Editing Coeliac disease (section)

==Signs and symptoms==
The classic symptoms of untreated coeliac disease include [[diarrhea]], [[steatorrhea|steatorrhoea]], [[iron-deficiency anemia]], and weight loss or failure to gain weight. Other common symptoms may be subtle or primarily occur in organs other than the bowel itself.<ref>{{cite journal |vauthors=Schuppan D, Zimmer KP |title=The diagnosis and treatment of celiac disease |journal=Deutsches Ärzteblatt International |volume=110 |issue=49 |pages=835–46 |date=December 2013 |pmid=24355936 |pmc=3884535 |doi=10.3238/arztebl.2013.0835}}</ref> It is also possible to have coeliac disease without any of the classic symptoms at all.<ref name=Lancet2009/> This has been shown to comprise at least 43% of presentations in children.<ref name=VriezingaSchweizer2015>{{cite journal |vauthors=Vriezinga SL, Schweizer JJ, Koning F, Mearin ML |title=Coeliac disease and gluten-related disorders in childhood |journal=Nature Reviews. Gastroenterology & Hepatology |volume=12 |issue=9 |pages=527–36 |date=September 2015 |pmid=26100369 |doi=10.1038/nrgastro.2015.98 |type=Review}}</ref> Further, many adults with subtle disease may only present with fatigue, [[anaemia]] or [[Osteopenia|low bone mass]].<ref name=VanHeelWest/> Many undiagnosed individuals who consider themselves asymptomatic are in fact not, but rather have become accustomed to living in a state of chronically compromised health. Indeed, after starting a gluten-free diet and subsequent improvement becomes evident, such individuals are often able to retrospectively recall and recognise prior symptoms of their untreated disease that they had mistakenly ignored.<ref name=WGO2016 /><ref name=LudvigssonCard2015 /><ref name=LionettiGatti2015 />

===Gastrointestinal===
[[diarrhea|Diarrhoea]] that is characteristic of coeliac disease is chronic, sometimes pale, of large volume, and abnormally foul in odor. [[Abdominal pain]], cramping, bloating with [[abdominal distension]] (thought to be the result of fermentative production of bowel gas), and [[mouth ulcer]]s<ref>{{cite journal | vauthors = Ferguson R, Basu MK, Asquith P, Cooke WT | title = Jejunal mucosal abnormalities in patients with recurrent aphthous ulceration | journal = British Medical Journal | volume = 1 | issue = 6000 | pages = 11–13 | date = January 1976 | pmid = 1247715 | pmc = 1638254 | doi = 10.1136/bmj.1.6000.11 }}</ref> may be present. As the bowel becomes more damaged, a degree of [[lactose intolerance]] may develop.<ref name=Lancet2009/> This is because in addition to damage in the intestines, coeliac disease can cause a lactase deficiency, which is the enzyme that is responsible for breaking down lactose.<ref>{{cite journal |last1=Ojetti |first1=Veronica |last2=Nucera |first2=Gabriella |last3=Migneco |first3=Alessio |last4=Gabrielli |first4=Maurizio |last5=Lauritano |first5=Cristiano |last6=Danese |first6=Silvio |last7=Assunta Zocco |first7=Maria |last8=Nista |first8=Enrico Celestino |last9=Cammarota |first9=Giovanni |last10=de Lorenzo |first10=Antonino |last11=Gasbarrini |first11=Giovanni |last12=Gasbarrini |first12=Antonio |title=High Prevalence of Celiac Disease in Patients with Lactose Intolerance |journal=Digestion |date=2005 |volume=71 |issue=2 |pages=106–110 |id={{ProQuest|195196307}} |doi=10.1159/000084526 |pmid=15775678 }}</ref> Frequently, the symptoms are ascribed to [[irritable bowel syndrome]] (IBS), only later to be recognised as coeliac disease. In populations of people with symptoms of IBS, a diagnosis of coeliac disease can be made in about 3.3% of cases, or four times more likely than in general.<ref name=AJ2017>{{cite journal | vauthors = Irvine AJ, Chey WD, Ford AC | title = Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis | journal = The American Journal of Gastroenterology | volume = 112 | issue = 1 | pages = 65–76 | date = January 2017 | pmid = 27753436 | doi = 10.1038/ajg.2016.466 | url = http://eprints.whiterose.ac.uk/106483/3/AJG-16-1318R1%20CLEAN.pdf }}</ref> Screening them for coeliac disease is recommended by the [[National Institute for Health and Clinical Excellence]] (NICE), the [[British Society of Gastroenterology]] and the [[American College of Gastroenterology]], but is of unclear benefit in North America.<ref name=AJ2017/><ref name=NICEIBS>{{NICE|61|Irritable bowel syndrome|2008}}</ref>

Coeliac disease leads to an increased risk of both [[adenocarcinoma]] and [[lymphoma]] of the small bowel ([[enteropathy-associated T-cell lymphoma]] (EATL) or other [[non-Hodgkin lymphoma]]s).<ref>{{cite journal | vauthors = Caio G, Volta U, Sapone A, Leffler DA, De Giorgio R, Catassi C, Fasano A | title = Celiac disease: a comprehensive current review | journal = BMC Medicine | volume = 17 | issue = 1 | pages = 142 | date = July 2019 | pmid = 31331324 | pmc = 6647104 | doi = 10.1186/s12916-019-1380-z | publisher = Springer Nature | doi-access = free }}</ref> This risk is also higher in first-degree relatives such as siblings, parents and children. Whether a gluten-free diet brings this risk back to baseline is not clear.<ref name=WJG2012>{{cite journal | vauthors = Gujral N, Freeman HJ, Thomson AB | title = Celiac disease: prevalence, diagnosis, pathogenesis and treatment | journal = World Journal of Gastroenterology | volume = 18 | issue = 42 | pages = 6036–6059 | date = November 2012 | pmid = 23155333 | pmc = 3496881 | doi = 10.3748/wjg.v18.i42.6036 | df = dmy-all | doi-access = free }}</ref> Long-standing and untreated disease may lead to other complications, such as [[Enteropathy-associated T-cell lymphoma#Ulcerative jejunitis|ulcerative jejunitis]] (ulcer formation of the small bowel) and stricturing (narrowing as a result of scarring with obstruction of the bowel).<ref name=AGA>{{cite journal | vauthors =  | title = American Gastroenterological Association medical position statement: Celiac Sprue | journal = Gastroenterology | volume = 120 | issue = 6 | pages = 1522–1525 | date = May 2001 | pmid = 11313323 | doi = 10.1053/gast.2001.24055 | doi-access = free }}</ref>

===Malabsorption-related===
The changes in the bowel reduce its ability to [[Small intestine#Absorption|absorb]] nutrients, minerals, and the [[Vitamin#Classification|fat-soluble vitamins]] A, D, E, and K.<ref name=Lancet2009/><ref name=AFP>{{cite journal |vauthors=Presutti RJ, Cangemi JR, Cassidy HD, Hill DA |title=Celiac disease |journal=Am Fam Physician |volume=76 |issue=12 |pages=1795–802 |year=2007 |pmid=18217518 |url=http://www.aafp.org/afp/20071215/1795.html |access-date=13 December 2009 |archive-date=19 April 2021 |archive-url=https://web.archive.org/web/20210419111728/https://www.aafp.org/afp/2007/1215/p1795.html |url-status=dead}}</ref>
* [[Malabsorption]] of carbohydrates and fats may cause [[weight loss]] (or [[failure to thrive]] or [[stunted growth]] in children) and [[fatigue]] or lack of energy.
* [[Anaemia]] may develop in several ways: iron malabsorption may cause [[iron deficiency anaemia]], and [[folic acid]] and [[vitamin B12|vitamin B<sub>12</sub>]] malabsorption may give rise to [[megaloblastic anemia|megaloblastic anaemia]].
* [[Calcium in biology|Calcium]] and [[vitamin D]] malabsorption (and compensatory [[secondary hyperparathyroidism]]) may cause [[osteopenia]] (decreased mineral content of the bone) or [[osteoporosis]] (bone weakening and risk of fragility fractures).
* [[Selenium]] malabsorption in coeliac disease, combined with low selenium content in many gluten-free foods, confers a risk of [[selenium deficiency]].<ref name="pietzak_book">{{cite book |vauthors=Pietzak MM |chapter=Dietary supplements in celiac disease |veditors=Rampertab SD, Mullin GE |title=Celiac disease |isbn=978-1-4614-8559-9 |pages=137–59 |date=2014|publisher=Springer }}</ref>
* [[Copper deficiency|Copper]] and [[Zinc deficiency|zinc deficiencies]] have also been associated with coeliac disease.<ref name="pietzak_book" />
* A small proportion of people have abnormal [[coagulation]] because of [[vitamin K deficiency]] and are at a slight risk of abnormal bleeding.

===Miscellaneous===
Coeliac disease has been linked with many conditions. In many cases, it is unclear whether the gluten-induced bowel disease is a causative factor or whether these conditions share a common predisposition.
* [[IgA deficiency]] is present in 2.3% of people with coeliac disease, and is itself associated with a tenfold increased risk of coeliac disease. Other features of this condition are an increased risk of infections and [[autoimmune disease]].<ref>{{cite journal |vauthors=Cunningham-Rundles C |title=Physiology of IgA and IgA deficiency |journal=J. Clin. Immunol. |volume=21 |issue=5 |pages=303–9 |date=September 2001 |pmid=11720003 |doi=10.1023/A:1012241117984}}</ref>
* [[Dermatitis herpetiformis]], an itchy cutaneous condition that has been linked to a transglutaminase enzyme in the skin, features small-bowel changes identical to those in coeliac disease and may respond to gluten withdrawal even if no gastrointestinal symptoms are present.<ref name=Marks>{{cite journal |vauthors=Marks J, Shuster S, Watson AJ |title=Small-bowel changes in dermatitis herpetiformis |journal=Lancet |volume=2 |issue=7476 |pages=1280–2 |year=1966 |pmid=4163419 |doi=10.1016/S0140-6736(66)91692-8}}</ref><ref>{{cite journal |vauthors=Nicolas ME, Krause PK, Gibson LE, Murray JA |title=Dermatitis herpetiformis |journal=Int. J. Dermatol. |volume=42 |issue=8 |pages=588–600 |date=August 2003 |pmid=12890100 |doi=10.1046/j.1365-4362.2003.01804.x }}</ref>
* [[Growth failure]] and/or [[delayed puberty|pubertal delay]] in later childhood can occur even without obvious bowel symptoms or severe [[malnutrition]]. Evaluation of growth failure often includes coeliac screening.<ref name=Lancet2009/>
* [[Pregnancy complication]]s can occur if coeliac disease is [[pre-existing disease in pregnancy|pre-existing]] or later acquired, with significant outcomes including [[miscarriage]], [[intrauterine growth restriction]], [[low birthweight]] and [[preterm birth]].<ref name="TersigniCastellani2014">{{cite journal |vauthors=Tersigni C, Castellani R, de Waure C, Fattorossi A, De Spirito M, Gasbarrini A, Scambia G, Di Simone N |title=Celiac disease and reproductive disorders: meta-analysis of epidemiologic associations and potential pathogenic mechanisms |journal=Human Reproduction Update |volume=20 |issue=4 |pages=582–93 |year=2014 |pmid=24619876 |doi=10.1093/humupd/dmu007 |doi-access=free|hdl=10807/56796 |hdl-access=free }}</ref>
* [[Hyposplenism]] (a small and underactive [[spleen]])<ref name=Ferguson>{{cite journal |vauthors=Ferguson A, Hutton MM, Maxwell JD, Murray D |title=Adult coeliac disease in hyposplenic patients |journal=Lancet |volume=1 |issue=7639 |pages=163–4 |year=1970 |pmid=4189238 |doi=10.1016/S0140-6736(70)90405-8}}</ref> occurs in about a third of cases and may predispose to infection given the role of the spleen in protecting against harmful bacteria.<ref name=Lancet2009/>
* Abnormal [[liver function test]]s (randomly detected on blood tests) may be seen.<ref name=Lancet2009/>
* [[Depression (mood)|Depression]], [[anxiety]] and other mental health disorders<ref>{{cite journal | vauthors = Zingone F, Swift GL, Card TR, Sanders DS, Ludvigsson JF, Bai JC | title = Psychological morbidity of celiac disease: A review of the literature | journal = United European Gastroenterology Journal | volume = 3 | issue = 2 | pages = 136–145 | date = April 2015 | pmid = 25922673 | pmc = 4406898 | doi = 10.1177/2050640614560786 }}</ref>

Coeliac disease is associated with several other medical conditions, many of which are autoimmune disorders: [[diabetes mellitus type 1]], [[hypothyroidism]], [[primary biliary cholangitis]], [[microscopic colitis]], [[ataxia|gluten ataxia]], [[psoriasis]], [[vitiligo]], [[autoimmune hepatitis]], [[primary sclerosing cholangitis]], and more.<ref name=Lund2015 />