Celiac Disease

Topic Overview

What is celiac disease?

Celiac disease is a problem some people have with foods that contain gluten. Gluten is a kind of protein found in foods like bread, crackers, and pasta. With celiac disease, your immune system attacks the gluten and harms your small intestine when you eat these kinds of foods. This makes it hard for your body to absorb nutrients that keep you healthy.

Gluten comes from grains like wheat, barley, and rye. It’s important to get treatment, because celiac disease can lead to iron deficiency anemia and osteoporosis. It can also raise your risk of lymphoma.

Celiac disease can slow growth and weaken bones in children. If it is not treated, your child can get very sick. Call a doctor if your child is losing a lot of weight, has diarrhea, or feels weak and tired for many days for no reason.

What causes celiac disease?

Doctors don't really know what causes the disease. Having certain genes can increase your chance of getting it. You are more likely to have these genes and get celiac disease if a close family member has it. In some people, viruses or infections can also trigger changes in your immune system that can lead to celiac disease.

What are the symptoms?

Symptoms of celiac disease include:

• Gas and bloating.
• Changes in bowel movements.
• Weight loss.
• Feeling very tired.
• Weakness.

These symptoms can be very mild.

Some people vomit after they eat gluten. This is more likely to happen in children than in adults.

How is celiac disease diagnosed?

Your doctor will ask questions about your symptoms and do a physical exam. You may have blood tests to see if you have certain antibodies that could mean you have the disease. To make sure you have celiac disease, you will probably have an endoscopy. In this test, a doctor uses an endoscope—a thin, lighted tube that bends—to look at the inside of your small intestine. During the endoscopy, the doctor may take a small sample of tissue to be tested in a lab. This is called a biopsy.

Often celiac disease is mistaken for another problem such as food intolerance orirritable bowel syndrome. You may be treated for one of these problems first.

After your celiac disease diagnosis, your doctor may do more tests, such as an X-ray, a stool test, or a bone density exam. These will help your doctor find out if you have other problems, such as osteoporosis, that can arise when you have celiac disease.

How is it treated?

To get and stay well, you need to avoid all foods that have gluten. Do not eat any foods made with wheat, rye, or barley. Don't drink any beer or ale.

You can still eat eggs, meat, fish, fruit, and vegetables. Flours and starches made from rice, corn, buckwheat, potatoes, and soybeans are also okay. Within 2 weeks after starting a gluten-free eating plan, most people find that their symptoms have improved.

For a short time after your treatment starts, you might also need to stop drinking cow's milk and foods made with it. Most of the time, but not always, people can have these foods again after their intestine has healed.

Some foods that are labeled “wheat-free” may still have gluten. Gluten can be in things you may not expect, like medicine, vitamins, and lipstick. Be sure to read labels. Those with “modified food starch” or “hydrolyzed vegetable protein” may contain gluten.

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	Celiac disease: Eating a gluten-free diet

Cause

Although the exact cause of celiac disease is not known, having certain genes increases your risk. You are more likely to have these genes and may get celiac disease if you have a first-degree relative (mother, father, brother, sister, son, or daughter) with the condition. Environmental factors, such as viral or bacterial infections, may trigger changes in the small intestine of a person with these genes. Then, eating foods that contain gluten can trigger an abnormal immune system response. Eventually, digestion and absorption problems may result.

Research continues on how genetic, environmental, and immune factors interact and affect a person's symptoms, at what age they begin, and whether long-term health problems develop.

Symptoms

Symptoms of celiac disease occur after eating foods containing gluten. These foods trigger an abnormal immune system response that damages the intestine. Symptoms vary widely: they may be very mild and go completely unnoticed, or they may be severe and impact daily life.

Common symptoms related to celiac disease may come and go. They include:

• Gas, abdominal swelling, and bloating. These symptoms result from a failure of the small intestine to absorb nutrients from food. You may also have mild stomach pain, but it is usually not severe.
• Abnormal stools. Diarrhea or bulky, loose (or watery), pale, frothy, and foul-smelling stools often occur. The stools may contain a large amount of fat and may stick to the sides of the toilet bowl, making them hard to flush. Although children and adults often experience the same types of symptoms, intestinal problems, such as constipation, are more likely to occur in children.
• Weight loss. Adults and children may have unexplained weight loss despite having a normal appetite. Younger children may fail to gain weight and grow as expected, a condition known as failure to thrive.
• Fatigue and weakness. Celiac disease can result in a general lack of energy and strength. Sometimes poor nutrient absorption causes fatigue and weakness.
• Vomiting. Some people may get sick after eating gluten. Children are more likely than adults to have this reaction.

Celiac disease may also lead to:

• Osteoporosis and other bone problems related to a lack of calcium absorption.
• Anemia caused by iron deficiency and/or folic acid deficiency.
• Infertility or having more than one miscarriage.
• Delayed onset of puberty.
• Frequent respiratory infections.
• Problems with memory and concentration.
• Irritability in children. And adults may show signs of depression.

Symptoms of celiac disease also occur with a variety of other conditions, which can delay the initial diagnosis.

What Happens

Celiac disease is a lifelong (chronic) condition that occurs when gluten triggers an abnormal immune system response that damages the small intestine. Tiny, finger-shaped tissues (villi) line the small intestine. The villi create a large surface that absorbs vitamins, sugars, and other nutrients as food passes through the small intestine.

When a person with celiac disease eats gluten, the villi flatten out and the intestinal lining becomes inflamed. This decreases the area in the intestine that can absorb nutrients. In some cases, the inability to absorb nutrients (malabsorption) may be severe enough to stunt growth and weaken bones. The loss of vitamins and minerals may lead to illnesses such as iron deficiency anemia, folic acid deficiency anemia, rickets, or osteoporosis.

People with celiac disease may have periods when their symptoms seem worse. Or symptoms may sometimes not be noticed at all.

Celiac disease in children

In some children, symptoms begin shortly after introducing cereal into the diet, usually after 6 months of age.

A child who has celiac disease may not grow and gain weight normally because the child's body is not absorbing needed vitamins and other nutrients. Children who have untreated celiac disease can become very ill. They may need hospitalization for treatment with fluids and medicine to restore nutrients. These treatments are usually short-term, and most children recover completely.

As children who have celiac disease grow into adulthood, they may be at a slightly increased risk for developing cancer (lymphoma) in the small intestine, the mouth, or esophagus, although the evidence for this is not clear. But studies have found that following a gluten-free diet lowers the risk for lymphoma.¹ Even if a child with celiac disease does not have symptoms after eating gluten, it is critical that he or she stay on a lifelong gluten-free diet to avoid intestinal damage. You can help your teenager follow a gluten-free diet by recognizing his or her need for independence. For example, you can let your teenager plan meals and choose gluten-free foods.

Although a gluten-free diet relieves symptoms and promotes the health of the intestines, children may not reach their full height if prolonged lack of nutrient absorption stunted their growth before treatment began.

Celiac disease in adults

Many adults who have celiac disease do not have any symptoms, or they have only mild symptoms. Symptoms may occur at any age but most commonly develop during the 20s, 30s, and 40s.

Adults who have celiac disease have a slightly higher-than-average risk of lymphoma, which usually develops in the intestine. They also may have a slightly increased risk of developing cancer of the esophagus. Following a gluten-free diet can reduce this risk.

You are likely to get better if you consistently and permanently follow a gluten-free diet. About 70% of people find their symptoms improve within 2 weeks of beginning a gluten-free diet.² After the villi return to normal, which usually takes several months to several years, the body can absorb nutrients properly. Maintaining a gluten-free diet even when symptoms disappear is very important. Doing so usually prevents symptoms from returning and reduces the risk for complications of celiac disease, which may include lymphoma.

Symptoms usually return any time foods with gluten are eaten. Although some people who have celiac disease may be able to eat foods that contain gluten without developing symptoms, this does not mean that the body is absorbing all nutrients normally. Even without symptoms, if the small intestine is injured from gluten, the lack of absorption of nutrients may cause complications such as iron deficiency anemia and osteoporosis.

In rare cases, people who appear to have celiac disease do not get better on a gluten-free diet. This condition is called refractory sprue. In these cases, corticosteroids or other medicines that change the immune system response may be used to control symptoms. People who do not improve on a gluten-free diet should be tested for other conditions, including T-cell lymphoma.

People with celiac disease have a slightly higher-than-average death rate, mainly because of the risk of lymphoma. But increasing evidence suggests that people with celiac disease can decrease their risk for developing lymphoma by permanently adopting a strict gluten-free diet.¹

What Increases Your Risk

Celiac disease is an immune system disorder in genetically predisposed people that results in damage to the lining of the small intestine when foods with gluten are eaten. The risk for the disease may be inherited, since about 10% of first-degree relatives (mother, father, brother, sister, son, or daughter) of people who have celiac disease also develop the condition. In people who are genetically predisposed, celiac disease may be triggered by environmental factors, including viral and bacterial infections.

People who have celiac disease are also more likely than others to have:

• Dermatitis herpetiformis (more common in adults but can occur in children).
• Osteoporosis.
• Type 1 diabetes (insulin-dependent diabetes).
• Autoimmune thyroid disease.
• Down syndrome.
• Sjögren's syndrome.
• Selective antibody deficiency (immunoglobulin A [IgA] deficiency).
• Iron deficiency anemia or folic acid deficiency anemia.
• Abnormal liver function tests that are not caused by any other disease.

When To Call a Doctor

Call a doctor if you or your child has symptoms of celiac disease. These symptoms include:

• Losing weight unexpectedly.
• Diarrhea that lasts longer than 1 to 2 weeks.
• Failure of a child to grow or gain weight as expected.
• Unusual fatigue or mood changes, especially if these last more than a week and are not related to any other illness, such as the flu.

If you or your child has been diagnosed with celiac disease, call a doctor if:

• Symptoms recur after having been absent.
• A change in symptoms occurs, such as increased tiredness or increased stomach pain.
• Your child has symptoms such as diarrhea or unexplained weight loss, and you know your child has not eaten gluten.
• You cannot tell whether your child has eaten foods that have gluten, and his or her symptoms continue.

Watchful Waiting

If celiac disease is suspected

If you think that you or your child may have celiac disease, watchful waiting is appropriate if mild symptoms of diarrhea or vomiting last only for a few days. Talk with a doctor if your child continues to have diarrhea and does not seem to be gaining weight as expected even though he or she has a good appetite.

If you or your child has celiac disease

If symptoms of celiac disease return after your child or you were symptom-free while following a gluten-free diet, it usually means that foods containing gluten were eaten. Try documenting your or your child's recent diet. Check food labels, looking closely for ingredients that may be sources of hidden gluten. Your local library or bookstore should have resources that can help you identify potential sources of hidden gluten. Also, a nearby hospital can usually direct you to local and national organizations that can help you follow a gluten-free diet. For more information, see the Other Places to Get Help section of this topic.

If your child has celiac disease and symptoms return, be sure to ask detailed questions about what he or she has recently eaten away from home. As children get older and more independent, they may be tempted to stray from a strict gluten-free diet. You can help your teenager follow a gluten-free diet by recognizing his or her need for independence. For example, you can let your teenager plan meals and choose gluten-free foods.

Call your doctor if you are confident that your or your child's diet is gluten-free but symptoms have returned or continue.

Who To See

Health professionals who may evaluate symptoms of celiac disease in adults or children include:

• Family medicine doctors.
• Pediatricians.
• Internists.
• Nurse practitioners.
• Physician assistants.

A doctor who specializes in problems with the digestive system (gastroenterologist) should be consulted to confirm the diagnosis with a small intestine biopsy. In addition, a dietitian can help you plan and stay with a gluten-free diet.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

In many cases of celiac disease, other conditions with similar symptoms, such as food intolerance or irritable bowel syndrome, are first suspected. Often, celiac disease is only considered after the initial diagnosis of another condition is rejected because treatments are not effective.

A medical history and physical examination and lab tests often point to celiac disease. The diagnosis is confirmed with a small intestine biopsy collected during an endoscopy. For this procedure, an endoscope is guided down a person's throat to the small intestine.

Blood antibody tests

Celiac disease triggers the immune system to produce certain antibodies. If celiac disease is suspected, your doctor will order certain blood tests to detect and measure specific antibodies.

• IgAtTG: Immunoglobulin A (IgA) and tissue transglutaminase (tTG) antibody
• IgAEMA: Immunoglobulin A (IgA) and antiendomysial antibody (EMA)

If either or both of these tests are positive, your doctor may perform a biopsy of the small intestine to confirm a diagnosis of celiac disease.

Endoscopy

A biopsy taken during an upper gastrointestinal endoscopy may be done to confirm celiac disease after antibody tests are positive. Sometimes a biopsy detects celiac disease when a person is being tested for another condition.

A biopsy should be done when you or your child is eating a diet that includes gluten. If the biopsy shows signs of celiac disease (such as abnormal villi and inflammation in the small intestine), a gluten-free diet will be recommended. If the symptoms go away on the gluten-free diet and antibody tests are normal, a diagnosis of celiac disease is confirmed.

If you or your child is on a gluten-free diet before a biopsy is done, you may have to eat a prescribed amount of gluten before the test.

Other tests

Tests for malabsorption may be done when celiac disease is suspected. These tests may include:

• A stool analysis to evaluate fat content. A 3-day collection of stools usually shows higher-than-normal fat content in people who have celiac disease that is causing symptoms.
• A bone density test. This may be done to see if you have problems such as osteomalacia (known as rickets in children) or osteoporosis, which may develop in some people with celiac disease.
• An upper GI series, which may detect intestinal problems but does not give precise information to guide diagnosis or treatment for celiac disease. An upper GI series is rarely needed when celiac disease is suspected.

Certain blood tests may be done to evaluate complications from celiac disease. For example, a complete blood count (CBC) may be done to test for anemia. Also, a chemistry screen, which tests a blood sample for sodium, potassium, chloride, and carbon dioxide levels, may be done to identify whether you or your child has an electrolyte imbalance.

If a diagnosis of celiac disease is suspected but symptoms don't improve with a gluten-free diet, further testing for other conditions and diseases, such as Crohn's disease or cystic fibrosis, may be needed.

Prepare your child for exams and tests that are needed to diagnose suspected celiac disease. Doing so will help your child understand what to expect and can help reduce fears.

Early Detection

Blood tests to measure antibodies, such as immunoglobulin A tissue transglutaminase (IgAtTG) or the immunoglobulin A antiendomysial antibody (IgAEMA), can be useful screening tools for people who are at increased risk for having celiac disease. This includes people with a family history of celiac disease or those who have type 1 diabetes, Down syndrome, dermatitis herpetiformis, an autoimmune disease, unexplained anemia, abnormal liver function tests not caused by another disease, or unexplained osteoporosis. Talk to your doctor if you think you or your child should be screened for celiac disease.

Treatment Overview

The treatment for celiac disease is a strict gluten-free diet, which means:

• Avoiding all foods with wheat, barley, rye, or oats. Oats may later be gradually reintroduced into the diet.
• Not drinking beer, even nonalcoholic versions.
• Eating meals that include rice, corn, millet, and buckwheat.

Most people with the disease who adopt this diet permanently and consistently do not develop health problems associated with celiac disease. If nutritional deficiencies are present, other treatments may be needed, such as vitamin, iron, and calcium supplements.

Initial treatment

When celiac disease is diagnosed, you should immediately adopt a strict gluten-free diet. Eating even the smallest amount of gluten can cause symptoms such as weight loss and diarrhea. You may be advised to temporarily avoid milk or milk products until your intestine heals, at which time you may be able to gradually reintroduce them. A registered dietitian can help you learn how to incorporate this diet and its restrictions. Most people also find local and national celiac disease support groups helpful. For more information, see the Other Places to Get Help section of this topic.

Within 2 weeks after starting a gluten-free diet, 70% of people with celiac disease find their symptoms improve.² Symptoms should completely disappear within 3 months. But it takes 2 to 6 months or longer on a gluten-free diet for the tiny, finger-shaped, raised tissues (villi) of the small intestine to return to normal.

Some children with untreated celiac disease become very sick and require hospitalization. Usually, they recover quickly after treatment with fluids and medicines. A gluten-free diet usually prevents these symptoms from returning.

Ongoing treatment

A gluten-free diet usually will eliminate symptoms of celiac disease and prevent long-term damage to the small intestine or other complications.

Symptoms of the disease are controlled by adopting a gluten-free diet, but you should see a doctor yearly for monitoring. A child especially needs to be watched for:

• Delayed growth. Children with celiac disease do not absorb needed nutrients if they eat gluten. This may result in delayed growth if gluten is eaten regularly over a long period. The vast majority of children catch up in growth unless diagnosis is delayed beyond puberty.
• Nutritional deficiencies. Eating gluten also can lead to an imbalance of chemicals, minerals, and vitamins. These deficiencies should reverse with a gluten-free diet, but vitamins, iron, or calcium supplements are sometimes needed.
• Tumors. As children who have celiac disease grow into adulthood, they may be at a slightly increased risk for developing cancer (lymphoma) in the small intestine and the esophagus, although the evidence for this is not clear. But studies have found that following a gluten-free diet lowers the risk for lymphoma.¹

Treatment if the condition gets worse

The most common cause of recurrent symptoms of celiac disease is eating foods containing gluten. In some people, eating even the smallest amount of gluten can cause symptoms of celiac disease, such as diarrhea and weight loss. Continuing to eat gluten causes inflammation and damage to the villi in the small intestine, regardless of whether symptoms are present. Nutrients may not be absorbed properly, which can lead to long-term complications, such as weak bones or growth problems (in children). Prolonged intestinal damage may increase the risk for developing severe complications, such as lymphoma.

If you or your child experiences symptoms or complications, you may need:

• A diet evaluation to ensure that it is gluten-free. Your doctor or registered dietitian can help you find out if you are eating foods with hidden gluten. Older children and teens may need to be reminded about the importance of staying with the diet.
• Testing for other diseases or conditions, such as irritable bowel syndrome, if no gluten is detected in your system.
• Reevaluation of your original upper endoscopy and biopsy to ensure the accuracy of diagnosis.
• Oral steroids (in very rare cases). Experts disagree about using steroid medications to treat people who have celiac disease and do not get better on a gluten-free diet. The American Gastroenterological Association recommends using injectable steroids to treat a sudden (acute), life-threatening attack of celiac symptoms. Oral steroids or other medicines that change the immune system response may be used to treat refractory sprue that doesn't respond to a gluten-free diet if other possible illnesses have been ruled out.

Treatment for complications varies depending on the specific problems and their severity. For example, some adults may require long-term treatment for complications, such as osteoporosis.

What To Think About

Sometimes a person who has celiac disease does not have symptoms after eating foods that contain gluten. But damage to the small intestine is still occurring. Such damage prevents the absorption of needed nutrients, which may cause complications such as growth delays in children. The damage to the small intestine can also cause an increased risk for lymphoma in the intestine.

Following a gluten-free diet can be challenging, especially for people who do not experience symptoms. Some teenagers find it extremely difficult to consistently avoid eating foods with gluten because it makes eating out with their friends difficult. You can help your teenager follow a gluten-free diet by continuing to emphasize its importance and thinking of ways to make it as easy as possible. If you are concerned about permanently staying on a gluten-free diet, talk with your doctor.

Prevention

Although celiac disease cannot be prevented, symptoms and damage to the small intestine can be reversed by maintaining a strict gluten-free diet. At first, you may also have to avoid milk and milk products. After you stop eating gluten, the intestines begin to heal and you likely will be able to gradually reintroduce milk products into your diet without triggering symptoms.

Some adults with celiac disease have a poorly functioning or nonfunctional spleen, which is a risk factor for developing a pneumococcal infection. For this reason, your doctor may recommend that you get immunized with the pneumococcal vaccine (What is a PDF document?).

Home Treatment

Having celiac disease means that you will need to follow a gluten-free diet for the rest of your life. Permanently following a strict diet can be difficult, especially if you do not have symptoms. But intestinal damage occurs when you eat foods with gluten, regardless of whether you notice symptoms. For more information, see:

Celiac disease: Eating a gluten-free diet

The following strategies may help you stay with your gluten-free diet:

• Seek guidance from a registered dietitian, other health professionals, and celiac disease support groups for ways to incorporate gluten-free foods. In the beginning, it may be helpful to keep a food diary until you are more familiar with planning meals without gluten.
• Be aware of foods that contain hidden gluten. Read labels of prepared or processed food carefully. For example, "hydrolyzed vegetable protein" may come from wheat and contain gluten.
• When eating out, let your server know you have special dietary needs. The Celiac Sprue Association has a "restaurant card" that lists foods to avoid (see the Web site at www.csaceliacs.org or the Other Places to Get Help section of this topic). Show this card to your server, who can help you select gluten-free foods or direct the kitchen to specially prepare a meal for you.
• Count calories and check your (or your child's) weight weekly to ensure that enough nutrients are being absorbed.
• Eat plenty of fruits and vegetables to avoid constipation. If necessary, use gluten-free commercial fiber preparations, such as those that contain rice bran.

Following a special diet may be especially hard for children and teens, who often don't want to feel different from their friends. Also, teens seem to have fewer symptoms than younger children after eating gluten. But gluten, if eaten, will continue to damage the intestine. This is why it is important for your teen to continue to follow a gluten-free diet. The following strategies may help your child or teen to stick to a gluten-free diet:

• Contact your local hospital, dietitian, or doctor for information about support groups in your area. Most people find these groups helpful for discovering ways to help them deal with their condition.
• Consider different ways to help your child follow the gluten-free diet at school. Talk to teachers or school nurses about everyday strategies. Find out what other kids are taking for lunch. For example, if other kids are carrying cold lunches, find ways to pack similar gluten-free cold lunches. If your child prefers a hot lunch, work with the school cafeteria to see whether gluten-free choices are available. The more "normal" the diet can seem, the better the chances that your child will follow it.
• Let your child have some responsibility. With younger children, make a game out of choosing foods that are gluten-free. Allow older children to choose gluten-free foods. Helping your teen follow a gluten-free diet usually includes recognition of his or her increasing need for independence. Although your teen will make his or her own food choices, talk realistically about the consequences of eating foods with gluten.
• Set realistic goals. Understand that food can be a part of socializing and fitting in. Your child may accidentally (or on purpose) eat some foods that contain gluten. If your child experiences symptoms after eating gluten, focus attention on how he or she feels physically. Periodically remind your child about these reactions, especially before going to a social event where foods containing gluten will likely be served, such as a slumber party. Try to plan ahead for these occasions by talking to friends' parents or preparing something gluten-free that the group can eat.

Some people with celiac disease and their family members may benefit from counseling. Consider talking to your doctor about counseling if you need some extra help managing the emotional challenges that can happen with celiac disease. Counseling can also help you learn ways to talk with your children better and help them follow a gluten-free diet.

Medications

Medicines usually are not needed to treat celiac disease. If you or your child has been diagnosed with this condition, your doctor may recommend taking a vitamin supplement that has iron and calcium. After you or your child is on a gluten-free diet, symptoms should get better within 2 or 3 weeks, nutrients should be absorbed more normally, and the small intestine should gradually heal.

Medicine is only needed if you or your child becomes seriously ill with celiac disease or if complications develop. Medicines will be given only long enough to correct these problems. Doctors may prescribe steroid medications to ease swelling in the intestine and to help it absorb nutrients better. But not all experts agree about the use of these medicines to treat celiac disease. Some complications, such as delayed growth, cannot be treated with medicine.

Surgery

There is no surgical treatment for celiac disease.

Other Treatment

You may want to consider seeing a counselor to help you deal with having celiac disease. Professional counseling involves speaking with a qualified counselor, psychologist, or psychiatrist who can help you cope with or change certain thoughts, feelings, or behaviors.

Nutritional counseling from a registered dietitian who is familiar with celiac disease and the specifics of gluten-free foods can help you create a practical and healthy gluten-free diet.

Other Places To Get Help

Organizations

References

Citations

1. Catassi C, et al. (2005). Association of celiac disease and intestinal lymphomas and other cancers. Gastroenterology, 129(Suppl 1): S79–S86.
2. Farrell RJ, Kelly CP (2002). Celiac sprue. New England Journal of Medicine, 346(3): 180–188.

Other Works Consulted

• Agency for Healthcare Research and Quality (2004). Celiac Disease (AHRQ Evidence Report/Technology Assessment No. 104). Rockville, MD: Agency for Healthcare Research and Quality. Available online: http://www.ahrq.gov/downloads/pub/evidence/pdf/celiac/celiac.pdf.
• Case S (2005). The gluten-free diet: How to provide effective education and resources. Gastroenterology, 128(4, Suppl 1): S128–S134.
• Dewar DH, Ciclitira PJ (2005). Clinical features and diagnosis of celiac disease. Gastroenterology, 128(4, Suppl 1): S19–S24.
• Farrell RJ, Kelly CP (2006). Celiac sprue and refractory sprue. In M Feldman et al., eds., Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 8th ed., vol. 2, pp. 2277–2306. Philadelphia: Saunders Elsevier.
• Gluten-free drugs for celiac disease patients (2008). Medical Letter on Drugs and Therapeutics, 50(1281): 19–20.
• Green PHR, Cellier C (2007). Celiac disease. New England Journal of Medicine, 357(17): 1731–1743.

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