Of chapatis and irritable bowel syndrome

Priscah* walked in looking a little hesitant. She was a first-time patient looking for a second opinion. With January being a fairly slow month in office, I had all the time to listen to her concerns.

She had been to see the doctor because of recurrent lower abdominal pains that had progressively gotten worse over the past month. She had undergone a pelvic ultrasound and had been diagnosed with adenomyosis. Adenomyosis is a gynaecological condition in which the inner lining of the uterus, the endometrium, invades the muscle layer of the uterus, lodging within the muscle fibers. 

The endometrial tissue is special in that it responds to the cyclic reproductive hormones of the woman, thickening throughout the cycle, and shedding off as a period at the end of the cycle as a period. Therefore, when it is located in other tissues, the bleeding occurring during menses will have to accumulate within this tissue. 

For endometriosis, the bleeding accumulates within the muscle fibers, causing intense pain as the irritated muscle fibers contract in an effort to expel this blood. As a result, the commonest symptom of adenomyosis in many women suffering from the condition is painful periods. They also tend to be very heavy and prolonged, and in severe disease, may actually result in intermenstrual spotting. 

As we chatted with Priscah, it was obvious that these were not her classical symptoms. She noted that she had never experienced period pain, and that since the start of her periods, she had maintained a regular 28-day menstrual cycle, bleeding for three days, and her flow was more on the light side. 

As we delved into her pain, she noted that she experienced pain throughout the cycle. The pain was on and off and would tend to be severe towards the early hours of the morning. This prompted a conversation away from her reproductive system, toward her digestive system. She noted that her stool varied a lot, sometimes from mild constipation, to gaseous bloating and mild diarrhoea. 

Bingo! We were clearly on the right track. We had a conversation regarding the upcoming surgery. Despite her reservations, Priscah had agreed to go through with the surgery because she desperately needed the pain to stop. She was agreeable to withholding the surgery as we further clarified her diagnosis. 

We came up with a plan to keep a food diary for the next two weeks and review it together afterwards. The diary was also expected to include the pelvic pains; when they happened and whether she had diarrhoea, constipation or bloating. I had a strong hunch that Priscah’s adenomyosis was not the problem. Furthermore, she was 48 years old and menopause was around the corner. Alongside surgery, she had a lot more treatment options available to her because of her age, hence surgery was not an emergency. 

Over the next few weeks, my hunch was proven right. Priscah’s problem was gluten intolerance. The food diary was able to demonstrate that every time she ate food with gluten in the diet, she would end up with gaseous bloating and diarrhoea. Going on a gluten-free diet for the next six weeks resulted in Priscah’s symptoms resolving! She was overjoyed, she did not need surgery. However, I referred her to a gastroenterologist for continued care. 

Priscah was struggling with gluten intolerance; a condition where a person is unable to tolerate gliadin or glutenin, components of the protein gluten. This protein is widely found in wheat, barley, rye or oats. 

Food sensitivities are classified into food allergies, which are immune-mediated; or food intolerances, which are non-immune-mediated. With regard to gluten allergies, the condition is known as Celiac disease or Celian sprue. This is a condition that manifests fairly early in childhood, with gluten diet triggering the immune system to regard the gluten as foreign, hence it fights back.

The manifestation of the immune system fighting back is inflammation of the intestinal lining, damaging it, hence interfering with digestion. This causes poor absorption of nutrients, resulting in nutrient deficiencies that manifest in multiple ways. 

Common intestinal symptoms include gaseous bloating; abdominal pain; diarrhoea; loss of weight, especially in infants and young children; and general fatigue and body weakness due to poor nutrition. 

Due to poor absorption, deficiency in micronutrients results in anaemia because of low iron; low calcium causing rickets and even osteoporosis in older people; skin rashes due to low zinc, vitamin A and C; abnormal sensation and muscle weakness due to vitamin B-12 deficiency; and hormonal abnormalities in men and women, manifesting as poor fertility and irregular menses for women. 

Food intolerance is more common and is not due to an unhappy immune system. Hence, the symptoms are less severe, as the intestines simply have a problem processing a specific food component; as is the case for gluten insensitivity.  The gut is unable to digest the gluten, hence it hinders absorption too. 

Gluten insensitivity doesn’t quite have a well-defined diagnostic process medically, hence it is best diagnosed when absence of gluten in the diet results in absence of symptoms. However, despite this, the patient benefits from an upper gastrointestinal endoscopy to collect biopsies of the upper intestine for study under the microscope to ensure that it is not celiac’s disease. Other diagnostic tests may not be as readily available in our set-up but blood tests do exist. 

For a long time, celiac disease was regarded as a white people’s disease. However, this is simply not correct. The traditional African diet did not have wheat; and barley was mostly used for brewing. This resulted in very limited exposure to wheat. 

Now, not only is wheat reserved for celebratory occasions like Christmas, it is a mainstream food product on our tables as we step away from corn, millet and root starch foods that we traditionally ate. Therefore, a lot more people are manifesting symptoms that seem to progressively get worse with age, especially in women in the perimenopause period. 

Treatment of gluten intolerance is dietary. There is no shortcut around complete avoidance of gluten. This means no chapati, pancakes, naan, mandazi, samosa, pasta, pizza, burgers, bread, cake, sandwiches, the list is endless. It takes a lot of discipline to enforce these dietary restrictions yet it is the one treatment that the patient is fully in charge. 

Unfortunately, President William Ruto’s promise of free chapati for school children may not be the healthiest promise for some of them. However, it is worth noting that with wheat products having taken centre stage, mankind is always looking for options. This has resulted in an increasing availability of gluten-free wheat flour that may just save our little ones from feeling left out, especially with regard to snacks for school. 

Dr Bosire is a gynaecologist/obstetrician