Tuesday, July 10, 2007
Celiac disease and gluten may be linked to allergic condition of esophagus, eosinophilic esophagitis
Eosinophilic esophagitis may be a manifestation of celiac disease and gluten sensitivity. Bua et al. from Italy report three patients aged 7, 17 and 19 years old, who were discovered to have eosinophilic esophagitis during evaluation for celiac disease. Biopsies of the lower esophagus obtained at the time of endoscopy performed to obtain duodenal biopsies to confirm celiac disease revealed eosinophilic esophagitis. All three had positive specific antibodies and small bowel biopsies diagnostic for celiac disease. However, they also had eosinophils greater than 20 per high power field found on esophageal biopsies though they were not symptomatic for eosinophilic esophagitis. I have also found eosinophilic esophagitis in patients with celiac disease and non-celiac gluten sensitivity. Like Bua, I believe there is a link to gluten and eosinophilic esophagitis.
Two of the three patients in the Italian report failed to resolved their eosinophilic esophagitis on follow up biopsies. However, both were teenagers who had known or suspected non-compliance with a strict gluten free diet. This is substantiated by both having persistently positive celiac blood tests and abnormal small bowel biopsies. On the other hand, the younger patient had laboratory and small bowel biopsy evidence of compliance with a gluten-free diet that was also associated with resolution of the findings of eosinophilic esophagitis on follow up esophageal biopsy.
How eosinophilic esophagitis occurs is not completely understood. Food allergies are known to play a role in a large number of patients but not all. Food sensitivity is suspected in others but not proven. The authors claim that this is the first report of association of eosinophilic esophagitis and celiac disease though there none of the patients reportedly had any esophageal symptoms.
Mast cells and eosinophils are reported to have a role in celiac disease. Lavo et al. reported in 1989 that gliadin causes increase mast and eosinophil chemical release in small bowel of patients with celiac disease given gliadin by intestinal infusion. Horvath et al. reported in 1986 evidence of mast cell release after a single dose of gliadin in children with celiac disease. Lancaster-Smith et al. reported in 1975 that the small intestine in patients with celiac disease and its skin equivalent dermatitis herpetiformis have increased intraepithelial lymphocytes, the characteristic white blood cell seen, and eosinophils after gluten exposure.
It makes sense to routinely obtain duodenal biopsies in people with suspected eosinophilic esophagitis and esophageal biopsies in people with suspected celiac disease not only to avoid missing diagnoses but also to avoid missing an important association not previously recognized. In my experience, eosinophilic esophagitis, mastocytic enterocolitis, and lymphocytic colitis occur in patients who are gluten sensitive and those who have celiac disease. In some patients more than one of these conditions is present and is only found because of my habit of obtaining biopsies routinely from all major areas of the GI tract during endoscopy. This common link to gluten in eosinophilic esophagitis and celiac disease has now been reported by others and the onus in on me to report my observations. I intend to do since we have been collecting our data. If you aren’t already one of my patients but have been diagnosed with more than one of these conditions, send me an email at firstname.lastname@example.org. Learn more about eosinophilic esophagitis and celiac disease at my website www.thefooddoc.com where we explore a healthy gut, healthy life on-line.
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Bua J. et al. Eosinophilic oesophagitis and coeliac disease: is it just a causal association? Gut 2007 56; 1029-1030.
Lavo B. et al. Challenge with gliadin induces eosinophil and mast cell activation in the jejunum of patients with celiac disease. Am J Med. 1989 Dec;87(6):655-60.
Horvath K. et al. Mast cell degranulation after a single dose of gliadin in the jejunum of patients with coeliac disease. Acta Paediatr Hung. 1986;27(4):311-6.
Lancaster-Smith M. et al. The cellular infiltrate of the jejunum in adult coeliac disease and dermatitis herpetiformis following the reintroduction of dietary gluten. Gut 1975 Sep; 16(9): 683-8.