Coeliac and Related Conditions

History of the Coeliac Condition

2nd Century A.D.

The physician Aretaeus of Cappodocia wrote the first description of childhood and adult coeliac disease in Greek. His writings survived and were translated into English by Francis Adams for the Sydenham Society in 1856. The chapter on “The Coeliac Diathesis” describes fatty diarrhoea (steatorrhoea) for the first time in European literature and then goes on to give an account of several other features including weight loss, pallor and the way it affects both children and adults. The word ‘coeliac’ comes from the Greek word ‘koiliakos’ and means ‘suffering in the bowels’. In the translation, the chapter on the Cure of Coeliacs describes exactly those persons to be called coeliacs; “If the stomach be irretentive of the food and it pass through undigested and crude, and nothing ascends into the body, we call such persons Coeliacs.”

1888

Samuel Gee, 1839-1911, a British Paediatrician, wrote in St Bartholomew’s Hospital Reports of 1888 under the heading, ‘The Coeliac Affection’ a vivid and accurate description of the clinical state we call Coeliac Disease. A disorder he described as “a kind of chronic indigestion which is met with in persons of all ages”. He noted that because of the wasting, weakness and pallor of the patient, the bowel complaint might easily be overlooked. He went on to declare that regulation of food was important, suggesting that errors in diet might be the cause and concluded, “but if the patient can be cured at all, it must be by means of diet”.

Studies from this time on were predominantly related to the understanding of the Coeliac condition in children, possibly because Coeliac children tend to respond more rapidly and more dramatically to dietary treatment than adult Coeliacs.

1908-1918

Paediatricians in the U.K. during this time noted that fats were better tolerated than carbohydrates in the diet. Stages in the introduction of foods were at this time, the only form of treatment. It might have taken periods of months or even years to trial and complete the treatment as breads, cereals and potatoes were the final foods to be reintroduced to the diet. The treatment therefore was time consuming but did have beneficial results.

The next dietary recommendation was the banana diet, a diet essentially low in carbohydrates except for ripe bananas.

1939-1945

Not until after the Second World War was there a fundamental discovery made relating to the successful treatment of Coeliac children and adults.

1939-1946

A Dutch Paediatrician, Professor Dicke demonstrated how children benefited dramatically when wheat, rye and oat flours were excluded from the diet and replaced with rice and maize flours. This discovery was due to the shortage of wheat grain during the war years in Holland. Dicke found that when these grains became plentiful again the incidence of coeliac disease returned to pre war levels

1954

John W. Paulley, a Physician from Ipswich, U.K. recognised the characteristic abnormality of the lining of the upper part of the bowel. He had been taking samples at operation and whilst this is a clear point at which the abnormality of the small bowel was accepted, mention of abnormality of the villi (the finger-like projections lining the intestine) was referred to in earlier times along with many other statements. The difficulty in these times was that conclusions rested on examination of the lining of the bowel after death and the lining is very rapidly digested and damaged by the contents of the bowel once the protective mechanisms of life are removed. Dr Paulley’s discovery concerning the abnormality of the bowel was confirmed by several other doctors in the U.K., United States and elsewhere to be the most essential single feature on which the diagnosis of coeliac condition could be based.

The most important conclusion was that, when complying with a strictly gluten free diet, the villi in the lining of the patient’s small intestine returned to the normal state after previously being flat.

1956

Dr Margot Shiner working in Hammersmith Hospital in London interpreted the changes in the intestinal lining of coeliac patients.

1957

An American Army Officer, Colonel Crosby, working with an engineer, designed what we now know as the Crosby Capsule, a completely flexible tube which soon became the most widely used biopsy instrument in the world.

1958

Cyrus L. Rubin and co workers demonstrated convincingly that coeliac disease in children and idiopathic or non-tropical sprues in adults were identical diseases with the same clinical pathogen feature.

1960

Physicians specialising in skin care discovered that patients with a particular type of itchy rash called Dermatitis Herpetiformis might also have gluten enteropathy. It was generally accepted that the intestinal villi returned to normal with a gluten free diet, but many investigators did not agree that the skin lesions were caused by gluten in the diet (see section on Dermatitis Herpetiformis).

1960-1980

There has been little significant advancement in understanding why gluten has a destructive effect on the villi lining the small intestine. However, since the study of hereditary material (DNA), found in nuclei of individual cells of the body, molecular biology is now coming to be applied to coeliac disease.

1990

A blood test to measure anti gliadin antibodies in serum by enzyme immunoassay was developed. This blood test while being less obtrusive than the jejunal biopsy still does not exclude the need for biopsy.

1992/3

The use of optic fibre for endoscopy replaced the Crosby Capsule

1995

Australian food labelling laws changed to adopt new gluten free standard of no detectable gluten (ie no wheat starch, malt extract, etc on gluten free diet).

1996

Anti-endomysial antibody test becomes widely available in Australia.

1997

Tissue transglutiminase antibody screening test is introduced in Australia.