Last month, we looked at the epidemiology, pathology and diagnosis of celiac disease (CD). This month we will consider some case histories illustrating the varied and pan-systemic presentation of this condition.
Case 1: CD with gastrointestinal and dermatological presentations
A fifty three year old vata-pitta woman presented with a history of collagenous colitis. This fairly rare condition is one of two forms of microsopic colitis, affecting mainly women typically in their fifth decade. Microscopic colitis is often associated with CD and causes non-bloody watery diarrhea. " Approximately 1/3 of patients with celiac disease have histologic findings consistent with microscopic colitis. For this reason microscopic colitis should be considered in patients diagnosed with celiac disease who have diarrhea that fails to respond to a gluten-free diet (1)."
She noted that she, as well as her mother and sister, had always suffered from digestive troubles, typical in a family with undiagnosed non-classical CD. She said, 'I always felt as if there was a rock in my stomach but thought this was normal." As a child, she suffered from dermatitis herpetiformis (DH), an intensely itchy blistering skin inflammation that is a cutaneous manifestation of CD. In recent years, following menopause, her DH returned, along with watery diarrhea. She adopted a gluten free diet (GFD) with notable improvement. However, she still had vata ojo-vyapad and ojokshay.
Case 2: Latent CD with auto-immune thyroid disease
A fifty nine year old vata woman presented with a complex mass on the isthmus of the thyroid. Her digestion alternated between tikshnagni and vishamagni and her tongue and nails showed malabsorption. Her stools were hard and dry and she suffered from fatigue, low ojas and chronic sinusitis. The combination of symptoms led us to suspect latent CD along with auto-immune thyroid disease (AITD). After beginning a three-month trial of GFD she gradually felt more energetic, with less sinus problems, better digestion and more normal stools.
Case 3: Atypical CD with autonomic neuropathy.
A sixty two year old pitta-kapha male Vietnam veteran had suffered from a coarse tremor for the last four years, increasing in frequency and intensity. His toes were numb. He also had osteoporosis. His stools were loose and he had mandagni, generally skipping lunch. His lymph nodes were swollen and he complained of lower back pain. He was provoked in vata and pitta with pitta ojo vyapad and ojokshay. The majja dhatu was weak with an irregular spike. The nature of his tremor, a coarse intention tremor with no bradykinesia, was incompatible with a clinical diagnosis of Parkinson's Disease and compatible with peripheral neuropathy. His history included probable Agent Orange exposure, sufficient in itself to be a cause of incurable peripheral neuropathy. However, the combination of peripheral neuropathy and osteoporosis, two manifestations of atypical CD, led us to favor a diagnosis of CD. Amazingly, within one day of stopping gluten, he noticed a marked diminishment of his peripheral neuropathy symptoms. His tremors completely ceased, the lymph nodes returned to normal and his lower back pain decreased.
Obviously, GFD is a major therapeutic intervention in all forms of CD. Initially we used to recommend a one-month trial of GFD (upashaya) to determine if it would be an effective strategy. Experience has led us to favor an initial three-month trial, with genetic testing to confirm the accuracy of the diagnosis. Although, some, like our Case 3, will see an immediate and dramatic response, others with latent CD, like our Case 2, will notice only gradual and incremental changes. The intestinal mucosa can take months to heal, so results may not be immediately noticeable. Compliance with GFD is greatly aided by providing a detailed handout, and we will offer a sample handout in our next issue.
The next question that arises of course is the place of Ayurvedic therapies if GFD is the main intervention needed. Healing can be very slow for celiacs recovering from a lifetime of gluten exposure, and Ayurvedic chikitsa can speed healing and tackle complications. Herbs and spices to address agni and ama help rehabilitate the digestive system. Provoked doshas must be pacified by diet, lifestyle and herbs indicated for the individual. Secondary diseases such as AITD require specific therapies (vyadhi pratyanika, against the disease). Where there is dhatu kshay, as in Case 3, specific dhatu pratyanika herbs are indicated. And for ojo vyapad and ojokshay, pancha karma and rasayana therapies should be instituted.
To give some examples, Case 1 took a vata and pitta soothing diet and used an agni churna for pitta, containing pitta-balancing spices such as coriander, fennel and turmeric. For ojokshay she took non-dairy ojas drink every other day. She was given a formula that included Shatavari for pitta, Vidari for vata and kaishore guggulu as vyadhi pratyanika for collagenous colitis.
Non Dairy Ojas drink.
- 10 raw almonds
- 2 cups pure water
- 20 raisins
- 1 tsp ghee (rejuvenative)
- 1/32 tsp saffron (increases digestion and rejuvenative)
- 1/8 tsp ground cardamom (increases digestion)
- pinch of black pepper (helps control the Kapha)
1. Soak almonds in 1 cup of water overnight, and soak raisins in 1 cup of water either overnight or for several hours
2. In the morning, drain off the almond water and rub the skins off the almonds
3. In a blender, add the raisins AND their soaking water with the drained and peeled almonds
4. Add ghee, saffron, cardamom, black pepper
5. Blend until smooth
Case 2 of course was mainly focused on vyadhi pratyanika herbs for her thyroid, such as punarnava and shilajit as well as nasya therapy for her sinus problem. She also did home pancha karma each change of season with good improvement in her ojas and diminution of her thyroid mass. Case 3 is just beginning his Ayurvedic protocol, taking Guduchi for pitta ojo-vyapad and Ashwagandha and kapi kacchu for his nervous system. He also takes Tulsi-brahmi tea as dhatu pratyanika for majja dhatu. Pancha karma will be planned in future to help get pitta out of ojas and to cleanse the Agent Orange from his system.
From these examples we can see the value of Ayurvedic treatment in CD to rehabilitate agni, clear ama, balance doshas, rejuvenate depleted dhatus and ojas and provide specific therapies for secondary conditions.
1. Eric Goosenberg MD http://emedicine.medscape.com/article/180664-overview