All About Celiac Disease

Podcast Transcript

Scott Steele: Butts and Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.

Welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Very pleased today to have Dr. Alberto Rubio Tapia who's a staff physician specializing in gastroenterology, hepatology, and nutrition here at Cleveland Clinic's Digestive Disease and Surgery Institute. Alberto, welcome to Butts and Guts.

Alberto Rubio Tapia: Thank you so much.

Scott Steele: So today we're going to talk a little bit about celiac disease, but before we go into that, I always like to start off with all of our guests, to give a little bit of background about yourself. Where you're from, where did you train and how did it come to the point that you're here at the Cleveland Clinic?

Alberto Rubio Tapia: Thank you so much. So I trained in Mexico. I did my medical school in Mexico City. Then I moved to the US and did my fellowship and residency at the Mayo Clinic in Rochester. All my life has been dedicated to the study of celiac disease.

Scott Steele: Well, we're very excited to have you here. And so let's start there. So for our listeners, celiac disease is probably a common term that many people have heard of in various contexts, but they may not know exactly what it is. So give us the overview about celiac disease.

Alberto Rubio Tapia: Celiac disease is a common problem where patients have difficulty with tolerance to wheat, barley, and rye. These foods are characterized by the high content of gluten in those foods. And the patients develop an immune reaction to those food components, and this is characterized by a small bowel disorder, but also multi-systemic symptoms.

Scott Steele: So let's carry on from that. So what type of symptoms occur?

Alberto Rubio Tapia: So most of the time the symptoms could be a gastrointestinal with bloating, Irritable Bowel Syndrome like symptoms, diarrhea, weight loss, but also the patients may develop symptoms that are not related to the rest of intestinal tract like infertility, hepatitis, bone disease, neuropathy, ataxia, migraines, and fatigue.

Scott Steele: That sounds like it's a pretty generic and wide ranging set of symptoms. So if I'm at home as a patient, just listening to you, I'm thinking to myself, oh my God, I've had some of those things at some time, so maybe not some of the more wide ranging ones but so how do you narrow it down and say, this might be celiac disease. How is it diagnosed?

Alberto Rubio Tapia: Yeah, so thank you for that question. That's very important. So celiac disease affects about 1% of the entire population. So we need to maintain a high index of suspicion to make the diagnosis. I think it's very important to test for celiac disease in patients with higher risk conditions such as first degree family members. If the patient has ever been diagnosed with Irritable Bowel Syndrome and has not been tested for celiac disease, that's a very good opportunity to detect the condition. Having unexplained systemic symptoms in the context of the absence of gastrointestinal symptoms is also a good indication for look for celiac disease.

Scott Steele: So what does the patient have to go through to actually get diagnosed with celiac disease?

Alberto Rubio Tapia: So the starting point for establish a diagnosis of celiac disease is a blood test. We are looking for antibodies that are associated with the condition. These antibodies are transglutaminase and the endomysial antibody and the gliadin peptides because the first step for screening for the condition and then if there's a test, came back positive, the next step is to do a small bowel biopsy to confirm the diagnosis.

Scott Steele: So in that case is it a biopsy through a scope? Is it a biopsy that they numb up the skin and take a needle or what does this all involve?

Alberto Rubio Tapia: Yeah, so there is going to be required, is a endoscopy with small bowel biopsies at the time of the procedure.

Scott Steele: What causes celiac disease? You mentioned that this is something, am I born with celiac disease? Is it something I've been exposed to? Am I a somebody who's at risk of this and based on what I'm around that I develop it? Or how does this all come about?

Alberto Rubio Tapia: This is a very good question and very difficult to answer but we know that there is a genetic background for celiac disease. Celiac disease runs in families. There is a specific gene that is associated with celiac disease that is called HLA DQ2 and DQ8. But the environmental factors are less characterized. The requirements for developing celiac disease are the presence of the genes at risk and also the ingestion of gluten in the diet.

Scott Steele: So Alberto, what can a patient expect during a meeting with you or someone on your team to kind of discuss celiac disease, their diagnosis and symptoms?

Alberto Rubio Tapia: When they come to us for the first visit, they should expect world-class care. So we have a dedicated team of dietitians, experts in pathology, gastroenterologists, that we are going to do our best to diagnose the condition, and then offer the treatment and follow-up that they need.

Scott Steele: So would they get their scope that same day or do you just take a history and a physical exam on that first day and then schedule them later? Or is there anything else?

Alberto Rubio Tapia: So most of the time, what happens during the first visit is that we get all the information from the patient. We review with detail the symptoms. We do a physical examination with the review of outside records, we have a definitive diagnosis of celiac disease by the end of the visit. They should expect to be seen by a celiac dietitian the same day. If there's some question about the diagnosis and we need to do more testing, most of the time we do the blood test the same day. And do a skilled endoscopy that is completed within the one or two weeks after doing the initial evaluation.

Scott Steele: Let's move on to treatment now, so what's the best way to treat the disease? Is it just diet manipulation or is there something more? Is there a pill I can take?

Alberto Rubio Tapia: The treatment for celiac disease is a gluten free diet. A gluten free diet is not easy, but with the adequate education, instruction, patients do well on the diet. It's very important to have instruction by a dietitian that knows about the gluten free diet and then we need to check for nutritional deficiencies and correct those deficiencies if they are present. Something that is very important for the treatment of the patient is to have a regular follow up with the physician and also the dietitian to make sure that we continue working with the patient to achieve the goal of being gluten free.

Scott Steele: So you mentioned gluten free and a lot of us have heard that. So I know there's a lot of things out there, but give us some examples of some foods that have gluten in them.

Alberto Rubio Tapia: So the foods that contain gluten are wheat, barley, and rye. Examples from this are cereals, cookies, pizza. But the problem with gluten is that it's present in other food components that are not so clear. So that's why the instruction by a dietitian is relevant for the patients.

Scott Steele: So here on Butts and Guts, we like to play a little game called Truth Or Myth. So let's say, is this a truth or a myth? After I get my diet and my symptoms under control, I can go back to eating gluten.

Alberto Rubio Tapia: That's myth.

Scott Steele: Truth or myth? There are other treatment options besides just changing my diet that can reduce my symptoms.

Alberto Rubio Tapia: That's probably true in some specific situations when the patients have lack of response to the gluten free diet. Sometimes we can try topical steroids to help the patients through the symptoms, but the most relevant treatment is to be strict with a gluten free diet.

Scott Steele: Truth or myth? The amount of gluten that I eat is directly proportional to the symptoms I might have.

Alberto Rubio Tapia: Myth.

Scott Steele: Truth or myth? If I have a family member with celiac disease or if I have one of the genes associated with the disease, I will definitely get the disease.

Alberto Rubio Tapia: Myth.

Scott Steele: Good. So let's just go back to that last one. So let's just say I do have a family member that has celiac disease. Is there a screening test I should get? Is it something that I routinely get screened with? And is it a blood test or what? What do we go do about that situation?

Alberto Rubio Tapia: I think it's a very interesting question. So if the patient family member is asymptomatic, then the initial screening test is a blood test. But if the family member has symptoms, I will suggest a visit with a gastroenterologist to talk about the symptoms because the screening for celiac disease may involve more than a blood test. And the patient may require testing for the genes at risk for celiac disease, or endoscopy with biopsies to diagnose the condition.

Scott Steele: So Alberto, you said something interesting previously about the wide ranging symptoms, even neuropathy and ataxia and all sorts of things that can occur in association with celiac disease. So are these health problems that accompany celiac disease or is that a part of celiac disease, and is this an autoimmune type disorder or what is going on here?

Alberto Rubio Tapia: Yes, celiac disease is an autoimmune disorder that is characterized by the injury to the small bowel, but is in reality a multi-systemic disease. And all these symptoms, may be part of celiac disease or may be associated with the condition because of shared genetic risk.

Scott Steele: So you and your team, world-class care. I've seen it firsthand, but tell me a little bit about what research is being conducted to help find a cure or better treatment strategies for this disease.

Alberto Rubio Tapia: There is a significant interest from patients and from providers to have an alternative to the gluten free diet and there are many clinical trials going on, testing for medications that may be helpful in this situation. Unfortunately, there is no medication available so far. The strategies include vaccines, the use of medications that help digest gluten before the ingestion. And also decrease the absorption of gluten in the gut, trying to help with the immune response that the patients with celiac disease develop after exposure to gluten.

Scott Steele: So now it's time for us to have a couple of quick hitters to get to know you a little bit better. What's your favorite sport?

Alberto Rubio Tapia: I love American football and soccer.

Scott Steele: Now what's your team there? The Browns? You've got to say it.

Alberto Rubio Tapia: Well the Browns, I'm starting liking Browns, but my team is the New York Giants.

Scott Steele: So what's your favorite food?

Alberto Rubio Tapia: I love Mexican food, and Italian food.

Scott Steele: What is the favorite place that you've traveled to?

Alberto Rubio Tapia: I love my country, Mexico.

Scott Steele: And how about the last nonmedical book that you've read?

Alberto Rubio Tapia: So I read a book by Carl Sagan, The Demon-Haunted World.

Scott Steele: Fantastic. And then you live here in Cleveland, you've been at different places. So tell our listeners one thing that you like about living here in Northeast Ohio.

Alberto Rubio Tapia: I really liked the people, they're very welcoming and friendly. So that's the thing that I like most.

Scott Steele: Yeah, one of the great parts of being here. So what's the final take home message for our listeners who are out there listening here and thinking they've got celiac disease or treatment. What do you want to end the thought with them about celiac disease?

Alberto Rubio Tapia: I think my message is if you think that you have celiac disease, you have the opportunity to look for that condition and be tested. There is a significant number of persons with celiac disease that remain undiagnosed without the benefit of the diagnosis and treatment.

Scott Steele: Well that's fantastic. And so for more information on celiac disease, please visit Cleveland Clinic's health library at clevelandclinic.org/health. That's clevelandclinic.org/health, H-E-A-L-T-H. And to speak with a specialist in the Digestive Disease and Surgery Institute, please call (216) 444-7000. That's (216) 444-7000. Alberto, thanks for joining us on Butts and Guts.

Alberto Rubio Tapia: Thank you for having me.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.