Tag: thyroid gland

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Making Sense of Celiac Disease and Non-Celiac Gluten Allergy is Not Easy

Gordon Wright waiting for birds to fly by so he can take pictures in Police Point Park on a beautiful spring afternoon in Medicine Hat. (Dr. Noorali Bharwani)
Gordon Wright waiting for birds to fly by so he can take pictures in Police Point Park on a beautiful spring afternoon in Medicine Hat. (Dr. Noorali Bharwani)

“Celiac disease is common and is associated with other immune diseases,” says an article in the Canadian Medical Association Journal (CMAJ January 8, 2013).

The symptoms of celiac disease are triggered by gluten (a protein found in wheat, rye, barley and triticale) in people who are genetically susceptible. Triticale is a hybrid of wheat and rye first bred in laboratories during the late 19th century.

Ten things to remember about celiac disease as summarized from the CMAJ article:

  1. A first-degree relative with celiac disease has a 10-fold increased risk of acquiring the condition. It affects one in 133 North Americans.
  2. The risk is increased among people with autoimmune thyroid disease (three to five per cent), type one diabetes mellitus (five to 10 per cent) and Down syndrome (5.5 per cent).
  3. Gluten perpetuates the destruction of villi in the small intestine. Intestinal villi are small, finger-like projections that help in digestion.
  4. The disease can develop at any age.
  5. Clinical symptoms can be diverse from abdominal pain to diarrhea, weight loss and malnutrition.
  6. Screening for celiac disease is recommended for people who have associated symptoms, an associated condition or a family history of celiac disease.
  7. The most widely available test is the tissue transglutaminase IgA antibody test, which has an estimated 95 per cent accuracy rate. If antibody testing is negative and celiac disease is suspected, the IgA level should be measured.
  8. All adults with an abnormal screening result should undergo a small-bowel biopsy to confirm the diagnosis of celiac disease.
  9. Because of an increasing awareness of celiac disease, people may choose to adopt a gluten-free diet before diagnostic testing. That is not the right way to manage the problem. Further diagnostic testing should be performed following a medically supervised gluten challenge of at least four weeks, with sufficient gluten to produce symptoms.
  10. Treatment is lifelong adherence to a gluten-free diet. Examples of gluten-free grains are oats, buckwheat, millet, rice and quinoa. Gluten-free diet reduces the risk of complications such as osteoporosis and intestinal lymphoma.

Is there an illness called non-celiac gluten sensitivity?

Yes. You have symptoms of celiac disease but it cannot be confirmed. Then you may have non-celiac gluten sensitivity.

An article by Sapone et al. (BMC Medicine 2012) titled, “Spectrum of gluten-related disorders: consensus on new nomenclature and classification,” says in only 10 years, key milestones have moved celiac disease from obscurity into the popular spotlight worldwide.

What has generated more interest is the spectrum of illnesses associated with ingestion of gluten. These are: 1. Allergy to wheat 2. Autoimmune celiac disease, dermatitis herpetiformis and gluten ataxia 3. Possible immune-mediated gluten sensitivity.

Research estimates that 18 million Americans have non-celiac gluten sensitivity. That’s six times the amount of Americans who have celiac disease. Researchers are just beginning to explore non-celiac gluten sensitivity.

These individuals seem to be sensitive to gluten often also experience headaches, rashes and fatigue. It is possible that it may in fact be other proteins or sugar in wheat (other than gluten) that may be triggering the reaction. There is no inflammation or damage to the intestinal lining as in celiac disease. More research is needed to understand this problem. Did I hear you say, “If only things in life would be simple and straight forward?”

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Overactive thyroid can affect your eyes.

According to Thyroid Foundation of Canada website, it is estimated that 200 million people in the world have some form of thyroid disease. One in every three Canadians (about 10 million people) has a thyroid disorder. Of those, as many as 50 per cent are undiagnosed.

The normal function of the thyroid gland is to secrete hormones. These hormones have multitude of functions and are vital to metabolism in adults and for normal growth and development of children.

Underactive thyroid (hypothyroidism) causes many symptoms like weight gain, lethargy, cold intolerance, menstrual irregularities, depression, constipation and dry skin. Deficiency of thyroid hormone in children leads to dwarfism and mental retardation.

Overactive thyroid (hyperthyroidism) results in palpitations, nervousness, tremor, heat intolerance, weight loss, muscular weakness and usually there is a presence of goitre.

Hyperthyroidism can be caused by a number of conditions, including Graves’ disease, toxic adenoma, Plummer’s disease (toxic multinodular goitre) and thyroiditis.

Graves’ disease accounts for at least 90 per cent of all patients with hyperthyroidism. It is a condition where eyes are affected. A condition called exophthalmos – protrusion of the eyeballs. Graves’ disease is an autoimmune disorder in which antibodies produced by your immune system stimulate your thyroid to produce too much thyroid hormone.

These antibodies mistakenly attack your thyroid and occasionally the tissue behind your eyes (Graves’ opthalmopathy) and the skin, often in your lower legs over the shins (Graves’ dermopathy). Scientists aren’t sure exactly what causes Graves’ disease, although several factors, including a genetic predisposition, are likely involved.

The disease has a genetic component, although not every member of the afflicted families will suffer this condition. It is more common in females than in males.

In Graves’ eye disease, the eyes are painful, red and watery – particularly in sunshine or wind. The eye lids and tissues around the eyes are swollen with fluid. The eyeballs bulge out of their sockets (exophthalmos). Because of eye muscle swelling, the eyes are unable to move normally and there may be blurred or double vision. Some patients have decreased colour vision as well.

Fortunately, the eye changes tend to “burn out” within a period of about 24 months and, in most cases, there is a satisfactory end result even without any treatment. The double vision and the bulginess usually do not disappear completely.

Unfortunately, there is no satisfactory treatment to prevent Graves’ eye disease. Because hyperthyroidism seems to influence the eye disease, it is very important to treat the hyperthyroidism quickly and effectively. In most patients, the eyes tend to get somewhat better when the thyroid abnormality has been treated.

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Thyroid Nodule

Recently, I saw a young lady with a lump in the neck. . The lump moves with swallowing. That means it is in the thyroid gland

The young lady wants to know: Is it cancer? Why did she get it? What can be done about it?

Thyroid lumps or nodules are tumors, most of which are benign. But some are malignant and invasive cancers.

A solitary nodule, within an otherwise apparently normal gland, is of more concern than a thyroid gland with multiple nodules which is known as a multi-nodular goiter. Multi-nodular goiters are usually benign.

Thyroid nodules are more common in women. Single nodule is four times more common in women than men.

About 42-77 percent of nodules are simple cysts (colloid nodules); 15 -40 percent are benign tumors (adenomas); and only 8 – 17 percent are cancers. In men, the frequency of cancer in the thyroid nodule is more than 50 percent by 70 years of age.

Radiation treatment to the neck, or any radiation exposure near the thyroid gland, increases the risk of developing nodules. These nodules tend to develop long after the radiation exposure. Family history of thyroid cancer increases the likelihood of thyroid nodule being malignant.

How do we investigate a solitary thyroid nodule?

To start with, only one blood test is required –thyroid stimulating hormone (TSH) level – to check if the thyroid is functioning normally or is over-active.

If the thyroid function is normal then the next line of investigation is a fine-needle aspiration (FNA) biopsy. In nine reports (comprising 9119 patients) the FNA showed benign tumor in 74 percent of patients, malignant tumor in four percent, indeterminate results in 11 percent, and inadequate biopsy specimen in 11 percent, says an article in the New England Journal of Medicine (NEJM).

If the TSH is suggestive of an over-active thyroid nodule or the FNA biopsy result is indeterminate then a radio-nuclear scan should be performed to further check the status of the nodule. If it is “hot” – then it is overactive.

Ultrasound is a good test for thyroid lumps. It can tell us if there is more than one nodule; if the lump is solid, cystic or mixed; and it is the best method to determine the size of the nodule.

What is the treatment of solitary thyroid nodule?

If the nodule is hyper-functioning then it requires medical treatment. Surgery is rarely indicated.

If the needle biopsy is clearly benign and there are no other symptoms suggesting pressure to the surrounding structures, like difficulty breathing or swallowing, then the nodule can be observed with or without thyroid hormone therapy. The nodule may enlarge, shrink or disappear.

Main indications for surgery are: malignant or indeterminate FNA biopsy results, local symptoms, or the gland is so big that it changes the appearance of the neck.

The NEJM article says that in six reports (10,850 patients) the rate of surgery for a solitary thyroid lump varied from 14 to 61 percent.

Why such a big variation in the rates of surgery? For three reasons: differing rates of accuracy of FNA biopsy results among centers, surgeon’s own preference and differing views on whether patients with unclear FNA results should routinely undergo surgery.

So, a solitary thyroid nodule is not always malignant. But it should not be ignored. Appropriate investigations should be done to rule out cancer.

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Thyroid Disease

Dear Dr. B: I am requesting from you an article about thyroid disease whose purpose would be to educate the community on this life long illness. I have a thyroid problem. Sometimes I have been told that I am lazy, depressed, having panic attacks, jittery, weird looking etc. Is there anyway you can assist in educating the people who do not understand my problem? Yours, Ms. Frustrated

Dear Ms. Frustrated: Sure we can do something about this issue. Let me start by explaining where the thyroid gland is and what is its normal function. Then we will discuss the symptoms and signs of abnormal thyroid function.

The thyroid gland is shaped like a butterfly. It has two lobes, one on each side of the neck (resembling butterfly wings) weighing about 20g. The lobes are connected in front of the neck, below Adam’s apple, by a narrow band of tissue called isthmus (resembling body of a butterfly). When the gland is enlarged, it can be seen to move with swallowing.

What does the thyroid gland do?

The normal function of the thyroid gland is to secrete hormones which are two closely related chemical substances: T3 (triiodothyronine) and T4 (thyroxine). These hormones have multitude of functions and are vital to metabolism in adults and for normal growth and development of children. Deficiency of thyroid hormone in children leads to dwarfism and mental retardation.

Formation of normal quantities of thyroid hormone requires the availability of adequate quantities of iodine from outside sources. Given the fact that at least 1 billion individuals live in iodine-deficient areas of the world, it is not surprising that iodine-deficiency disorders (IDD), including endemic goitre and cretinism (stunted growth), are the most common thyroid-related human illnesses, indeed the most common endocrine disorders worldwide, says one textbook of endocrine diseases.

Normally iodine balance is maintained from dietary sources, i.e., food and water, but iodine may enter the body via medications, diagnostic agents, dietary supplements, and food additives, says the textbook.

The Thyroid Foundation of Canada estimates that thyroid disorders affect one in twenty Canadians and that most thyroid disorders are five to seven times more common in women.

Under-active thyroid (hypothyroidism) causes many symptoms: weight gain, lethargy, cold intolerance, menstrual irregularities, depression, constipation, dry skin etc. Overactive thyroid (hyperthyroidism) results in: palpitations, nervousness, tremor, heat intolerance, weight loss, muscular weakness and usually there is a presence of a goitre.

Diagnosis is made by history, physical signs and blood tests.

There are many causes of hypothyroidism. Anywhere from congenital development defect to acquired conditions like radiation therapy or autoimmune disease. But the cause of hyperthyroidism is not very clear.

Who is at increased risk for thyroid disease?

Women over 45, postpartum women, patients on lithium and amiodarone, patients with autoimmune diseases like type 1 diabetes, and patients with a strong family history of thyroid disease.

Ms. Frustrated, I hope this information will be of help. But as you may know, educating and changing people’s attitudes is not easy. Ignorant, prejudiced, shallow, self-centred people are hard to deal with. They get their strength by making life difficult for others. You will just have to ignore them. Try and get your strength from people who care about you. And I am sure they outnumber the shallow and the self-centred ones.

Good luck and good health!

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