Coeliac

Question 1

When a celiac disease patient reaches adolescence, what beverage should be warned against?

Answer 1

Beer

Question 2

Why is it important to give celiac disease patients a “trial of gluten” after their condition has normalized?

Answer 2

In some cases, gluten intolerance is transient

Question 3

What grains contain gluten?

Answer 3

Wheat

Barley

Rye &

Oats (to a lesser extent)

Question 4

What is the overwhelmingly common (80 %) presentation of celiac disease?

(4)

Answer 4

1.  FTT
2.  Irritability
3.  Explosive & foul-smelling stool
4.  Vomiting

Question 5

At what age do celiac disease patients usually come to medical attention?

Answer 5

Toddlerhood

Question 6

What are the main changes expected on evaluation of an intestinal biopsy in a celiac disease patient?

Answer 6

1.  Villus flattening/atrophy
2.  Lymphocytes in the lamina propria
3.  Crypt hyperplasia

Question 7

What is the “classic” body habitus for a celiac disease patient?

Answer 7

Short kid, bloated abdomen, & wasted buttocks

Question 8

Although mucosal biopsy is the gold standard for diagnosing celiac disease, what lab test is nearly as good?

Answer 8

Anti-tTG-IgA antibody test

A level 10× normal is expected in celiac

Question 9

Why should you continue to consider celiac disease if the antibody test is negative?

Answer 9

Some celiac disease patients are also IgA deficient

Question 10

Which possible celiac patients do not require biopsy confirmation?

Answer 10

Those with positive anti-TTG-IgA antibody tests

  +

Celiac compatible HLA types (HLA-DQ2 or DQ8)

Question 11

What hematologic abnormality is often found in celiac disease patients?

Answer 11

Microcytic anemia

Question 12

How long should you expect to wait before a gluten-free diet improves a celiac disease patient to normal?

Answer 12

Up to 6 months

Question 13

What oncologic diseases are celiac patients at increased risk for, if they do not stay on a gluten-free diet?

(2 general sorts)

Answer 13

Intestinal lymphoma

& Small bowel cancers

(and sometimes other malignancies)

Question 14

What is gluten?

Answer 14

After starch has been extracted from wheat flour, gluten is the residue that remains. This residue is made up of multiple proteins that are distinguished by their solubility and extraction properties. For example, the alcohol-soluble fraction of wheat gluten is wheat gliadin. It is this protein component that is primarily responsible for the mucosal injury that occurs in the small bowel in patients with celiac disease. The alcohol-soluble components of barley and rye are also toxic.

Question 15

What classic clinical features suggest celiac disease?

Answer 15

Gluten-sensitive enteropathy (celiac disease) is a relatively common cause of severe diarrhea and malabsorption in infants and children. The classic presentation of celiac disease is a 9- to 24-month-old child with FTT, diarrhea, abdominal distention, muscle wasting, and hypotonia. After several months of diarrhea, growth slows; weight typically decreases before height. Often, these children become irritable and depressed and display poor intake and symptoms of carbohydrate malabsorption. Vomiting is less common. On examination, the growth defect and distention are commonly striking. There may be a generalized lack of subcutaneous fat, with wasting of the buttocks, shoulder girdle, and thighs. Edema, rickets, and clubbing may also be seen. Many patients with celiac disease, however, have a more subtle presentation rather than the classic constellation of symptoms and can present at an older age.

Question 16

What are possible nongastrointestinal manifestations of celiac disease?

Answer 16

• Dermatitis herpetiformis
• Iron deficiency anemia (unresponsive to treatment with oral iron supplements)
• Arthritis and arthralgia
• Dental enamel hypoplasia
• Chronic hepatitis
• Osteopenia and osteoporosis
• Pubertal delay
• Short stature
• Hepatitis
• Arthritis

Question 17

What is the definitive way to diagnose celiac disease?

Answer 17

Definitive diagnosis of celiac disease requires multiple small bowel biopsies via endoscopy while the patient is on a gluten-containing diet. Intestinal biopsies obtained on gluten may show a number of abnormalities including villous atrophy, elongated crypts, increased crypt mitoses, increased intraepithelial lymphocytes, plasma cell infiltrate in lamina propria, absence of brush border, and disorganization and flattening of the columnar epithelium (“villous blunting”). These abnormalities should resolve fully with repeat biopsies after a strict gluten-free diet. Recent European guidelines have recommended that the need for confirmatory biopsy can be omitted in children with clear symptoms of celiac disease, with high levels of transglutaminase antibody and with positive HLA typing. Celiac disease is strongly associated with HLA-DQ types 2 and 8.

Question 18

What is the mainstay of treatment for celiac disease?

Answer 18

A strict gluten-free diet needs to be followed throughout life, although nearly one in four patients continues to experience gastrointestinal symptoms. Gluten-free diets should be without wheat, barley, and rye. Upon initial diagnosis, most recommend avoiding oats because of contamination, but eventually most patients with celiac can tolerate oats. Good substitutions are rice and corn flour products.