Is an iceberg where only the tip reveals itself; the rest of it hides under water.
      Celiac Disease is the iceberg of abdominal and intestinal disorders because for every diagnosed case (tip of the iceberg) seven remain undiagnosed. The disease is common, affecting about 1% of earth’s population, and causes a high mortality due multiple conditions that are associated with it.
      The disease is caused by a genetic sensitivity to certain protein components present in wheat, rye, and barley known collectively as Gluten.  It is thought that the disorder made its appearance after the first ice age in the fertile crescent of the Middle East where grain cultivation was developed.  The initial description of the disease dates back to the first century of the Christian Era.
      When gluten crosses the intestinal membranes, it causes those individuals who are genetically prone to make antibodies against their own small intestinal linings.  These unnatural ‘auto-antibodies’ attack the small intestine, causing inflammation and destruction of the absorbing hair-like structures called villi.
      Symptoms may be absent, atypical, minor, or major:
a) Silent disease is common and impossible to detect without a high index of suspicion.  It is usually discovered after a person is diagnosed by doing screening blood tests on that person’s relatives.
b) Atypical disease presents with a group of unusual symptoms that have nothing to do with the person’s intestines and abdomen.  Such symptoms include broken bones due to osteoporosis, psychiatric troubles, nerve and muscle problems, fatigue, anemia, skin rashes, thyroid inflammation, diabetes, recurrent miscarriages, dental diseases, liver inflammation, depression, epilepsy, headache, etc.  Autoimmune disorders—where the body’s immune system attacks the body—such as lupus and so many others, occur more frequently in Celiac Disease patients than in the general population.
c) Minor disease presents with trivial, transient, recurrent, or chronic symptoms such as indigestion, abdominal discomfort, bloating, altered bowel habits, diarrhea, constipation, food sensitivities, abdominal cramps, belching, and increased abdominal gas.
d) Major disease presents with frank malabsorption symptoms such as severe diarrhea, incontinence, fatty stools, weight loss, edema, cramps, malnutrition, frailty, and vulnerability to infections.
      The clinical course of the disease is lifelong and usually progressive.  Diagnosis is made with blood tests that detect the abnormal antibodies and is confirmed by doing small intestinal biopsies that show inflammation and flattening of the intestinal lining.  The abnormal antibodies, which serve as screening tests, are positive in 85-100% of patients.  There are some patients, however, who have biopsy proven Celiac Disease but negative antibodies and there are others who have positive antibodies and negative biopsies.  In such cases, management is individualized based on clinical judgment.
      Treatment is preventive and entails total avoidance of gluten, which means total abstinence from wheat, barley, and rye.  However, avoiding these grains is not as easy as avoiding breads and pastas because small amounts are present in many canned foods, soups, food additives, and restaurant meals.  To gain more insight into how to avoid gluten, one can do a Google search on gluten-free-foods and find a wealth of information.
      Abstaining from gluten reverses the disease over a few months to a few years; the abnormal antibodies tend to go away, the intestinal lining tends to regenerate itself, abdominal symptoms tend to disappear, autoimmune disorders may show striking improvement, and many atypical manifestations may slowly resolve.
      Not treating Celiac disease doubles or triples mortality and the risk of death rises in proportion to the delay in making the diagnosis.  Cancer of the lymph nodes is a leading cause of death in undiagnosed or in poorly treated disease.  A third of untreated patients have poor spleen function, which allows infections to enter the bloodstream and cause life-threatening problems.
      Although it is not practical to screen the population for Celiac Disease, it is appropriate to screen for it in patients who suffers from undiagnosed diseases, autoimmune diseases, chronic abdominal problems, mental problems, liver troubles, skin disorders, nerve and muscle problems, fatigue, bone thinning, and other chronic conditions that have defied diagnosis and treatment.