Types of Celiac Disease

1. Typical celiac disease

Typical celiac disease with gastrointestinal symptoms — also called the classical type — was once the only form described in medical textbooks, and so the only one clinicians associated with celiac disease. It was considered a "wasting" condition of early childhood (six to twenty-four months). These cases are usually diagnosed easily within the first few years of life, and the biopsy shows sub-total villous atrophy.

The typical celiac child displays:

• Persistent diarrhoea
• Large belly (abdominal distension)
• Anorexia
• Failure to thrive / weight loss
• Abdominal pain
• Constipation
• Vomiting
• Irritability and sleep disturbances

According to current estimates, for each symptomatic case there are approximately six silent or asymptomatic ones.

2. Atypical celiac disease

Atypical celiac disease, without gastrointestinal symptoms, is now considered more common than the typical kind. It combines a few typical symptoms with atypical ones and is commonly seen in adults and older people. Atypical cases may present "extra-gastrointestinal" symptoms such as:

• Iron-deficiency anaemia that doesn't respond to oral iron
• Soft bones (osteopenia, the precursor to osteoporosis) and brittle bones (osteoporosis)
• Short stature and delayed puberty
• Lethargy and joint pains
• Infertility
• Dermatitis herpetiformis
• Dental enamel defects in permanent teeth
• Hepatitis and arthritis
• Epilepsy with occipital calcifications

In atypical celiac disease the inflammation may involve only the upper gastrointestinal tract, so there may be just one affected nutrient — iron or calcium, for example — causing anaemia, osteopenia or osteoporosis. Gut symptoms are usually mild but persistent and are often misdiagnosed as irritable bowel syndrome.

3. Silent celiac disease

Silent celiac disease shows damaged mucosa and positive blood tests but very mild or no gut symptoms. It is sometimes discovered through blood screening of people without symptoms — such as first-degree relatives, or people with type 1 diabetes or Down's syndrome.

People with silent celiac disease often develop symptoms later in life, usually as associated conditions: dermatitis herpetiformis, peripheral neuropathy, depression, infertility or small-intestine cancer (adenocarcinoma). They may also have fatigue or dental enamel defects, with or without poor growth in height.

4. Potential celiac disease

Potential celiac disease shows minimal change: the villi look normal but there are subtle abnormalities such as more intraepithelial lymphocytes (IEL). These patients test positive for anti-endomysial antibodies (EMA) and may have gut symptoms. Over time, they may develop a flat mucosa.

5. Latent celiac disease

Latent celiac disease has no symptoms and a normal mucosa. Patients may have positive blood tests and negative biopsies — or negative blood tests that later turn positive months or years on.

It is often seen in first-degree relatives of people with celiac disease, or in people with other autoimmune diseases such as diabetes, thyroiditis and rheumatoid arthritis. A gluten-free diet should not be started until test results are clear, as it can mask the condition or lead to a misdiagnosis.

6. Transient gluten intolerance

A rare condition seen in children under two. At diagnosis these children have gut symptoms with severe small-intestine damage, but symptoms disappear completely on a gluten-free diet and the gut lining returns to normal. They need regular long-term follow-up with repeated biopsies, because celiac disease can relapse later.

7. Dermatitis herpetiformis

Dermatitis herpetiformis (DH) is a chronic inflammatory skin disease with itchy, red, blistering rashes — usually on the elbows, buttocks and knees, and sometimes the shoulder blades, lower spine, face and scalp. The rashes tend to appear symmetrically on both sides of the body. It is usually diagnosed in young or middle-aged adults.

Nearly 90 per cent of people with DH have no gut symptoms, yet about 75 per cent show villous atrophy. Unlike celiac disease (more common in women, 1:1.5), DH is more common in men (1.5:1) and is rare in children.

DH is strongly associated with celiac disease, and some studies suggest both are caused by the same genes. It is treated the same way: a lifelong gluten-free diet. Moderate skin improvement can take six months, and full control by diet alone two years or more. Drugs such as dapsone give rapid interim relief from the rash and itching, but they do nothing for the intestine — so the gluten-free diet is essential.

8. Wheat sensitivity in children: 25 tips for parents

1. Your attitude matters. Don't transfer your anxiety to your child — stay calm.
2. A positive approach helps the whole family change its food patterns.
3. Children under five adapt more easily.
4. Families must be empowered with knowledge.
5. Make food tasty and interesting.
6. Support groups help a great deal.
7. Inform teachers, school authorities and your child's friends. Children may be teased — be prepared, and prepare your child.
8. School meals and snacks need to be modified, or arrange permission to send packed food from home.
9. In joint families, inform all family members and household staff.
10. Keep alternatives to favourite foods available.
11. Focus on healthy eating. Discourage commercially processed foods.
12. Avoid introducing wheat, barley, oats and rye until your child is at least six months old — ideally one year. Avoid cow's milk before one year.
13. Play dough contains wheat flour. Supervise play, stop children putting it in their mouths, and insist on thorough hand-washing afterwards.
14. Anticipate situations with a risk of contamination and take precautions.
15. Young children should carry a celiac wristband or allergy alert card.
16. Accidental gluten at a party can cause panic. Simply make sure it doesn't happen again.
17. If you're hosting a party, serve gluten-free food for everyone — it's no compromise, and just as delicious.
18. Watch for emotional difficulties if your child's behaviour changes. Don't hesitate to seek professional help.
19. Address associated conditions such as type 1 diabetes and thyroid disorders.
20. Young teenagers can be rebellious. They need special care and understanding — seek help if needed.
21. Keep talking with your child and keep educating them.
22. Encourage them to take charge as they grow.
23. Teach them to read labels.
24. Involve them in choosing and preparing food.
25. Seek advice on vaccination schedules with autoimmunity in mind.