Coeliac

Question 1

What are non GI symptoms of coeliac disease?

Answer 1

Skin rash (dermatitis herpetoformis)
Lactose intolerance
Pancreatic insufficiency

Question 2

What are complications of untreated coeliac?

Answer 2

Malignancy and osteoporosis

Question 3

What is the aspect of wheat that is responsible for coeliac ?

Answer 3

Gliadin

Question 4

What foods is gluten found in?

Answer 4

Wheat, barley and rye

Question 5

What is the pathogenesis of coeliac?

Answer 5

Mucosal damage to the small bowel by triggering an immunological pathway that has an innate or adaptive immune response

Question 6

What genotype is associated with coeliac disease?

Answer 6

HLA-DQ heterodimer in 95% of cases

HLA-DQ2 and HLA-DQ8

Question 7

What are presenting symptoms of coeliac?

Answer 7

GI symptoms- weight loss
Malabsorption
Tiredness
Anaemia (iron deficiency anaemia and pernicious anaemia)
Osteoporosis
Dental enamel defects
Neurological symptoms (chronic inflammatory state)

Overweight can be common too

Question 8

What blood tests would you be looking for to diagnose coeliac?

Answer 8

Positive for

tTG (tissue transglutaminase antibodies)

EMA (endomysial antibodies)

Immunoglobulin-A deficiency (can give a false positive result alone though)

Question 9

What histology is looked for in coeliac diagnosis?

Answer 9

Mucosal parlour
Mosaic pattern
Miconodular appearance
Scalloping
Reduction in duodenal folds

Crypt hypertrophy
Villi atrophy

Question 10

What is the classification system used for coeliac disease severity?

Answer 10

MARSH

Question 11

Describe MARSH 0 classification of coeliac

Answer 11

Normal mucosa

Question 12

Describe MARSH 1 classification of coeliac

Answer 12

Increased number of intraepithelial lymphocytes

Question 13

Describe MARSH 2 classification of coeliac

Answer 13

Increased number of epithelial lymphocytes AND crypt atrophy

Question 14

Describe MARSH 3 classification of coeliac

Answer 14

Partial or complete villous atrophy - classic coeliac lesion

Question 15

Describe MARSH 4 classification of coeliac

Answer 15

Villous atrophy without increased epithelial lymphocytes. (VERY RARE and typically unresponsive to diet therapy)

Question 16

What are long term consequences of untreated coeliac disease?

Answer 16

Malignancy: increased risk of lymphomas in small intestine (non-Hodgkin’s lymphoma)

Increased risk of small bowel adenocarcinoma

Osteoporosis (bone metabolism is disturbed)

Malnutrition (iron, folate, Vit D, Mg, Ca)

Question 17

Calcium requirements for someone with coeliac?

Answer 17

1000-1500 mg/day.

Higher need than usual.

Question 18

Associated comorbidities of coeliac?

Answer 18

Type 1 diabetes
Autoimmune disorders
Abnormal liver function
Dermatitis herpetiformis

Question 19

What is HLA?

Answer 19

Human Leukocyte Antigen

Question 20

In coeliac blood tests what values may be depleted?

Answer 20

Calcium
Magnesium
Total protein
Vitamin D
Albumin

Question 21

Describe the 5 steps of Coeliac pathophysiology

Answer 21

1. Gluten peptides are taken up by the epithelial cells
2. Gluten peptides are disseminated by the enzyme ‘tissue transglutaminase’ in the sub epithelial layer
3. They then fit the antigen binding motif on HLA-DQ2+ antigen presenting cell
4. Recognition by CD4+ T-cells trigger a T-helper cell-1 immune response with generation of pro-inflammatory cytokines (IL-1; INF-gamma; TNF-alpha)
5. Lymphocytes infiltrate the lamina propria and increase in intra-epithelial lymphocytes (IEL) causes crypt hyperplasia and villous atrophy