Celiac and Crohn’s Disease: Recurrence Of Bowel Symptoms Despite The Maintenance Of A Gluten-Free Diet
The inspiration for this post came from a comment/question on my post “Gastrointestinal Symptoms In Undiagnosed Celiac Disease”. I decided to post my recommendations since many others could be dealing with this or a variation of this problem.
Question: I have been diagnosed with celiac and chrohn’s disease for one and a half years. My doctor put me on a gluten-free diet and it was instant relief; a miracle. However, it’s like my body is going back to the way it was. I don’t believe the diet is working anymore. Can this be possible? I am actually going back to my doctor to get another colon. exam done. I am thinking the diet is helping the celiac, but what about the crohn’s?
Celiac Nurse: There are many conditions that may cause similar symptoms. I’m not sure exactly what your symptoms are, but I will outline some possible causes that may lead to the recurrence of gastrointestinal symptoms. The presence of Crohn’s Disease can definitely complicate the puzzle. I’ll include some recommendations that you can discuss with your MD and Gastroenterologist.
Possible causes can include lactose intolerance, pancreatic insufficiency, bacterial or fungal overgrowth, parasites, accidental gluten consumption, small bowel lymphoma, ulcerative jejunitis, a new food intolerance/allergy, microscopic colitis, refractory sprue, liver or gallbladder dysfunction, side effect of a drug, and vitamin/mineral deficiency or toxicity if taking high supplement doses. The new presence of other autoimmune diseases, such as Sjögren’s Syndrome, Addison’s Disease, or Autoimmune Thyroid Disease may cause similar symptoms (1,2,3,4,5,8). Increased bowel permeability may pre-dispose someone with Crohn’s Disease or Celiac disease to develop additional allergies. The presence of new allergies/intolerances/sensitivities may also lead to the re-occurrence of bowel symptoms (3,4,6,7,8).
Recommendations
1. Upper endoscopy and colonoscopy (with inspection of the stomach, duodenum, jejunum, upper and lower ileum and colon) with biopsies. This will help rule out lymphoma, other cancers, refractory sprue, ulcerative jejunitis, microscopic colitis, or another disease process (1,3,4). There are many possible causes so try to keep that in mind emotionally when you read this first recommendation (avoid focusing on the cancer part).
2. Stool tests for parasites, fungal and bacterial infections (1,4). 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 (12,13). A blood test, CBC with differential, can show how well your immune system is functioning and can be elevated with an infection.
3. 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. Keep in mind that the best test to check Celiac and Crohn’s related mucosal health is a scope with biopsies (1,4).
4. Tests to check pancreatic, liver, and gallbladder function. As discussed in the “Gastrointestinal Symptoms in Undiagnosed Celiac Disease” article, these organs aide in digestion and can be affected in Celiac Disease. Malabsorption can lead to flatulence, diarrhea, and bowel infections (1,5,9,10,11).
5. Testing for lactose intolerance. Lactose is found in dairy products. It is a disaccharide and requires lactase-phlorizin hydrolase (enzyme) produced within the intestines to digest it. Loss of this brush border enzyme results in hypolactasia (low lactase production), and can occur from the intestinal epithelial damage evident in CD. Once the lactose passes undigested into the colon, it is broken down by commensal bacteria. This process produces CO2 and hydrogen which cause abdominal discomfort, bloating, flatulence, and possibly diarrhea. This may be temporary, since lactase production may resume once the bowel has healed or the underlying cause is treated. In others, it is a permanent condition (1,2,5).
6. Blood tests to check for vitamin and mineral deficiencies or toxicities. Also ask about checking drug levels for any medications you are taking. Review side effects with a pharmacist to see if any of the medications you take cause gastrointestinal symptoms. Ask the MD about checking your BUN and creatinine levels to ensure your kidneys are functioning well. Dysfunction may lead to a drug or vitamin toxicity.
7. Consume nutritionally dense foods to help meet your nutritional needs. Avoid processed foods or foods high in processed refined sugar. Eat natural foods, hopefully, without additives if possible. Ensure the fats you consume are healthy (include omega 3). Adequate fat intake is necessary for absorption of vitamin A,D,E, and K. Since you have Crohn’s, you need to ensure you are getting enough B12 either through injections or food/vitamin intake. A periodic blood test can verify that your levels are normal. Overall, with Celiac and Crohn’s Disease you need to ensure an adequate intake of fat and water soluble vitamins, minerals, trace elements, electrolytes, proteins, fats, and carbohydrates (2). Ask your MD/Gastroenterologist about a multivitamin and probiotics. Ask for a referral to a Registered Dietitian (who is knowledgeable about Celiac and Crohn’s disease) to review your nutritional needs. Some find a Paleolithic Diet helpful to settle symptoms, but you need to ensure you are consuming all the nutrients your body requires, especially with 2 autoimmune diseases. Also, with diarrhea or vomiting, ask your MD about checking your electrolyte levels since electrolytes can be lost through both emesis and diarrhea. Your doctor may prescribe an electrolyte replacement drink and medications if you are having frequent vomiting or diarrhea.
8. Ensure adequate hydration is maintained. 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. Remember caffeinated fluids do not do a great job of hydrating you since these fluids promote diuresis and may increase peristalsis leading possibly to more diarrhea. Flushed dry skin, poor skin turgor, dry mouth and lips, coated tongue, low concentrated urine output, decreased level of orientation, irritability, or confusion are some symptoms that may indicate you are getting dehydrated.
9. Ask your specialist/Gastroenterologist about the possible presence of other autoimmune diseases that may cause the symptoms you are having. Some possibilities that may cause bowel symptoms are Graves Disease (hyperthyroidism-diarrhea, weight loss), Hashimoto’s Disease (hypothyroidism-constipation), Sjögren’s Syndrome, Microscopic Colitis, or Addison’s Disease (1,2,4,14).
10. Check for other food intolerances/sensitivities or allergies. Ask about a referral to an allergist for blood tests and other allergy tests. If negative, a core or elimination diet can also help you to figure out the offending foods. Zonulin, a human protein, influences increased bowel permeability found in Celiac Disease and possibly Crohn’s Disease as well. Increased expression of zonulin 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/sensitivities (6,7,8,14).
Exposure to food allergens could potentially have the same effect in the development of other autoimmune diseases, such as Crohn’s Disease (14). I have a close family member with Crohn’s Disease. He has found that processed corn causes a flare up of abdominal discomfort, flatulence, and diarrhea. Corn is often processed with fungus and a bacteria that is used to break it down into different products. Since he can eat corn on the cob, he feels that it is either the bacteria or the fungus that he is reacting to. Aspergillus, a type of fungus that is used can cause skip lesions, therefore he is suspecting that it may be responsible. Processed corn is in about 80-90% of the grocery store foods we eat in developed countries (where Crohn’s is more prevalent). Google “corn allergy” and you will see the wide variety of foods that corn is in. For example, I have surprisingly found that 1%, 2%, and skim milk often has corn oil as a carrier for the fat soluble vitamin D, table salt can be coated with dextrose (dextrose is usually derived from corn) to stabilize the iodine, and also some of the IV fluids with dextrose used at our local hospital contain corn. Key words to look for on ingredient lists can be found at various corn allergy sites on the internet, such as www.corn-free.ca and www.corn-freefood.blogspot.com. Your allergist can probably supply a list for you as well. I found an independent movie called “King Corn” and a book I read called “Omnivores Dilemma” that was very informative about the corn industry. My family member with Crohn’s finds that he is intolerant to almonds and chocolate as well. He lives drug and surgery free. More research is needed to look at the association between diet and Crohn’s Disease.
Two of my children have the same corn sensitivity. They tested negative to a corn allergy at the allergist which leads me to believe they might be intolerant/allergic to an agent used to process corn. They both can eat corn on the cob, but have bowel symptoms and eczema with consumption of processed corn. Food allergies/intolerances/sensitivities can be difficult to identify. Patient detective work will often benefit those affected with a better quality of life.
I hope you found this helpful. Print it out and take it with you to your next appointment. Review my recommendations with your MD/Gastroenterologist before making any changes.
I wish you the best,
Shelly Stuart, RN
References
1. Excellent Book: Green PHR, Jones, R. Celiac Disease A Hidden Epidemic. Collins, Harper Collins Publishers, 2006.
2. Gibney MJ, Marinos E, Olle L, Dowsett J. Clinical Nutrition. Blackwell Publishing 2005.
3. Gislason SJ. Core Diet For Kids. Persona Audiovisual Production, 1989.
4. Feldman Mark, MD, Friedman Lawrence S, MD, Sleisenger, Marvin H, MD, Gastrointestinal and Liver Disease Pathophysiology/Diagnosis/Management 7th Edition, Volume11, 2002,Saunders
5. Barrett KE. Gastrointestinal Physiology. Lange Medical Books/McGraw-Hill 2006.
6. 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.
7. 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.
8. University of Maryland Medical Center. Dr. Alessio Fasano MD. Researchers Find Increased Zonulin levels Among Celiac Disease Patients, Public Release 28-Apr 2000.
9. Rhodes RA, Tai HH, Chey WY. Impairment of Secretin Release in Celiac Sprue. Am J Dig Dis 23:833, 1978.
10. Maton PN, Seldon AC, Fitzpatrick ML, et al. Defective Gallbladder Emptying And Cholecystokinin Release In Celiac Disease. Reversal by Gluten-free Diet. Gastroenterology 88:391, 1985.
11. Vuoristo M, MiettinenTA. The Role Of Fat And Bile Acid Malabsorption in Diarrhoea Of Coeliac Disease. Scand J Gastroenterol 22:289, 1987.
12. 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
13. Bateson-Koch Carolee. How to Permanently Heal Your Allergic Condition Permanently and Naturally. Alive Books 1994.
14. Alessio Fasano, M.D. Physiological, Pathological, and Therapeutic Implications of Zonulin-Mediated Intestinal Barrier Modulation. American Journal of Pathology, 2008;173:1243-1252.
