numerous studies by scientists have shown, the prevalence of celiac disease is approximately one case per 250 people.

Although celiac disease was formally described in the late 19th century, treatment remained empirical until the mid-20th century. Even then, there was an improvement in the well-being of patients after removing wheat from the diet. With the development of intestinal biopsy techniques, the small intestine was identified as the target organ.

You might be interested to know something unusual about this disease:

celiac disease - genetic disease, but it is not transmitted to all family members;
a person can be a carrier of the celiac enteropathy virus all his life, and the disease itself can only worsen in crisis situations for the body - operations, pregnancy and childbirth;
Celiac disease occurs more often in women than in men;
Celiac disease is rare in African Americans and Asians;
Celiac disease is especially common in Western Europe, North America and Australia.

Causes and symptoms of the disease

The causes of celiac disease are due to a combination of immunological and genetic factors. The interaction of gliadin (a protein present in grain products) with the walls of the small intestine leads to the development of celiac disease. When people with celiac disease eat gluten-containing foods, gliadin is identified immune system like a threat. As a result, the body produces antibodies that stimulate characteristic reactions.

Symptoms of the disease

It is impossible to say exactly when the disease manifests itself. The first symptoms can appear both in infancy and after 30-40 years of life. That is, a person may not know for the rest of his life that he has celiac disease, which is deplorable for the intestines.

Symptoms in children:

stomach ache;
nausea and vomiting;
diarrhea;
bloating;
flatulence;
moodiness, bad mood;
low performance in school-age children.

The onset of symptoms usually occurs gradually and coincides with the introduction of grains into the diet. Symptoms usually improve during adolescence.

Symptoms in adults

Celiac disease usually affects adults in the third or fourth decade of life, but sometimes later. Signs and symptoms of celiac disease are variable and may include the following:

diarrhea;
abdominal discomfort;
bloating and flatulence;
steatorrhea or fatty stools;
fatigue and weakness.

I would like to pay special attention to fatty stools. In medicine, this phenomenon is called malabsorption. The fact is that it occurs in cases where there is an excess amount of fat in the body. Fats are not able to dissolve nutrients, resulting in vitamin deficiency.

This, in turn, leads to consequences such as anemia, hypocalcemia (lack of calcium affecting skeletal development), osteoporosis (bone fragility, and, as a result, frequent fractures). Lack of folic acid can lead to infertility, decreased sexual power and impotence.

To the very severe consequences, perhaps, can be attributed to ulcers and stomach cancer. For pregnant women, the disease threatens miscarriage, premature birth, stillbirth. Children under two years of age may experience delayed growth and mental development.

How to diagnose celiac enteropathy?

There are many methods for diagnosing celiac disease. Naturally, the disease is diagnosed by a doctor, and it is he who determines desired method determining or confirming the diagnosis. Depending on whether the diagnosis is known or not, at what stage the disease is, the following methods are prescribed:

serological blood test for antibodies;
general blood and urine tests;
blood chemistry;
hormonal blood test;
stool analysis;
X-ray of the intestines;
intestinal biopsy.

And based on the data from these tests, your attending physician will prescribe appropriate treatment.

How is celiac disease treated?

Since the symptoms of the disease appear after eating products made from wheat, oats, rye or barley, the main treatment is to avoid these products. Clinical guidelines imply a therapeutic diet. What can't you eat? - you ask. - Only flour products? But no. The list of prohibited foods on a gluten-free diet is quite wide:

flour and pasta products, cereals from the above mentioned cereals;
mango;
store-bought sauces, ketchups, mayonnaise;
smoked products;
chocolate, cocoa in any form;
fried, salted, pickled foods;
fast food;
alcohol.

The basic diet of a sick person should consist of:

lean meat;
fruits, berries, vegetables;
legumes;
greenery;
nuts;
dairy products;
fish;
corn;
buckwheat;
rice;
potatoes.

When choosing food products for your diet, you need to do this carefully. I have already said in previous articles that gluten can be present even where it should not be. For example, in produced industrially. Also be careful when eating in places Catering. For example, chicken cutlets cannot contain gluten, but breadcrumbs will make this dish hazardous to your health. And be sure to read the labels on the products you buy in stores.

The effectiveness of a gluten-free diet

You will feel the results of treatment with a gluten-free diet within a couple of months. Gluten-free results in:

intestinal microflora is normalized;
the whole body is cleansed of toxins and toxic substances;
Children do not have gas formation or colic.

The disadvantage of a gluten-free diet is that the body is not satiated required quantity vitamins and nutrients.

Agree, because the products that you have to give up also bring benefits. To provide the body with complete, fortified nutrition, it is necessary to regularly take a course of multivitamins. This is especially true for B vitamins, calcium, iron and fiber.

To summarize, I want to say that gluten-free nutrition is, rather, not dietary, but correct and healthy eating. And this diet does not mean treatment so much as providing the body with health.

On this note, dear readers, I bid you farewell. Don’t forget to look after your health, and I’ll tell you how to do it correctly. See you soon!

In addition to the article, watch the video.

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Celiac disease. Start.

...The young mother is alarmed. Her baby developed so well in the first months of his life, but now it seems that he has become ill - he has become restless, capricious, and has a swollen tummy. A child's stool is especially frightening. It is somehow unusual - too light, loose, foaming. Is it really from simple semolina porridge? Or did the oatmeal milk mixture turn out to be of poor quality?

In such cases, it is better not to get lost in guesswork and not hope that “it will go away on its own.” One thing is that intestinal disorder is accompanied by “not the same” stool, a sufficient reason to sound the alarm: most likely your child has celiac disease or whatever they call her celiac enteropathy(glutenenteropathy), Guy-Herter-Heubner disease, intestinal infantilism.

What lies behind these complex and obscure names? How dangerous is the disease for a child? Do only children get sick or do people of all ages suffer from celiac disease?

Celiac disease: getting to know the “dossier”

The world learned about this disease in 1888, when the doctor at the Bartholomew Hospital in London, Samuel Guy, described its classic symptoms in children... Many years have passed since then. During this time, experts have compiled a solid “dossier” on celiac enteropathy, although many questions have not yet been answered.

So, what is celiac disease? This chronic disease caused by hereditary factors . Expressed in digestive disorders due to damage to the villi by certain foods small intestine . Such products include cereals, namely wheat, rye, oats and barley. They contain proteins certain group: gluten (gluten) and related hordein, avenin and others. Actually, they damage the mucous membrane of the small intestine, which disrupts absorption in the damaged areas. Exclusion from the menu of food products containing protein fractions cereals, leads to restoration digestive function. But as soon as gluten and its “relatives” enter the intestines again, everything starts all over again...

Why this happens is not entirely clear. Exists "enzyme defect" hypothesis, that is, insufficiency or complete absence of gliadinaminopeptidase and some other substances that are involved in the breakdown of cereal proteins. It is believed that the immunological component, that is, the reaction to gluten, plays an important role protective forces organism on humoral and cellular level, occurring directly in the mucous membrane of the small intestine.

However, the direct connection of these violations with flour products was established only in 1951 by the Dutch pediatrician Willem Dicke. A year later, a gluten-free diet was used for the first time to treat patients. In Russia, celiac disease seriously interested specialists in the 90s of the last century. Since then, debates have not ended in our country about what it actually is - a syndrome or secondary disease. In some regions of the Russian Federation, it is completely ignored and such a diagnosis is not made in medical institutions. But her clinical picture is obvious.

Gluten attacks - health suffers

Typically, celiac disease manifests itself during the first two years of a child’s life.. This often happens at 4-8 months of age, when mothers decide to feed their babies semolina porridge, milk formula, and give them cookies. Gluten intolerance may also appear later if the introduction of gluten-containing products into the diet is delayed for some reason.

Universal symptoms of celiac enteropathy does not exist, that is, their expression is different. One can call it classic clinical picture, which is observed in children under two years of age. It is as follows:

increased abdominal circumference;
decreased appetite;
chronic diarrhea;
vomit;
behavioral disorders (the child is irritable or, conversely, apathetic);
growth retardation and/or retardation in physical development;
thinning or complete absence subcutaneous fat layer.

Special mention should be made about stool with celiac disease. In all respects it is atypical: copious, liquid, distinctly pale or “multi-colored”, pasty consistency, foams. His parents describe him more colorfully, saying that he is like eggplant caviar, sometimes resembles rising dough or soap suds. The degree of abundance can be judged by the fact that the pot instantly fills to the brim. Often found in stool undigested remains food, which makes it resemble vomit. In some young patients, it has an “unpredictable” consistency, being mushy, liquid, or even formed. But in all cases its excessive abundance is noted.

In some cases, symptoms are less pronounced or completely absent. This is possible if the disease is detected in children over two years of age. These forms of celiac disease are called atypical. The difference from “classic” glutenenteropathy is that non-intestinal symptoms predominate. For example, unexplained growth retardation or that occurred without apparent reason anemia. In patients, tooth enamel may be affected.

The importance of an accurate diagnosis

Unfortunately, celiac disease often detected late. And this despite the ease of diagnosis. After all, a lot says about the disease: the cumulative data of the anamnesis, characteristic appearance the patient and the improvement/worsening of his condition depending on whether he adheres to a gluten-free diet or deviates from it.

If gluten intolerance is not diagnosed immediately and treatment is accordingly started late, then this leads to the development of complications. They are also associated with impaired absorption of nutrients. These are anemia, vitamin and protein deficiency, problems with the absorption of fats, microelements such as calcium and iron, etc.

So preliminary diagnosis can be placed with a high degree of probability. To clarify it, patients are prescribed:

blood chemistry;
X-ray examination (detects osteoporosis, intestinal dyskinesia and the presence of horizontal levels in the intestinal loops);
scatological examination (shows the presence of fatty acids and washed in large quantities).

It happens that celiac disease is mistaken for intestinal form cystic fibrosis, disaccharidase deficiency, anomalies gastrointestinal tract. To find out what the patient really suffers from, they conduct differential diagnosis, which allows you to exclude illnesses that do not match the symptoms.

You can't heal, but you can get along

There is no cure for celiac disease. It becomes a way of life. But you can avoid it unpleasant symptoms and complications if you constantly adhere to a special gluten-free diet. Diet therapy is the only way It's okay to live with this disease.

It is necessary to completely eliminate foods that contain gluten from your diet. In addition to the above-mentioned wheat, rye, oats and barley, these are sausages, sausages and sausages that may contain flour. Prohibited mayonnaise, sauces, canned food, imported cheeses, ketchup, some yoghurts. There is a taboo on certain types of chocolate, caramel, filled candies, corn flakes (contain malt) and instant coffee. Any product containing gluten in a proportion of more than 1 mg per 100 g should never be consumed.

Products made from rice and corn flour are allowed, from potato starch. You can eat rice, corn, millet and buckwheat porridge. Not limited to vegetables, fruits, berries, soya beans and all animal products. Milk is excluded or limited at the beginning of treatment. Other products are consumed as tolerated.

A strict diet gives results after 2-6 months. The “fragile peace” with celiac disease can only be disrupted by one thing – a voluntary or involuntary deviation from a regulated diet. In this case, the patient is set back several months and faces a resumption of symptoms of glutenenteropathy.

Is also carried out drug therapy. Patients take vitamin complexes and some digestive enzymes. In severe cases, they are prescribed prednisolone. In case of severe violation of the diet, it is carried out replacement therapy: amino acids, fat mixtures and glucose are administered intravenously. If a patient with celiac disease is being treated for other diseases, then he should not take tablets and pills whose shells contain gluten.

Another problem with celiac disease is intestinal dysbiosis. If its manifestations are pronounced, patients have their composition adjusted. microflora.

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Celiac disease (otherwise known as celiac enteropathy) is a disease associated with intolerance to a fraction of proteins contained in wheat grains (gliadin), barley (hordein), rye (secalin) and oats (avenin), which are common name"gluten".

The harmfulness of a protein depends on its structure, that is, on the sequence of amino acids it contains. When it enters the body, the concentration of certain proteins in the blood increases, causing damage to the intestinal mucosa. This leads to atrophy of the intestinal villi and loss of their ability to perform their functions.

Gluten enteropathy found in children between 2 and 4 years of age, and sometimes later. It can also develop in adulthood, mainly as a complication after other diseases.

Causes of celiac disease

Toxin theory

This hypothesis is based on the existence of enzymatic disorders that are responsible for the improper digestion of gluten. In a non-degradable form, they have a toxic effect on enterocytes (cells of the intestinal tract).

The immune basis of the disease is indicated by the body's production of antigliadin bodies (detected in a blood test), as well as the presence of lymphocytic edema in the mucous membrane of the small intestine with a predominance of T cells.

Aggression theory

This theory sees the cause of the problem as an immune response against one's own normal cells body Antibodies are detected in the patient’s blood serum, for example, IgA-EMA, IgA-ARA, accompanying other autoaggressive diseases, for example, ulcerative colitis, systemic lupus erythematosus, sarcoidosis.

Inheritance theory

IN in this case It is assumed that the development of the disease is significantly influenced by genetic predisposition. Existence has been proven close connection between celiac disease and histocompatibility antigens HLA-DR3 and/or DR7, DC3, HLA-B8.

Symptoms of celiac disease

Based on the types of disease symptoms that occur, we can divide celiac disease into 3 types: classic, silent and hidden (latent).

Incorrect treatment of celiac disease or started late causes symptoms of chronic malnutrition: growth deficiency, delayed bone development, spinal curvature, hypochromic anemia, atrophic gastritis, rickets, skin changes, delayed puberty, emotional disturbances(irritability, difficulty concentrating, apathy). Classic celiac disease occurs in only 30% of all cases of the disease.

Silent celiac disease

Diagnosed in people who do not have underlying clinical symptoms However, typical changes in the colon occur, detectable in laboratory tests.

Indications for performing a screening test are:

abdominal pain, bloating, loose stool;
symptoms of delayed somatic development;
chronic diseases (type 1 diabetes mellitus), diseases thyroid gland, hypoplasia of dental enamel, oral ulcers (aphthae), which often progress, mental disorders(eg, schizophrenia), tumors of the small intestine, mainly lymphoma.

Hidden celiac disease

The disease potentially exists, but there are no clinical symptoms or changes in the small intestine. Certain circumstances, such as gastrointestinal tract infections, surgical procedures, pregnancy, stress, increased gluten consumption, can lead to the onset of symptoms and the discovery of the disease.

Diagnosis and treatment of celiac disease

anti-reticulin antibodies (ARA) in the IgA and IgG classes;
antigliadin bodies (AGA) IgA class and IgG;
antibodies against endomysium (EMA) in the IgA and IgG classes;
IgA class antibodies against tissue transglutaminase.

Real quantity...

A form of treatment is the use of a gluten-free diet. Its introduction into life causes regeneration of intestinal villi, and, consequently, a weakening of unfavorable clinical symptoms.

In children who have acute process disease, sometimes in the first stage of treatment, it is also necessary to use dairy-free, hypoallergenic diet. Gluten-free foods include: rice, soy, corn, millet and wheat starch.

Patients with celiac enteropathy exhibit individual gluten intolerance, which depends on age, stage of the disease and dose of gluten. Children are the most sensitive. A gluten-free diet should be followed throughout life.

Despite the lack of specific clinical signs, pathognomonic for celiac enteropathy, all must be taken into account listed symptoms, the analysis of which in combination with data from other research methods and treatment results will allow a correct diagnosis.

Laboratory signs of celiac disease, like clinical ones, vary depending on the extent and severity of intestinal damage and are also nonspecific.

Laboratory and instrumental data

Complete blood count: hypochromic iron deficiency or B12-deficient macrocytic hyperchromic anemia.
Biochemical blood test: decreased blood levels total protein and albumin, prothrombin, iron, sodium, chlorides, glucose, calcium, magnesium, a slight increase in bilirubin content is possible. With celiac enteropathy, a number of organs and systems are involved in pathological process, in connection with this, many biochemical indicators deviate from the norm. In severe diarrhea, the body is depleted of electrolytes with a decrease in the content of sodium, potassium, chlorides and bicarbonates in the blood serum. Sometimes there is significant metabolic acidosis due to loss of bicarbonates in feces. In patients with diarrhea and steatorrhea, the content of serum calcium, magnesium, and zinc decreases. In osteomalacia, the level of phosphorus in the blood serum may be reduced, and alkaline phosphatase- increased. The content of serum albumin and, to a lesser extent, serum globulins may decrease as a result of significant release of serum protein into the intestinal lumen. With severe damage to the small intestine causing steatorrhea, the level of serum cholesterol and carotene is usually reduced. Serum cholesterol levels of less than 150 mg/ml in adults should alert the clinician to possible violation gastrointestinal absorption.
General urine analysis: no significant changes, in severe cases - albuminuria, microhematuria.
Coprological analysis: polyfecal count is characteristic. The stool is watery, semi-formed, yellowish-brown or grayish in color, fatty look(brilliant). At microscopic examination determined a large number of fat (steatorrhea). Significantly more than 7 g of fat is released per day (normally, the daily excretion of fat in feces does not exceed 2-7 g). With limited damage proximal part small intestinal steatorrhea is mild or even absent.
Study of the absorption function of the small intestine: tests with D-xylose, glucose are used (after an oral glucose load, a flat glycemic curve is determined), lactose (after oral administration lactose, an increase in the concentration of exhaled hydrogen is noted). Tests indicate a decrease in intestinal absorption function.
Immunological blood test: the most characteristic is the appearance of antibodies to gluten in the blood, which are detected using the express method by applying the patient’s blood serum to wheat grain media. Antibodies circulating in the blood can also be detected by an indirect fluorescence reaction. The detection of autoantibodies to reticulin and epithelial cells of the small intestine is also characteristic. There may be a decrease in the level of immunoglobulin A in the blood.
Hormonal blood test. The blood levels of T3, T4, cortisol, testosterone, and estradiol are reduced. These changes observed with the development of hypofunction of the corresponding endocrine glands.
X-ray examination of the gastrointestinal tract. The expansion of the loops of the small intestine, the disappearance of its folds, and a change in the relief of the intestinal mucosa are detected. Sometimes there is excess fluid in the proximal small intestine (due to impaired absorption of the intestine), which leads to dilution contrast agent and as a result, in the distal parts of the small intestine, the pattern of the mucous membrane appears unclear.
Various diagnostic tests. With malabsorption syndrome, tryptophan metabolism is disrupted, which may be due to a deficiency of pyridoxine and nicotinic acid; at the same time, the urinary excretion of 5-hydroxyindolebutyric acid and indican increases. At severe violation digestion, causing pituitary or adrenal insufficiency, the daily urinary excretion of 17-KS and 17-OX decreases. As diagnostic test propose to use the LIF factor, which is formed as a result of the interaction of lymphocytes from patients with celiac enteropathy with gluten fractions and suppresses the increased migration of leukocytes. The secretion of IgA and IgM in vitro by isolated lymphocytes from the duodenum and jejunum using an enzyme-based immunosorbent technique.
For rapid diagnosis of celiac enteropathy, antibodies to gluten are detected in the blood serum by applying whole wheat grain media or diluted with buffered isotonic solution sodium chloride (pH 7.4) in a ratio of 1:11 to the patient’s serum. Antibodies to gluten circulating in the blood, as well as autoantibodies to reticulin and epithelial cells of the small intestine, were detected by an indirect immunofluorescence reaction.
Biopsy of the mucous membrane of the small intestine. It is most advisable to take a biopsy from the duodenal junction near the Treitz ligament. In this place the intestine is fixed and therefore it is easier to take biopsies here. Characteristic signs of celiac enteropathy are:
- an increase in the number of goblet cells in the intestinal mucosa;
- an increase in the number of interepithelial lymphocytes (more than 40 per 100 epithelial cells of intestinal villi);
- villous atrophy;
- infiltration of the superficial and pit epithelium with lymphocytes, and the lamina propria with lymphocytes and plasma cells.

Diagnostic criteria for celiac disease

The appearance of diarrhea, malabsorption syndrome in early childhood, retarded growth and physical development in childhood and adolescence.
Typical results of examination of biopsy specimens of the mucous membrane of the duodenum or jejunum.
Detection of circulating antibodies to gluten in the blood, as well as autoantibodies to reticulin and epithelial cells of the small intestine.
A clear clinical and morphological (according to the results of a repeat biopsy) improvement after excluding gluten from the diet (products made from wheat, barley, rye, oats).
Positive results of loading with gliadin ( rapid rise level of glugamine in the blood after oral administration of 350 mg of gliadin per 1 kg of body weight).

Differential diagnosis of celiac disease. The first stage of diagnosis is to establish the violation of intestinal absorption and the underlying cause. Steatorrhea and decreased levels of serum cholesterol, carotene, calcium, and prothrombin alone do not differentiate celiac enteropathy from other diseases that may be due to insufficient absorption. They are also observed in cases of disturbance of cavity digestion caused by preliminary resection of the stomach and ileum or pancreatic insufficiency.

In differential diagnosis primary disease of the mucous membrane of the small intestine, a xylose tolerance test is of particular importance, since its normal absorption in the case of impaired cavity digestion persists for quite a long time - until the structure of the mucous membrane changes. X-rays of the small intestine after administration of a contrast agent also help differentiate malabsorption due to either mucosal lesions or other causes. “Abnormal” relief of the mucous membrane, dilatation of the intestine, liquefaction of barium sulfate suspension are highly suspicious for mucosal disease.

Normal biopsies obtained from the proximal small intestine reliably exclude the diagnosis of clinically significant untreated celiac enteropathy. At the same time, biopsy specimens demonstrating lesions typical of gluten enteropathy reliably confirm this diagnosis. It is excluded from its detection during biopsy examination. histological features, characteristic of Whipple's disease and Crohn's disease. Hypogammaglobulinemia, in which changes in the mucous membrane of the small intestine resemble the picture observed with celiac enteropathy, is characterized by the absence or significant decrease in the number of plasma cells.

The absence of absolutely specific histological features pathognomonic for celiac enteropathy indicates the need to consider the biopsy results in combination with other manifestations of the disease.

Mucosal lesions identical or close to those observed in celiac enteropathy occur in tropical sprue, diffuse lymphoma of the small intestine, Zollinger-Ellison syndrome with significant hypersecretion, unclassified sprue, viral gastroenteritis in young children.

Detection of circulating antibodies to gluten in the blood, as well as autoantibodies to reticulin and epithelial cells of the small intestine, simultaneously with an assessment of the histological structure of the mucous membrane of its initial section makes the diagnosis and differential diagnosis reliable.

Clinical and morphological improvement after treatment with a diet completely free of toxic gluten confirms the diagnosis of celiac enteropathy. It should be noted that clinical improvement occurs after a few weeks, and normalization of the histological picture requires adherence to a gluten-free diet for several months and even years, although some morphological improvement can be observed even after early stages clinical remission.

In young children suffering from gastroenteritis, diagnosis is complicated not only by the similarity of histological changes in the mucous membrane of the small intestine with gluten enteropathy, but also positive reaction on a gluten-free diet.

Differentiate celiac enteropathy from other diseases of the small intestine, in particular from chronic enteritis, a gliadin load test helps (a rapid increase in the level of glutamine in the blood after oral administration of 350 mg of gliadin per 1 kg of body weight); long history of illness, starting in childhood; exacerbation of the disease due to the consumption of products made from wheat, rye, barley, oats; good effect from a gluten-free diet.

The diagnosis of celiac disease is made based on the following signs: dysfunction of the mucous membrane of the small intestine; best documented characteristic features its damage; the presence of circulating antibodies to gluten; clear clinical and morphological improvement after eliminating toxic gluten from the diet.

Gluten enteropathy or celiac disease is a chronic disease of the small intestine characterized by reversible atrophy of the villi of the small intestinal epithelium associated with intolerance to certain protein fractions—gluten (gliadin), which is found in some grains (wheat, rye, barley, millet). Violation of membrane digestion and absorption of nutrients leads to the development of malabsorption syndrome varying degrees severity in individuals genetically predisposed to the disease.

Relevance.

In Russia it is 1 Hard case per 5-10 thousand children, on average - 1 case per 8000 population. Among patients, 80% are women.

Etiology and pathogenesis.

The occurrence of an immunopathological reaction to gluten, or rather to its component b - gliadin, leading to damage to the intestinal mucosa, is of decisive importance hereditary predisposition. Most patients (80% according to foreign research) are carriers of HLA-B8. The disease is inherited in an autosomal dominant manner and is polygenic; genetically determined, probably an enzyme defect. In such patients, due to a deficiency of the enzyme glutaminyl peptidase, the hydrolysis of gliadin is impaired, which, when accumulated, initiates pathological immune reactions. The lymphoid tissue of the intestine reacts with an increase in lymphoid and plasma cells that produce antigliadin antibodies - immunoglobulins of classes A, O, M, leading to atrophy of the mucous membrane.

Morphological examination of patients, in addition to atrophy of the mucous membrane with a sharp shortening of the villi, reveals elongation of the crypts, lymphoplasmacytic infiltration of the lamina propria, changes in the number of goblet cells, lymphoid infiltration of the epithelium, and fibrous changes.

Clinic.

There are several clinical forms celiac disease: a) typical — the disease usually begins in early childhood and is manifested by diarrhea, steatorrhea, polyfecal matter, weight loss, anorexia, flatulence, and growth retardation. The course is undulating, periods of exacerbations can be replaced by long-term remission; b) torpid (refractory) - characterized by a severe course, lack of effect from the therapy; c) erased - extraintestinal symptoms predominate ( hemorrhagic syndrome, osteomalacia, myopathies, endocrine disorders, developmental delay); d) latent - occurs in old age, characterized by a subclinical course.

Classification.

There is no generally accepted classification of celiac disease. The Central Research Institute of Gastroenterology proposes to use a classification as a working one, which distinguishes typical and atypical form, asymptomatic, latent, as well as periods: active and remission. Celiac disease is classified according to the age at which the disease develops. early childhood, in adults, in old age. Depending on morphological picture defeats — with subtotal or total atrophy of the small intestine. According to the phase of the course - compensation, subcompensation or subsiding exacerbation due to the use of diet, decompensation (exacerbation). Diagnostics. Diagnosis is based on biopsy of the mucous membrane of the distal duodenum or jejunum; The criteria for the disease are total atrophy of the mucous membrane and restoration of the structure of the mucous membrane after the use of a gluten-free diet.

PREVENTION OF GLUTEN ENTEROPATHY (CELIAC DISEASE)

Primary prevention.

Goals primary prevention celiac disease is to prevent the development of the disease. The primary prevention program boils down to genetic testing for family planning and pregnancy, genetic testing children at birth from parents with a predisposition to celiac disease, active identification of risk factors and persons predisposed to the occurrence of this disease. But mere predisposition is not enough; the role of the trigger mechanism belongs to unfavorable factors external environment And wrong image life, this can be severe psychological stress, surgery or viral infection. The onset of the disease may also coincide with the introduction of foods containing flour products into the diet. Necessary dispensary observation for persons at risk of developing the disease with the implementation of a set of social and individual measures to eliminate risk factors, compliance with recommendations for changing lifestyle and lifestyle, as well as diet and nutrition. To identify healthy individuals with increased risk occurrence of the disease, it is necessary to conduct a survey to identify pre-disease conditions: a feeling of discomfort in the epigastrium, dyspepsia, asthenia, detection of risk factors.

It is necessary to observe food hygiene: routine and rhythm, avoid smoking and drinking alcoholic beverages. Need to give up food products, causing thermal, mechanical or chemical irritation of the gastrointestinal mucosa. The nutrition program should include in the diet foods that have an antioxidant effect and do not have an irritating or secretory effect on the gastrointestinal glands, especially the small intestine.

Important preventive value has timely sanitation of lesions chronic infection gastrointestinal organs. It is necessary to remember the need timely treatment diseases of the hematopoietic apparatus and cardiovascular system, diseases endocrine system and metabolism, in which the trophism of the gastrointestinal tract is disrupted. Required condition Primary prevention of celiac disease is the implementation of a whole complex of general and individual preventive, hygienic, sanitary, educational, educational measures aimed at preserving the health and working capacity of a person with the development and observance of the correct behavioral stereotype that defines the concept “ healthy image life." Close relatives of a patient with celiac disease are recommended to undergo a screening examination to detect the disease. Women with celiac disease who are planning pregnancy should remember high probability miscarriages and the risk of having a child with birth defects development. A large-scale program for the diagnosis and control of celiac disease has been launched in Europe, the goal of which is to develop a new diagnostic tool for the detection and control of celiac disease. The project, called CO-ME01C8

259B1a§pos18 izt§ Vyuvepzogz apy 1n1e§ga1es1 SYr Zuz1:et), combines the latest diagnostic and communication technologies. The device being developed is a device intended for use at the primary level medical care. Using a replaceable microchip, the device will detect the presence of celiac enteropathy and transmit the received information directly to a centralized database. The device will allow not only to diagnose celiac disease, but also to monitor the patient's response to exclusion of gluten from the diet. The operating principle of the device is based on the determination of antibodies associated with celiac disease, as well as the genes involved, HbA-B()2 and B()8.

Secondary prevention

Secondary prevention of the disease and progression of complications is strict lifelong adherence to a gluten-free diet. All grains should be excluded from the diet, except rice, buckwheat, corn, millet, as well as products that may contain them. Conventionally, there are groups of products that contain the so-called. obvious or hidden gluten. Gluten is found in products containing rye, wheat, barley, oats and their processed products (flour and bread from the corresponding cereals, bakery, pasta and confectionery, cereals - wheat, semolina, oatmeal, pearl barley, oatmeal, barley, bran, Muesli, baby porridge, cutlets, breaded dishes, etc.). It must be remembered that a number of non-food products may contain gluten, for example, glue on postage stamps and envelopes, some types of cosmetics, toothpaste, as well as medications, coated.

Gluten also contains:

Boiled sausages, frankfurters, semi-finished products from minced meat and fish;

— Meat and canned fish;

— Many canned vegetables and fruits, incl. tomato pastes, ketchups;

— Ice cream, yoghurts, cheeses;

— Margarines with gluten-containing stabilizers;

— Some types of vinegars and salad sauces, mayonnaises;

— Soy sauces;

— Multi-component dry seasonings and spices (“Vegeta”, etc.);

— Concentrated dry soups, bouillon cubes;

— Some types of tea, coffee and cocoa mixtures for instant cooking;

— Cornflakes when using barley molasses;

— Imitation seafood — crab sticks, etc.;

- Caramel, soy and chocolate candies with filling, lollipop, oriental sweets, industrial jam;

- Some nutritional supplements(annatto dye E160b, caramel colors E150 a-E150y, oat gum E411, maltol E636, ethyl maltol 637, isomaltol E953, malitol and maltitol syrup E965, mono- and diglycerides of fatty acids E471);

— Kvass and some alcoholic drinks(vodka, beer, whiskey).

Rice, buckwheat, corn, and millet are considered non-toxic cereals for celiac disease. Flour and starches made from potatoes, tapioca, cassava, sweet potatoes, beans, peas, soybeans, and various nuts are also safe. Patients with celiac disease can eat meat, fish, vegetables, fruits, eggs, dairy products, high-grade sausages (the composition needs to be clarified), legumes, corn, chocolate, marmalade, some candies, marshmallows, and some types of ice cream.

Specialized gluten-free products are recommended for feeding patients with celiac disease. Recommended acceptable gluten levels are<20 ррт для продуктов питания, естественным образом не содержащих глютен, и <200 ррт для продуктов, из которых глютен удаляется в процессе их выработки.

Almost all milk formulas for feeding children in the first year of life and all therapeutic formulas do not contain gluten. For the nutrition of older people, special products are produced for the nutrition of patients with celiac disease.

Patients are advised to avoid all types of stress: food, psycho-emotional, physical, and it is necessary to eliminate occupational hazards. Close relatives of a patient with celiac disease are recommended to undergo a screening examination to detect the disease. Women with celiac disease who are planning a pregnancy should be aware of the high likelihood of miscarriages and the risk of having a child with congenital malformations. Patients with celiac disease, which can be treated with a gluten-free diet, are subject to an annual medical examination. They conduct the following studies: general and biochemical blood tests; stool examination; Immunological parameters are determined, imaging examination methods are performed (ultrasound, CT, MRI of the abdominal cavity, X-ray studies). In the absence of complete disappearance of signs of the disease, a biopsy of the mucous membrane of the small intestine is performed. Patients with a poor response to a gluten-free diet are subject to clinical examination and examination at least 2 times a year. If necessary, constantly take multienzyme drugs (Creon, Micrazym) and probiotics (Linex, Laminolact). Patients with celiac disease have an increased risk of developing malignant intestinal tumors.