10 Facts About Intestinal Villi And Steps To Improve Villi Health For Individuals With Celiac Disease or Gluten Intolerance
In many individuals with Celiac Disease (CD), the small intestinal villi, responsible for absorbing nutrients, becomes damaged, creating a flattened mucosal surface (villous flattening). Autoimmune reactions to ingested gluten cross-react with intestinal villi and create this damage. The resulting malabsorption, possible development of allergies, and opportunistic intestinal infections may further complicate villi health. In this post, 10 facts about intestinal villi and steps you may take to improve villi health will be discussed. Links to pictures and a short video will be provided at the end of the post.
10 Facts
1. Small intestinal villi are finger-like projections that are each approximately 1mm in length. Millions of villi cover the circular folds of the small intestine. These small intestinal folds are valuable because the folds increase the intestinal surface area that is available to interact with and absorb nutrients. As well, smooth muscle within each villus help it to lengthen and shorten which allows the villi to inter mix with the nutrients in the intestinal lumen for optimum absorption. Enzymes on the villi’s surface assist with digestion (1,17,18).
2. The outer layer of each villus consist of columnar shaped epithelial cells that have absorptive abilities. Nutrients are absorbed through these epithelial cells into the core of each villi and enter into the bloodstream through the blood capillaries within each villus. As well the lacteal, a lymphatic capillary within the villus, absorbs nutrients (dietary fats) for distribution to the body (1,2,5,16-18).
3. Microvilli are are tiny projections located on the outer absorptive epithelial cells of the villi and are often referred to as the brush border. The microvilli assist with absorption and the microvillis plasma membranes excrete digestive enzymes (mainly for protein and carbohydrate digestion) (1,2,5,16-18).
4. Dispersed intermittently among the absorptive epithelial cells are are another type of epithelial cell called goblet cells. These cells secrete a lubricating mucous. Also interspersed in among the absorptive epithelial cells of the villi are enteroendocrine cells (another type of epithelial cell) that belong to the enteric endocrine system and these cells produce enterogastrones (hormones) in response to the current food particles in the intestinal lumenal environment. The villus epithelium, including absorptive columnar, goblet, and enteroendocrine cells renews itself every 3-6 days. The villi cells are shed at the tip of each villus (2,5,16-18).
5. Autoimmune damage makes the intestinal villi become dysfunctional. The absorptive cells of the damaged villi become cuboidal, sometimes squamoid, when the absorptive cells should be columnar. The cytoplasm in the absorptive cells becomes more basophillic and the nuclei’s basal polarity is absent. The villi become flat and dysfunctional. The crypt (area at base of each villi) become elongated resulting in crypt hyperplasia. The affected small intestine’s lamina propria cellularity is increased resulting in an infiltration of lymphocytes. Cytologically abnormal surface cells are present. This is a problem since the intestinal villi are responsible for absorbing the nutrients required to maintain a functional body (2,5,13,14,16).
6. Autoimmune damage to the villi (villus flattening), in CD, can lead to malabsorption of nutrients. Once diagnosed, accidental ingestion of gluten or related prolamines can lead to ongoing villi damage and malabsorption of nutrients. The extent of malabsorption is dependent on the total length of the small intestine affected. Typically, proximal small bowel damage is more severe and it tends to diminish distally. Nutrient deficiencies can result in a variety of multisystem symptoms that are described in my 12 part series about celiac and gluten intolerance symptoms (1,5,14,16).
7. Adverse reactions to various food antigens in the small intestine can also lead to villus flattening. In CD, gluten intolerance or sensitivity, reactions to other food antigens (in addition to gluten) is a risk. Increased expression of zonulin (a human protein) in the intestinal tissues increases permeability allowing macromolecules (ex. food antigens, bacterial, and viral particles) exposure to the immune system. The immune systems exposure to gluten and the subsequent autoimmune reaction is thought to be responsible for the intestinal and other systemic damage seen in Celiac Disease. Unfortunately, the increased bowel permeability can also increase the risk of developing food allergies, intolerances, or sensitivities. Identification of food allergies is important to help preserve the integrity of the intestinal villi. Reactions to food antigens may be responsible for continuing gastrointestinal symptoms even when you are maintaining a strict gluten-free diet (3,15,25,27,19-22).
8. There are bacteria, viruses, and parasites that may affect intestinal villi health, possibly leading to villous flattening. As well, intestinal lymphoma, certain medications, and immunodeficiency syndromes may affect villi health. Individuals with undiagnosed CD are at a higher risk for intestinal infections, lymphoma, and the use of medications which may be ordered to treat the many multisystem symptoms of undiagnosed CD (23,28).
9. Preservation of the villi epithelial cell’s function and integrity is dependent on the availability of luminal and bloodstream sources of nutrients. The villi require nutrients to remain viable and functional. A diet that is deficient in nutrients or the presence of dysfunctional villi leading to malabsorption (due to autoimmune damage) can decrease the availability of nutrients for villi health. This may lead to abnormal growth, division, and differentiation of villi cells possibly adding to the dysfunctional flattened villi (12-14,6-9,12,24).
For example, in animal studies, prolonged vitamin A deficiency in rats lead to decreased height of the intestinal villi (10), decreased cell division and differentiation were noted, and reduced goblet cells were found in the villus (10,11). Another animal study described how vitamin A deficiency in mice combined with a rotavirus infection caused more inflammation and damage to the villus tips (12).
A few human studies have shown that vitamin A supplementation can help to lesson diarrhea episodes with intestinal illnesses in impoverished countries where vitamin A intake is often inadequate (6-9). You can imagine how a vitamin A deficiency, often present in undiagnosed CD, could add to the autoimmune damage, increase malabsorption due to the negative effect on the villi, and increase the risk of intestinal infections which may further hinder the villi. Vitamin A deficiency is just one example, multiple nutrient deficiencies, often present in CD, could further decrease intestinal health.
10. Dysfunctional villi can lead to a variety of gastrointestinal symptoms. Some of the symptoms occur as a result of malabsorbed nutrients remaining in the intestine and increasing the osmotic load. Others are a result of a nutrient deficiency. Some symptoms can include diarrhea, flatulence, abdominal cramping, constipation, occult blood, steatorrhea, bloating burping, vomiting, and infections. See my Gastrointestinal symptoms post for more detail. As mentioned above, the resulting nutrient deficiencies can cause many other multisystem symptoms that are discussed in the 12 part series about symptoms.
Steps To Improve Villi Health
You can see how intestinal autoimmune damage to villi in CD/gluten intolerance, combined with the dysfunctional effects of nutrient deficiencies, certain medications, infections, and food intolerance or allergic reactions can collectively or individually decrease the function and integrity of small intestinal villi. There are many steps I believe can help improve intestinal villi health.
1. Consume a nutrient rich diet. This will help supply all the required nutrients for intestinal villi health. Consult a Registered Dietician to ensure your diet is complete.
2. Ask your MD and your dietician about a nutrient supplement.
3. Consume a strict gluten-free diet. Re-check ingredient lists on the foods/vitamins/supplements/medications you consume to ensure that all are gluten-free. Products that were once gluten-free may not be now due to a change in the ingredients. It’s worth viewing the label each time you buy a product. Also, check with companies to ensure that there is no cross contamination at their company due to packaging gluten and non-gluten foods on the same machine. It can be time consuming, but well worth the effort. Ask your MD/Gastroenterologist to do a Celiac Screen to see if you still have circulating antibodies. This can help you to see if you are still exposed to gluten.
4. If symptomatic, talk to your doctor about stool tests for parasites, fungal and bacterial infections. An overstressed intestinal immune system, maladaptive intestinal environment, and damaged mucosa may predispose individuals to develop bacterial or fungal bowel infections or provide an environment for parasites to thrive.
5. Upper endoscopy with biopsies can be used to assess villi health when diagnosed with CD and for follow-up.
6. Ensure adequate hydration is maintained. All human cells, including intestinal villi cells, require water for hydration. Usually, 8-10 glasses of fluids should be consumed every day. However, the recommended fluid intake can depend on your current hydration status and your health history. For example, an individual with a cardiac or kidney medical history may have fluid restrictions. Check with your MD.
7. Take precautions to avoid infections. Wash your hands, keep healthy, and avoid contact with others who have infections.
8. Check for other food intolerances/sensitivities or allergies. Ask about a referral to an allergist for blood tests and other allergy tests.
9. Consult your doctor about an effective probiotic. I take probiotics bi-annually (and after antibiotics) to help improve my intestinal health. Two interesting articles about probiotics, “Probiotic Modulation of Immune Response in Gluten Sensitivity” and “Probiotics and Their Benefit to Your Health” can outline the benefits.
With probiotics, there are a few possible concerns to consider. Christina Tennyson (MD), from the Celiac Disease Center in Chicago, mentioned that she is not sure about recommending probiotics yet. Probiotics might help to inhibit pathogens and modulate the immune system. However, there are many unanswered questions. With Celiac disease, what are the best and safest strains to use? Is there a possibility that a Celiac’s immune system may respond to probiotics differently? A 2008 study, “Antigenic Proteins Of Lactobacillus Acidophilus That Are Recognised By Serum IgG Antibodies In Children With Type 1 Diabetes And Coeliac Disease”, highlights this possibility. As with any food, gluten contamination leading to an immune reaction is also a concern? Overall, is there enough research to know how probiotics will affect those with celiac disease? I do take probiotics and I have not had a reaction that I’m aware of. However, as we know with silent Celiac Disease, pathological changes can be occurring within the body without any obvious symptoms (29,30). If you are interested in consuming probiotics, I recommend that you talk to your medical doctor to discuss the pros and cons before making any changes.
10. Review all medications with your MD and a Pharmacist. Ask if any affect the intestinal villi.
I eat a nutrient rich diet, take cod liver oil (contains vitamin A, D, & omega#3) daily, frequently eat hemp seed (nutrient rich), and take probiotics to help improve my intestinal health. I believe that these steps, along with the 10 listed above have helped me to increase my intestinal villi health.
Links To Pictures Of Intestinal Villi And A Video
Pictures of villi- http://cellpics.cimr.cam.ac.uk/villi.html
Stages of intestinal damage in CD http://en.wikipedia.org/wiki/File:Coeliac_Disease.png
Simplified intestinal villi picture http://medical-dictionary.thefreedictionary.com/villus
Small Intestinal villi http://en.wikipedia.org/wiki/File:Gray1061.png
Transverse section of a villus to show inner lacteal http://en.wikipedia.org/wiki/File:Gray1060.png
Diagram showing villus, crypt, and microvillus http://en.wikipedia.org/wiki/File:Normal_Villus_Illustration.png
Microvilli in the duodenum http://en.wikipedia.org/wiki/File:Microvilli-Duodenum.JPG
Short video that includes small intestinal villi http://www.encyclopedia.com/video/yOL7eOkBgXc-microscopic-anatomy-of-intestinal-villi.aspx
Note: USE CAUTION WITH SUPPLEMENTS. Toxicities can occur with over supplementation and this can lead to permanent damage. Consult your MD, Registered Dietician, or other medical specialists involved in your care to determine which nutrients should be supplemented and to identify appropriate dosages for you. Review your symptoms and everything in this post with a Medical Doctor and your specialists before you make any changes. Your MD knows your medical history and the treatments that are appropriate for you.
References
1. Green PHR, Jones, R. Celiac Disease A Hidden Epidemic. Collins, Harper Collins Publishers, 2006 http://tinyurl.com/ljeqjc
2. Marieb Elaine. Human Anatomy And Physiology.The Benjamin/Cummings Publishing Company, Inc.,1992.
3. Fasano A, Not T, Wang W, Uzzau S, Berti I, Tommasini A, Goldblum SE. Zonulin, a newly discovered modulator of intestinal permeability, and it’s expression in coeliac disease. Lancet, 2000 Apr 29;355(9214):1518-9
4. Marsh, Michael N.; Miller, Victor. Studies of Intestinal Lymphoid Tissue. VIII. Use of Epithelial Lymphocyte Mitotic Indices in Differentiating Untreated Celiac Sprue Mucosa from Other Childhood Enteropathies. Journal of Pediatric Gastroenterology and Nutrition:
5. Feldman Mark, MD, Friedman Lawrence S, MD, Sleisenger, Marvin H, MD, Gastrointestinal and Liver Disease Pathophysiology/Diagnosis/Management 7th Edition, Volume11, 2002,Saunders
6. Ghana VAST Study Team. Vitamin A Supplementaion in Northern Ghana: Effects on Clinic Attendances, hospital admissions, and child mortality. Lancet 1993;342:7-12.
7. Hossain S, Biswas R, Kabir I, et el. Single Dose Vitamin A Treatment In Acute Shigellosis In Bangladesh Children: Randomized Double Blind Controlled Trial. BMJ 1998;316:422-6.
8. Barreto M, Santos L,Assis A, et el. Effect of Vitamin A Supplementaion On Diarrhea and Acute Lower Respiratory Tract Infections In Young Children In Brazil. Lancet 1994;344:228-31.
9. Bhandari N, Bhan M, Sazawal S. Impact of Massive Dose of Vitamin A Given to Preschool Children With Acute Diarrhea On Subsequent Respiratory and Diarrhoeal Morbidity. BMJ 1994;309:1404-7.
10. Warden RA, Strazzari MJ, Dunkley PR, O’Loughlin EV. Vitamin A Deficient Rats Have Only Mild Changes In Jejunal structure and Function. J Nutr 1996;126:1817-26.
11. Rojanapo W, Lamb AJ, Olsen JA. The Prevalence, Metabolism And Migration of Goblet Cells in Rat Intestine Following The Induction of Rapid, Synchronous Vitamin A Deficiency. J Nutr 1980;110:178-88.
12. Ahmed F, Jones DB, Jackson AA. The Interaction of Vitamin A Deficiency and Rotavirus infection In the Mouse. Br J Nutr 1990;63:363-73.
13. Gibney MJ, Vorster HH, Kok FJ. Introduction to Human Nutrition. Blackwell Publishing 2002.
14. Gibney MJ, Marinos E, Olle L, Dowsett J. Clinical Nutrition. Blackwell Publishing 2005.
15. Drago S, El Asmar R, Di Pierro M, Grazia Clemente M, Tripathi A, Sapone A, Thakar M, Iacono G, Carroccio A, D’Agate C, Not T, Zampini L, Catassi C, Fasano A. Gliadin, zonulin and gut permeability: Effects on celiac and non-celiac intestinal mucosa and intestinal cell lines. Scand J Gastroenterol. 2006 Apr;41(4):408-19.
16. Friedman SL, McQuaid KR,Grendall JH. Current Diagnosis and Treatment in Gastroenterology. Lange Medical Books/McGraw-Hill. 2nd Edition 2003.
17. Radivoj V. Krstic. Human Microscopic Anatomy: An Atlas For Students Of Mediicine And Biology. Springer; 1st ed. 1991. Corr. 3rd printing edition (Mar 18 2004).
18. Helga Fritsch and Wolfgang Kuehnel. Color Atlas of Human Anatomy: internal organs v. 2 Thieme Publishing Group; 5th Revised edition edition (Nov 21 2007).
19. Arnaldo Cantani. Pediatric Allergy, Asthma and Immunology. Springer; 1 edition (Feb 6 2008).
20. SCOTT H. SICHERER, M.D. Manifestations Of Food Allergies: Evaluation And management. American Family Physician, 1999.
21. Author: Professor Cassim Motala, South Africa Web Editor: Professor Richard Lockey, USA. Food Allergy, 2004. http://www.worldallergy.org/professional/allergic_diseases_center/foodallergy/
22. D. D. Metcalfe, Hugh Sampson, and Ronald Simon. Food Allergy: Adverse reactions to food and food additives. Wiley-Blackwell; 3 edition (Jun 16 2003)
23. Yezid Gutierrez. Diagnostic Pathology of Parasitic Infections With Clinical Correlations. Oxford University Press; Second Edition edition (Dec 15 1999).
24. Barrett KE. Gastrointestinal Physiology. Lange Medical Books/McGraw-Hill 2006.
25. University of Maryland Medical Center. Dr. Alessio Fasano MD. Researchers Find Increased Zonulin levels Among Celiac Disease Patients, Public Release 28-Apr 2000.
26. Tursi A,Brandimarte G, Giorgetti G. High Prevalence of Small Intestinal Bacterial Overgrowth in Celiac Patients With Persistance of Gastrointestinal Symptoms After Gluten Withdrawl. Am J Gastroenterol 98(4):839-43
27. Alessio Fasano, M.D. Physiological, Pathological, and Therapeutic Implications of Zonulin-Mediated Intestinal Barrier Modulation. American Journal of Pathology, 2008;173:1243-1252.
28. Dr. Scott Lewey. Celiac Disease Biopsy Explained: Part I Villous Atrophy. http://ezinearticles.com/?Celiac-Disease-Biopsy-Explained:-Part-I-Villous-Atrophy&id=315570
29. Anna-Liisa Prangli, Meeme Utt, Ija Talja, Epp Sepp, Marika
Mikelsaar, Tarvo Rajasalu, Oivi Uibo, Vallo Tillmann, Raivo Uibo.
Antigenic Proteins Of Lactobacillus Acidophilus That Are Recognised By
Serum IgG antibodies In Children With Type 1 Diabetes And Celiac
Disease. Pediatr Allergy Immunol. 2009 Jul 2.
http://www.ncbi.nlm.nih.gov/pubmed/19573144
30. Dr. Christina Tennyson. The Celiac Disease Centre’s Channel. Videos
Part 1: http://www.youtube.com/user/CeliacDiseaseCenter#p/c/E4747F2C9D008E6D/9/bL9RJhZjuyg
Part 2: http://www.youtube.com/user/CeliacDiseaseCenter#p/c/E4747F2C9D008E6D/10/cQmYYwMpeNc
Part 3: http://www.youtube.com/user/CeliacDiseaseCenter#p/c/E4747F2C9D008E6D/11/bhkzesfqh_k
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Thank you for posting this information! I just discovered your blog – it’s great!