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Lactose Intolerance

Lactose IntoleranceWhat Is Lactose Intolerance?

Lactose intolerance is a well known symptom of carbohydrate malabsorption characterized by inability to properly digest lactose, the sugar in milk, due to low lactase digesting activity in the small intestine.

Lactase is an enzyme produced by specialized cells in the tips of villi within the brush border of the small intestinal lining that digests lactose.

Lactose is a disaccharide, or double sugar, made up of a molecule of glucose and a molecule of galactose (simple sugars). Lactose cannot be absorbed as is into the body unless it is broken down by lactase into glucose and galactose.

Q: How does lactose cause diarrhea?

A: If lactose is not broken down, undigested lactose moves into the colon where it acts osmotically to draw water from the walls of the colon into the lumen, which causes diarrhea by the unnatural amount of water. How much water? Can be 2 liters! Meanwhile, the normal population of colonic bacteria ferment the undigested lactose, generating short-chain fatty acids and hydrogen gas, resulting in bloating pain and flatulence.

Testing for intolerance is based on the action of lactose to increase intestinal permeability.1 Positive response to a breath hydrogen test (BHT), involving 1 – 3 hours of time post ingestion of lactose test dose, signifies malabsorption in the small intestine and fermentation in the colon. If BHT is positive before 60 minutes, the result implies bacteria is abnormally present in the small intestine, causing fermentation there.

Endoscopy is used to measure activity of lactase in a tissue sample.

Treatment is avoidance of milk and dairy products that contain lactose. Nevertheless, milk treated with lactase enzyme can be safely consumed. Fermented milk products like yogurt or kefir are safe because the lactose has been digested by organisms. If there is also a problem with milk protein, then no milk is acceptable that comes from the cow or animal that is causing the allergy.

What Is Lactose Intolerance In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩]

Anorexia or Loss of Appetite

anorexia nervosa celiac disease gluten symptomWhat Is Anorexia?

Anorexia or loss of appetite is a reduced desire to eat which can cause unintentional weight loss.

Anorexia is a feature of many disorders caused by malutrition such as celiac disease and aging or gastrointestinal problems such as chronic gastroenteritis, and dysgeusia (loss of taste).

Q: Are there other conditions that cause anorexia?

A: Other underlying problem include medication side effects, infection, chronic pain, depression, grief, dehydration, hormonal dysfunction such as thyroid disease, primary hyperparathyroidism, or Addison’s disease, autoimmune mechanisms such as sarcoidosis,  and cancer growth.

What Is Anorexia In Celiac Disease and/or Gluten Sensitivity?

Maltose Intolerance

Fermentation of Grain by Yeast Releases Carbon Dioxide Which rises the Dough. Courtesy Johnson Mathey Catalyst
Bread is a Major Source of Maltose. Courtesy Johnson Mathey Catalyst

What Is Maltose Intolerance?

Maltose intolerance is an enzymopathy (enzyme failure) characterized by inability of the gut to properly break down maltose sugar molecules in food due to low maltase enzyme activity of the small intestinal lining.

Q: What is maltose and maltase?

A: Maltose is a double sugar made up of two molecules of glucose and is derived from starch. Maltase is the enzyme required to digest or release glucose from maltose. Maltase is produced in the microscopic brush border (microvilli) at the base of villi.

Here’s what happens when maltose is not digested:

  • Undigested maltose cannot be absorbed into the body but remains inside the small intestine where it acts osmotically to draw an unnatural amount of water from the body into the intestine which produces diarrhea.
  • Additionally, normal gut bacteria ferment the abnormal abundance of unabsorbed maltose, thereby generating an abundance of short-chain fatty acids and hydrogen gas which result in bloating and pain.1
  • Positive response to a breath hydrogen test (BHT), involving 1 – 3 hours of time post ingestion of maltose test dose, signifies malabsorption in the small intestine and fermentation in the colon. If BHT is positive before 60 minutes, the result implies bacteria is abnormally present in the small intestine, causing fermentation there.

What Is Maltose Intolerance In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Kathleen Mahan, Sylvia Escott-Stump. 2000. W.B. Saunders Company. [↩]

Aphthous Ulcers (Canker Sores) 

Aphthous_ulcer[1]What Are Aphthous Ulcers?

Aphthous ulcers, also called canker sores, are a chronic disorder of soft mouth tissue characterized by small, painful purpuric, papular, or erosive lesions that are often surrounded by erythematous (red) margins.1

Q: What soft mouth tissues develop canker sores?

A: Canker sores can erupt on the mucosal surface of the inside lip, sides of mouth, under the tongue and along the side of the tongue. When they are forming, the area swells into a papule, or small bump. Later, the surface erodes and a crater forms with firm pus.

What Are Aphthous Ulcers In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Lahteenoja H, Toivanen A, Viander M, Maki M, Irjala K, Raiha I, Syrjanen S. Oral mucosal changes in coeliac patients on a gluten-free diet. European Journal of Oral Sciences. Oct 1998;106(5):899,8p. [↩]

Cheilosis (Cracks in corners of mouth)

cheilosisWhat Is Cheilosis?

Cheilosis is a painful feature of nutritional deficiencies, especially riboflavin and/or pyridoxine deficiency, and less frequently, from vitamin B12, folic acid, and iron. It is characterized by redness of the lips with cracking and weeping in the corner of the mouth.

Q: What is the consequence of weeping at the corners of the mouth?

A: The open sores that develop at the corners of the mouth invite infection by candida albicans, a yeast organism, and less commonly by bacteria normally present on the skin such as staphylococcus aureus.

These sores make opening the mouth very painful and so restrict eating, talking, socializing, and dental care.

What Is Cheilosis In Celiac Disease and/or Gluten Sensitivity?

Bleeding / Swollen Gums

Vitamin C Deficiency: Clean Teeth with Swollen Gums.
Vitamin C Deficiency: Swollen Gums.

What Are Bleeding / Swollen Gums?

Bleeding and/or swollen gums is  an inflammatory disorder characterized by changes in gum integrity that may result in tooth loss.

Sponginess of the gum (swelling) indicates inflammation, called gingivitis. 

Q: What causes gingivitis?

A: Gingivitis that is caused by inadequate dental hygiene shows as pockets of swollen gum between or along the base of teeth where sticky plaque was allowed to build up. Plaque holds bacteria that inflames the gums where it occurs.

Gingivitis that is caused by vitamin C deficiency, pregnancy, certain drugs such as the anti-epileptic drug phenytoin, and leukemia affects the whole gum irrespective of mouth care.

What Are Bleeding / Swollen Gums In Celiac Disease and/or Gluten Sensitivity?

Oral Mucosal Lesions, Chronic (Mouth Soreness)

Canker Sore Inside Mouth. Notice The White Spot on This Person's Nail Showing Zinc Deficiency.
Inflammation/Sore Inside Mouth. Notice White Spot on Fingernail Nail Showing Zinc Deficiency.

What Are Chronic Oral Mucosal Lesions?

Chronic lesions of the oral mucosa are disorders of the mouth that are characterized by soreness and sores of the soft mucosal lining of the mouth.

What Are Chronic Oral Mucosal Lesions In Celiac Disease and/or Gluten Sensitivity?

Hypophosphatemia (Low Phosphate Blood Level)

Testing Thigh Strength. Courtesy Charlie Goldberg, M.D., UCSD School of Medicine
Testing Thigh Strength. Courtesy Charlie Goldberg, M.D., UCSD School of Medicine

What Is Hypophosphatemia?

Hypophosphatemia means the level of phosphates in the bloodstream is too low to meet metabolic needs of the body for this mineral.

Q: How important is phosphorus in metabolism?

A: Phosphorus is crucial to  life, being present in every cell of the body and constitutes 45% of skeletal bone weight along with 40% calcium needed to support the body as a framework.

A low blood phosphate level is characterized by alterations in blood acid-alkaline balance and serious neuromuscular, hematologic, renal, skeletal, and dental abnormalities.

Symptoms result primarily from decreased production of adenosine triphosphate (ATP), the main energy source in cells, and phosphocreatine, a secondary energy source for muscle contraction.

  • Acute phosphorus deficiency may precipitate rhabdomyolysis which is destruction of muscle.
  • Nervous system dysfunction is observed in severe hypophosphatemia.
  • Chronic phosphorus deficiency causes proximal myopathy (upper arms and thighs).1
  • Severe phosphorus deficiency has widespread and ultimately fatal consequences.

What Is Hypophosphatemia In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Takeda E, Ikeda S, Nakahashi O. Lack of phosphorus intake and nutrition. Clin Calcium. 2012 Oct;22(10):1487-91. [↩]

Macroamylasemia

Depiction of pancreatic amylase molecule.
Depiction of pancreatic amylase molecule.

What Is Macroamylasemia?

Macroamylasemia is an acquired enzyme disorder that causes elevated levels of the enzyme amylase (hyperamylasaemia) in the bloodstream. It is characterized by altered amylase molecules that have become abnormally bound with plasma proteins in the bloodstream, commonly IgG (immunoglobulin G) and/or IgA (immunoglobulin A).

The resulting molecule is too large to be properly filtered by the kidneys and excreted in the urine as would be normal unbound amylase, causing sustained elevation of amylase levels in the plasma.

With normal kidney function, a hyperamylasemia without an increase in urine amylase suggests the diagnosis of macroamylasemia, and is confirmed by identifying the macromolecular components.1

Amylase is a an enzyme produced by the pancreas and the parotid glands to digest starch in the diet. Comparatively small amounts are also produced by other organs.

Q: How do the pancreas and parotid glands deliver their amylase for digestion of starch?

A: The parotid glands deliver their amylase into the mouth. The action of amylase in the mouth starts the breakdown of starch as it is chewed and moistened with saliva.

After the starchy food is liquified in the stomach, the mass empties into the duodenum. Here pancreatic amylase is delivered through the common bile duct into the duodenum where it turns starch into maltose sugar. The next step to final digestion of starch is carried out by enzymes in the small intestinal lining that split maltose into its component sugar which is glucose.

Glucose is a simple sugar that can be absorbed into the bloodstream for use in the body. Humans cannot live without adequate glucose.

Distinquishing macroamylasemia from hyperamylasemia due to pancreatic disease is necessary to prevent needless treatment and investigation for pancreatitis.2

What Is Macroamylasemia In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. Torrent Vernetta A, Segarra Cantón O, Soler Palacín P, Segura Cardona RM, Infante Pina D. Macroamylasaemia in paediatrics. An Pediatr (Barc). 2008 Nov;69(5):439-41. [↩]
  2. Isham CA, Ridgeway NA, Hedrick R, Cate JC 4th. Screening for macroamylase in a community hospital. Clin Chem. 1984 May;30(5):741-2. [↩]

Macrolipasemia

Lipase Enzyme. Courtesy johnsonmatthey.
Lipase Enzyme. Courtesy Johnson Matthey Catalysts.

What Is Macrolipasemia?

Macrolipasemia is a rare enzyme disorder characterized by altered molecules of lipase, a pancreatic enzyme needed to digest fats, that are abnormally bound with serum antibody proteins. These antibodies are commonly immunoglobulin G (IgG) and/or less likely immunoglobulin A (IgA).

Q: What happens when lipase is bound to immunoglobulins (IgA and/or IgG)?

A: The resulting molecule is too large to be filtered by the kidneys and excreted in the urine, consequently these abnormal molecules build up in the plasma causing sustained elevation of lipase levels called macrolipasemia.

Macrolipasemia occurs with or without macroamylasemia, which is the binding of immunoglobulin A and/or G to amylase, a pancreatic enzyme needed to digest starches.1

What Is Macrolipasemia In Celiac Disease and/or Gluten Sensitivity?

Sources:
  1. La Villa G, Pantaleo P, Tarquini R, Cirami L, Perfetto F, Mancuso F, Laffi G. Multiple immune disorders in unrecognized celiac disease: a case report. World J Gastroenterol. 2003;9(6):1377-1380, Available at: http://www.wjgnet.com/1007-9327/9/1377.asp. Accessed Jan 3, 2005. [↩]