19.1 Coeliac disease and inflammatory bowel disease

Question 1

What is coeliac disease?

Answer 1

A sensitivity to gluten, a protein found in wheat, barley and rye, which causes an immune reaction in the lining of the bowel and sometimes the skin (dermatitis herpetiformis).

Question 2

What causes coeliac disease?

Answer 2

There is a genetically inherited susceptibility to the condition, but other factors are believed to be required to trigger the condition such as severe emotional stress, pregnancy, infection.

Question 3

How prevalent is coeliac disease?

Answer 3

1 in 100 people are affected.
1 in 500 are diagnosed.

Question 4

How is coeliac disease diagnosed?

Answer 4

Through a blood test for anti-tissue trans-glutaminase antibodies.

Question 5

What are the effects of coeliac disease on the gastrointestinal tract?

Answer 5

• Villus atrophy: gluten damages the villi lining the small intestine
• Leads to diarrhoea, poor absorption of fats, proteins, iron, vitamins etc.
• Can be diagnosed through an endoscopic biopsy

Question 6

What are the effects of coeliac disease on the skin?

Answer 6

• Dermatitis herpetiformis
• On the back of arms and front of legs
• Skin biopsy

Question 7

What are the effects of coeliac disease on the skeletal system?

Answer 7

• Joint pain
• Osteoporosis

Question 8

Name other symptoms of coeliac disease.

Answer 8

• Stunted growth in infants due to poor nutrition
• Anaemia due to iron and vitamin deficiencies
• Reduced fertility if untreated
• Neurological problems
• Enamel defects
• Recurrent aphthous ulceration

Question 9

Describe the onset of coeliac disease.

Answer 9

• More predominant in women than men
• Peak age of diagnosis in midlife
• Also commonly diagnosed in babies (stunted growth)

Question 10

How is coeliac disease treated?

Answer 10

• Lifelong dietary avoidance: gluten free diet
• Switch from wheat-based products to rice-based, potato-based, maize, buckewheat
• Vitamin replacement e.g. iron, folate, calcium, B12
• Treatment of osteoporosis (main complication due to malabsorption of vitamin D and calcium), scans to check bone density and prescribe medicine where necessary

Question 11

What is IBD?

Answer 11

Chronic, relapsing and remitting (gets better and worse intermittently) inflammatory GI tract disorder of unknown cause.

Question 12

What are the 2 types of IBD?

Answer 12

• Ulcerative colitis
• Crohn’s disease

Question 13

What is the difference between ulcerative colitis and Crohn’s?

Answer 13

• Colitis is inflammation of the colon, only involves the large intestine
• Crohn’s can affect any part of the GI tract
• Crohn’s can present as oral ulcers, anal ulceration (perianal Crohn’s disease)

Question 14

What is the difference in depth of involvement between ulcerative colitis and Crohn’s?

Answer 14

• Crohn’s can affect the full thickness of the gut, including the outside of the gut (serosa)
• Ulcerative colitis only involves the mucosa and submucosa

Question 15

What are the 3 main patterns of presentation of Crohn’s?

Answer 15

Because the full thickness of the gut layers can be involved, there are 3 main patterns of behaviour:
- Inflammatory
- Stenotic
- Fistulising

Question 16

What is inflammatory Crohn’s?

Answer 16

• Wall of bowel inflamed
• Can cause malabsorption of vit B12
• Bowel narrowing
• Diarrhoea

Question 16

What is stenotic Crohn’s?

Answer 16

• Narrowed bowel wall creates blockage
• Causes adjacent part to become distended
• Causes obstruction, vomiting and pain

Question 17

What is fistulising Crohn’s?

Answer 17

Parts of the gut stick/connect to other organs e.g. bladder, vagina, skin. Creates fistulae.
Painful and unpleasant.

Question 18

What are the different extents of ulcerative colitis?

Answer 18

UC can affect different parts of the large intestine.
- Procitis: only affecting the lower end of the large intestine
- Left sided
- Pancolitis: entire large intestine affected

UC always affects the lower part of the bowel.
Extent of UC dictates treatment choice.

Question 19

What is the prevalence and epidemiology of IBD?

Answer 19

• Most prevalent in Europe, Canada and USA
• Intermediate levels in Australasia and South Africa

In the UK:
- 1 in 500 have UC
- 1 in 1000 have Crohn’s

Peak onset of UC and Crohn’s is early to mid-20s.
Slight male predominance with Crohn’s.

Question 20

What are the causes of IBD?

Answer 20

Seems to be a combination of genetic and environmental factors.
- Family history = increased risk
- Several genes identified with increased risk
- Luminal antigens
- Environmental triggers: gut infections, antibiotics, NSAIDs, diet, stress, smoking

Question 21

What are the blood test findings in patients with IBD?

Answer 21

• Decreased haemoglobin, albumin, iron, folate, B12
• Increased ESR, CRP, WBC, platelets, faecal calprotectin

Question 22

What are the differences in symptoms between UC and Crohn’s?

Answer 22

Question 23

What are the extraintestinal manifestations of IBD related to disease activity?

Answer 23

Inflammation of joints, eyes and skin

Question 24

How is IBD treated?

Answer 24

• Medication (steroids, immunosuppressive drugs, biologic therapy)
• Lifestyle changes (diet)
• Surgery (post operative recurrence of Crohn’s is common, surgery is not a common treatment choice)
• Nutritional support
• Emotional support

Question 25

What are the oral consequences of Coeliac disease?

Answer 25

• Dental enamel defects, enamel hypoplasia
• Tooth discolouration
• Mottled teeth
• Delayed eruption
• Aphthous ulcers

Question 26

What are the oral consequences of Crohn’s disease?

Answer 26

• Recurrent aphthous ulcers
• Oral granulomatosis
• Gingivitis
• Angular cheilitis
• Immunosuppressive drugs can lead to oral thrush

Question 27

What are the oral consequences of ulcerative colitis?

Answer 27

• Aphthous ulcers
• Xerostomia
• Pyostomatitis vegetans (pustules on the oral mucosa)

Question 28

Compare the possible oral conditions associated with Crohn’s vs UC.

Answer 28

Extensive, don’t need to know every single one.