CELIAC
DISEASE
AND
WHEAT
SENSITIVITY
By H. A. Weijers, M.D., and J. H. van de Kamer, Ph.D.
Central Institute for Nutrition and Food Research T.N.O., Utrecht
ADDRESS: (J.Il.v.d.K.) Catharynesingel 61, Utrecht, The Netherlands.
(gluten)
45% soluble 45% insoluble
n ethanol in ethanol
(gliadin) (glutenin)
FIG. 1.
PEDIATRICS, January 1960
127
S
INCE Dicke, in 1950, demonstrated thesensitivity for wheat of patients with
celiac disease, tilis disease has presented
itself in a different light. The treatment has
become much simpler and more efficient,
and tile prognosis has become favorable in
almost all cases in which a wheat-free diet
is prescribed.2
At present it is also possible to
demon-state experimentally-with wheat as noxious
agent-the constitutional disposition to this
affection, so that a better understanding can l)e obtained of the nature of the metabolic defect which underlies this disease. The metabolic defect cannot be understood well,
however, if we do not know exactly which
component of wheat causes the harmful effect.
In order to detect this harmful agent,
wheat was split into its components, which
subsequently were individually tested in
patients with celiac disease (Fig. 1). It was proved that neither tile crude fibre non the fat, nor the mineral components exerted a
ilarmful effect. The stanch, which had long
been considered a very harmful substance
for patients with celiac disease was also
shown to be entirely innocuous. It became
clear that the harmful activity of wheat was inherent to the protein, in particular the
gluten. If the gluten is split into gliadin and
gllltenin, the harmful effect proves to he
nlainly caused by the gliadin fraction (Fig.
2). Although gliadin can also be split into
various components, e.g., by means of elec-trophonesis or ultnacentnifugation, these methods were not used by us in the further investigations, because in this way it would he impossible to obtain enough of each frac-tion to enable us to test them clinically.
As, moreover, it is not to be expected
that the separation methods mentioned just now will enable us to split gliadin into components with a markedly different amino-acid composition-while it was
ex-actly the remarkable amino-acid
composi-tion of gliadin (Table I) which drew our attention-the investigation was continued
with gliadin as such.
We directed our attention in the first place to the abnormally high glutamine content of gliadin: 43%. This figure is very high indeed, if one realizes that gliadin must be used for the synthesis of body pro-tein which contains only 17% glutamine. Tile low contents of lysine, methionine, threo-nine, etc. are not factors of importance, be-cause it has been shown that the harmful effect of wheat cannot be counteracted by a diet very rich in proteins; there can there-fore be no question of an amino-acid defi-ciency.
To find out whether the excess of
gluta-mine indeed causes the harmful effect of gliadin, a few children with celiac disease
wheat
:
fat crude fbre
protein
10’/o soluble 90% Insoluble
GiIt
Fic. 2.
CIIEIIIcAL CoIlPosITIoN OF GLIADIN, MILK PROTEIN
AND EGG PROTEIN (CALCULATED TO
16.0 GM OF NITROGEN)
were given 3 gm glutamine pen day. Six the steatorrhea. Glutamic acid (3 to 10 gm weeks later no effect whatever was to be pen day) also proved to be without any observed, neither clinically nor as regards harmful effect.
However this was not vet a sufficient
TABLE! . . ..
reason to discard tile possibility of tne harmfulness of glutamine. Especially the fact that gliadin loses its harmful effect
: _____________________________________ when it is carefully treated with
hydro-(‘1 Milk Egg chlonic acid (Fig. 3) in such a way that it
I zadzn Protein Protein may be assumed that only the glutamine of
--- the protein is converted into glutamic acid,
:
:
:
I while the rest of the protein moleculere-1
:
8.7 6.5 mains practically intact-is an argument in3.() 6.0 4. favor of the opinion that the harmful effect
0.8 1.5 1.5 is still related in some way or other with
5.8 5.5 7.5 glutamine.4 It is indeed not impossible that
the harmful effect of gliadin is caused by
1:9 4.7 4. glutamine in bound form, e.g., hound to
4.4 4.3 8.5 other amino acids, i.e., in peptide form.57
6.1 11 .0 9.4 We can try to verify this hypothesis hi
4.7? 7.5 7.5 various ways. In the first nlace with the
.4 7.0 64
42.8 21 .5 16.0 help of protein-splitting ferments, e.g., with
,9.O 7.5 9.0 pepsin and trypsin gliadin can be split into
1 .3 3.6 mixtures of peptides, and these can be
1.9 3.5 7.4 tested in patients. The clinical behavior and
1 .1 1 .0 8.1 the degree of steatonrhea are taken as
en-Arginine Histidine
Lysine
‘I’yrosine
‘I’ryptophaii Phenylala nine
Cystine
Methionine
Threonine Serine Leucine Isoleucine
Valine Glutamic ado Aspartic acid Glycine
A)anine
Proline
C
Sn
‘5 Cu
L
a,
V
a,
a, 0 U ‘C 0i
‘0
4-0
I
200 .c
‘0
‘5w
150 E
SA as
100 .
4- Sn
E
2 2 22 j 1 2i 1 11/ 21 3/ . 20
ho /10 /10 Ii Ill Ii2 (12 /2 /2 R
T19 % glutamine
Ifl blood
12
‘1
10
8
7
0 1 2 3 4 5hrs.
a462
Fic. 4.
Fic. 3.
tenia. This method is used by Shaw et al.8 and Krainick7 and Haex.9 Some striking re-suits have already been described, e.g., the harmful effect of gliadin is not counter-acted by the action of pepsin or trypsin, but it is abolished when in addition the peptides are entirely split up into amino-acids by the action of an extract of the in-testinal mucosa of a pig.
The problem can also be approached in another way, namely, by trying to find out
whether abnormal substances are present in
the blood of patients with celiac disease after oral loading with gliadin. If glutamine-containing peptides which are formed from gliadin are causing the difficulties in celiac disease, it is to be expected that these sub-stances would also be demonstrable in the blood.
Because we had no specific method to de-termine these peptides in the blood (as neitiler their size non composition was known), we used the method of Prescott and Waelsch, with which glutamine-con-taming peptides and also free glutamine are determined.
Fifty patients with celiac disease were
given loading tests with 350 mg gliadin/kg body weight; the rise of the blood glut-amine level was on an average 90%, while in about 25 normal test subjects the rise was on an average 15%, maximally 40%
(Fig. 4).b0
By using, besides the method of Prescott and Waelsch, the method of Archibald and Knebs, with which only free glutarnine can be determined, it is possible to calculate
9
6
5
4
3
0 1 2 3hrsO
-
blood g/warnine #{247}peptides (method Pescot & Wae/seh)1 2 3hrs 0. 1 2 3hs
blood glulamine
(method Archibald aP7(J tireb)
Fic. 5.
the peptide content by subtracting the results of the two methods from each other.
It now appeared that the rise of the gliadin loading curve is not caused by free glutamine, which justifies the conclusion that it is bound glutamine which appears in the blood, probably in the form of pep-tides (Fig. 5).h1
Alvey and coworkers1l likewise observed
a rise of the blood glutamine, however, after loading with gluten. As they used the method of Archibald and Knebs and not
G 639
that of Prescott and Waelsch, the increase found by them should not be attributed to peptides but to free glutamine. The
in-crease found by them is therefore not
con-sistent with the flat free-glutamine levels
determined by us by means of the
Archi-bald-Krebs method.
By application of the method of Prescott and Waelsch, Payne et al.” also found a rise
of the gliadin tolerance curve, while
Payne, however, did not find such a
nlarked difference between patients with
celiac disease and normal subjects. In a
number of his patients with celiac disease
the rise of tile “glutamine” level did not
occur after loading with 350 mg gliadin;
in the cases who did react, he found in gen-eral a less marked rise than we did in our
cases.
At tile time, we found that only 2 of 50
gliadin tolerance curves determined in
pa-tients with celiac disease did not show a
rise,’ ‘ but of late our results-in the small
number of cases still seen by us-have
been more on less the same as those of
Payne.
We believe that the decreased reaction
to gliadin is due to the fact that at the
present time patients with celiac disease
react less vehemently to wheat than in
the years shortly after the Second World
War. Tilis is not only demonstrated by the
smaller rise after loading with gliadin, but
also by the slower and less catastrophic
re-action to wheat in clinical trials.
Assuming tilat wheat sensitivity is based
on a congenital enzyme deficiency, so that
gliadin is not digested by the body in a
normal way, it is very well possible that the
improved general conditions and especially
the better nutrition (sufficient high-value
proteins) have exerted a strong favorable
influence on tile degree of enzyme
de-ficiency. We may therefore assume that the
threshold value for wheat for patients with
celiac disease is at present higher than
form-erly; hence that a load of 350 mg gliadin/kg
body weight is not in all cases still sufficient
to cause a rise of tile “glutamin” curve.
Fnazer and Krainick take into account
the possibility that the peptides also
con-tam proline, apart from glutamine. They
assume that the enzyme deficiency in celiac
disease consists of a shortage in prolinase
or prolidase, which may cause insufficient
breakdown of proline-containing peptides.
This shortage should not be located in the
intestinal lumen, but in the cells of the
intestinal wall: in the first place, because
the enzymes in the intestinal lumen of a
patient with celiac disease are the same as
those in a normal child, and secondly,
be-cause the harmful action of gliadin, which
is not abolished by pepsin or trypsin, does
disappear after the action in vitro of an
extract of pig intestinal mucosa.8
Moreover, the proline hypothesis is sup-ported by the fact that, by the action of pepsin and trypsin, proline is indeed
liber-ated in vitro from casein and zein (which
are innocuous for patients with celiac
dis-ease7), in contrast to gliadin, from which
proline is only liberated after the addi-tional action of extract of pig intestinal mucosa.
These data, in combination with the fact
that gliadin contains a relatively great
pro-portion of proline (about 12%), led Frazen and Knainick to the hypothesis that the harmful action of wheat is based on a
pro-linase or prolidase deficiency.
When, however, the free proline values in
the blood of patients with celiac disease are
studied after loading with gliadin, a rise
is found equal to that in normal subjects
(Table II). This is difficult to bring in agree-ment with a shortage of prolinase or
proli-dase; therefore, in our opinion it is
im-probable that the peptides in the blood will contain much proline.
The necent publication of Gr#{252}ttner et al.36
also points in this direction; these workers
found (by paper chromatography) peptides which did not contain proline after
hydroly-sis.
In normal children gliadin is broken down to peptides in the stomach and small
in-testine; these peptides are absorbed by the
cells of the intestinal wall and split there
into amino acids.
If, as is the case in celiac disease, glut-amine-containing peptides are found in the blood, this must therefore be a result of incomplete proteolysis of gliadin in the intestinal cell-at any rate, if it is assumed
that the peptides in the blood originate directly from gliadin.
neces-it; 4.6 .8 3.0
1.4 3.2 3.4 2.0
1.9 4.6 .5.0 3.1
2.H 6.6 4.6 3.6
4.2 7.6 5.4 3.4
mean increase: 3.0
1.6 4.2 4.1
1.8 4.3 3.6
2.2 4.2 4.4
2.3 4.7 4.8
2.3 5.6 4.2 3.3
nean increase: 2.6
sary for this has not been formed, on only
to an insufficient degree. Celiac disease,
then, would be based on an “inborn error
of metabolism.”
It is also possible that the enzymes ne-quired are indeed present, but that their activities are inhibited, for example, by an abnormal pH on by inadequate removal of metabolites like NH,. In this fashion, es-pecially in celiac disease and sprue, we might therefore consider the hypotonia and
circulatory disturbances in the intestine, to which attention has been called by De
is
Although in normal subjects there are no grounds for assuming that peptides get into the liver via the portal system and that the liven has therefore probably no function in this respect in healthy persons, it is not excluded that when peptides do get into the liven, as is possible in celiac disease,
the liver would try to break down these
peptides, thus compensating the defect as far as possible. We believe that it is pos-sible that a wheat-containing diet may cause an overloading of the liven in this respect.
All this might be represented
schematic-ally as in Table III. In this schema some
speculations on the question of how the glutamine-containing peptides can cause a
disturbance of the metabolism are also
in-terwoven. The peptides may exert a direct
toxic activity or they may cause an indirect
harmful effect by a blockade of metabolic processes. Perhaps here is to be sought the cause of the excretion of 5-hydroxy-acetic
acid in the urine by patients with celiac disease when they are eating wheat.21
There is also some evidence for the hy-pothesis that the peptides could possess an allergic action, on the basis of antigen-antibody reactions.’9 Moreover several pa-tients have been described in the literature who showed shock-like reactions after ad-ministration of wheat.3’ H 20 This does not
warrant the conclusion, however, that the
reaction to wheat of every patient with
celiac disease has an allergic basis. It seems to us that only patients who, apart from celiac disease, also have an allergic consti-tution will respond to the peptides with a shock-like reaction.
It may also be, although in our opinion
not probable, that the peptides found in the blood do not originate directly from gliadin, but that the peptides in the in-testinal cell which are formed from gliadin cause a blockade of the metabolism, which gives rise to the appearance of other toxic peptides in the blood. This can only be de-cided when the composition of the peptides has been clarified after isolation from the blood.
SUMMARY
Celiac disease is considered “an inborn error of metabolism,” which becomes mainly manifest after the consumption of wheat
(rye, barley, oats). Wheat gluten, especially its gliadin fraction, is shown to be the harmful substance.
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REFERENCES
1. Dicke, W. K.: Coeliakie. Thesis, Univ. of
Utrecht, 1950.
2. Weijers, H. A., van de Kamer,
J.
H.,and Dicke, W. K. : Celiac disease.
Ad-vances Pediat., 9:277, 1957.
3. van de Kamer,
J.
H., Weijers, H. A., and Dicke, W. K. : Coeliac disease IV. Actapaediat., 42:223, 1953.
4. van de Kamer,
J.
H., and Weijers, H. A.: Coeliac disease V. Acta paediat., 44: 465, 1955.5. Weijers, H. A., Dicke, W. K., and van de Kamer,
J.
H. : Enige beschouwingenover coeliakie. Maandschr. kinder-geneesk., 23:451, 1955.
6. Frazer, A. C. : On the growth defect in
coeliac disease. Proc. Roy. Soc. Med.,
49:1009, 1956.
7. Krainick, H. G., et al.: Weitere Untersuch-ungen #{252}berden sch#{228}dliehen Weizen-mehleffekt bei der C#{246}liakie. II. Helvet. paediat. acta, to be published.
8. Shaw, B., Frazer, A. C., Ross, C. A. C.,
and Sammons, H. G. : The digestion of
wheat gluten in the intestinal tract and
its effect on toxicity in coeliac disease.
Third International Congress of
Bio-Arch. Dis. Childhood, 32:434, 1957. 13. Payne, W. W., and Jenkinson, V. : A test
for coeliac disease. Arch. Dis. Childhood, 33:413, 1958.
14. Visakorpi,
J.
K. : Gliadin tolerance test.Ann. paediat. Fenniae, 5:67, 1959. 15. Puranen,
J.,
Puranen, A. L., and Hallman,N. : Determination of plasma glutamine
by high-voltage paper electrophoresis. Ann. paediat. Fenniae, 4:203, 1958. 16. Gr#{252}ttner, R., Mellin, R., and Bramsedt, F.:
Untersuchungen #{252}berdas Auftreten von
Serumpeptiden bei der C#{246}liakie. KIm.
Wchnschr., 37:237, 1959.
17. De Langen, C. D. : Steatorrhoea and the
in-testinal circulation. Acta med. scandinav.
146:7, 1953.
18. Idem: Die Vasomolit#{228}t bei Sprue und anderen Resorptionsstorungen. Gastro-enterologia, 85: 1, 1956.
19. Berger, E. : Zur allergischen Pathogenese
der C#{246}liakie. Basel, S. Karger, 1958. 20. Krainick, H. C., et al. : Weitere
Unter-suchungen #{252}berden sch#{228}dlichen Wei-zenmehleffekt bei der C#{246}liakie.I. Helvet. paediat. acta, 13:432, 1958.
21. Sleisenger, M. H., Law, D. H., Kowlessar, 0. D., Pert,
