Against the Grain

Peter H. R. Green became the go-to doc for a shadowy illness by learning to diagnose celiac disease.

by David J. Craig Published Winter 2009-10
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Spotting bad labels

Photo Credit: Levi StoloveGreen has been practicing gastroenterology at Columbia University Medical Center since 1981, and in that time he has diagnosed and treated about 2000 people with celiac disease. He launched the Celiac Disease Center at Columbia, a full treatment, and research operation that employs three full-time doctors and a nutritionist, in 2002.

“I didn’t set out to be an expert at this,” Green says. “I was just doing my job as a gastroenterologist, ordering plenty of blood tests and endoscopies to look for celiac. Along the way I developed a reputation for diagnosing it and I started getting lots of patients by word of mouth.”

First-time patients often arrive at Green’s office frustrated and distrustful of doctors. “These are people who have collected doctors and wrong diagnoses,” he says. “They’ve been told that they have irritable bowel syndrome, perhaps, and so every doctor they see afterwards looks down at his chart and says, ‘OK, Mrs. Smith, how are you managing your irritable bowel syndrome lately? Not well? Oh well, yes, it’s a difficult condition. You need to be more diligent, blah, blah, blah.’”

Over the years, many of Green’s patients have made their medical records available to be studied anonymously, leading the Celiac Disease Center at Columbia to amass one of the country’s largest databases of clinical information on celiac disease. Patients have also given financially to support the center’s research mission, which has enabled Green to become a prolific study author.

In fact, to read the titles of the some 100 papers Green has authored is to survey almost all of the major questions related to the disease’s clinical presentation. Green’s work has helped demonstrate, for example, that very large numbers of celiac patients have thin bones and iron deficiency; that people with celiac have a twofold risk of developing intestinal cancer; that some of the worst health problems associated with celiac disease affect patients with no obvious gastrointestinal symptoms; that a gluten-free diet enables the small intestine to repair itself in all but the most severe cases of celiac disease; and that nonwhite people often develop celiac despite a misconception, common among doctors both in Europe and in the United States, that celiac is a Caucasian disease.

Green also has contributed to the most profound insight into celiac disease in the last half century: that much of its damage doesn’t involve poor digestion at all. Research by Green and others suggests that the small intestine’s inflammatory response can prompt other parts of the body to attack themselves, too, as happened to dermatologist Robyn Gmyrek. Green has helped demonstrate that people with celiac disease have unusually high rates of autoimmune diseases, such as type 1 diabetes, arthritis, Graves’ disease, which attacks the thyroid, and Sjögren’s syndrome, which destroys the mucous glands.

Photo Credits: Levi Stolove“Nearly 30 percent of the celiac patients I’ve seen have another autoimmune disorder, compared to 3 percent of the general population,” Green says. “A gluten-free diet will often lessen the severity of their other disease symptoms.”

Doctors have long observed that autoimmune diseases travel in packs; patients with one of these disorders, therefore, are usually tested for others. But American physicians have been slow to recognize that celiac disease is an autoimmune disorder, instead continuing to regard it simply as a digestive ailment, according to Green. He says this contributes to a lack of screening among people with disorders such as type 1 diabetes, who might unknowingly fuel their illness by eating wheat.

Interestingly, celiac disease is the only autoimmune disorder for which scientists have identified the primary environmental trigger. Scientists know of behavioral factors that contribute to other autoimmune disorders, such as how poor diet influences diabetes, says Govind Bhagat, a Columbia associate professor of clinical pathology who studies celiac disease. But in the case of diabetes, for example, it is suspected that a virus must also weaken the pancreas, and no one’s identified that virus yet. Celiac disease, therefore, provides a unique window into the mechanics of autoimmunity. Scientists know its trigger is gluten, and Bhagat and his colleagues now are asking: Why does the immune response seem to spread to other parts of the body? Are the attacker cells in the small intestine actually migrating? Or do biochemical changes in the small intestine signal to other organs that they should stop regulating their own immune cells?

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