coeliac

Question 1

definition of coeliac

Answer 1

inflammatory disease caused by intolerance to gluten = chronic intestinal malabsorption

immune mediated enteropathy

Question 2

aetiology of coeliac

Answer 2

sensitivity to gladin component of cereal protein, gluten

triggers an immunological rn in SI = mucosal damage and loss of villi

10% risk of 1st degree relatives being affected

genetic susceptibility: HLA-B8, DR3, DQW2 haplotypes

associated with autoimmune disease, dermatitis herpetiformis

Question 3

epidemiology of coeliac

Answer 3

prevalence 1 in 100-300 in W ireland, 1 in 2000 in UK

any age - peak 50-60yr

female more

relative risk in 1st degree relatives - 6x

Question 4

sx of coeliac

Answer 4

insidious - come on over a period of time

younger

tired

weight loss

diarrhoea on and off

may be asymptomatic

abdo discomfort, pain and distension

nausea and vom

steatorrhoea (pale, bulky stool, offensive smell and difficult to flush)

failure to thrive in children

amenorrhoea in young adult

aphthous ulcers

angular stomatitis

osteomalacia

approx 30% less severe - mimic IBD

Question 5

signs of coeliac

Answer 5

anaemia - pallor (IDA)

malnutrition - short, abdo distension and wasted buttocks in children. Triceps skin fold thickness gives indication of fat stores

vit/mineral def - osteomalacia, easy bruising

intense, itchy blisters on elbows, knees or buttocks - dermatitis herpetiformis

Question 6

general Ix for coeliac

Answer 6

blood

serology

stool - exclude infection, faecal fat tests for steatorrhoea

d-oxylose test

endoscopy

HLA DQ2 and DQ8 genotyping may help.

Question 7

blood for coeliac

Answer 7

FBC (low Hb), iron and folate, UE, albumin, Ca, phosphate

low B12

low ferritin

high RCDW

Question 8

serology for coeliac

Answer 8

testing for IgG anti-gliadin (AGA), IgA and IgG anti-endomysial transglutaminase ab - can be diagnostic, anti-tTG Ab

As IgA deficiency is common (1 in 50 with coeliac disease), immunoglobulin levels should also be measured to avoid false negatives.

Question 9

de-oxylose test

Answer 9

reduced urinary excretion after an oral xylose load indicates small bowel malabsorption

Question 10

endoscopy in coeliac

Answer 10

villous atrophy in SI - jujenum and ileum = mucosa has flat, smooth appearance

biopsy - villous atrophy with crypt hyperplasia of duodenum

= reduced SA = widespread deficiency

epithelium is cuboidal, inflammatory infiltrate of lymphocytes and plasma cells in lamina propria

Question 11

mx of coeliac

Answer 11

advice

• gluten free diet - wheat, rye and barley
• rice, maize, soya, potatoes, and sugar are OK. Limited consumption of oats (≤50g/d) may be tolerated in patients with mild disease.

medical

• vitamin and mineral supplements
• oral corticosteroids if disease persists after diet change

monitor response by symptoms and repeat serology

Question 12

complications of coeliac

Answer 12

iron, folate, B12 deficiency

osteomalacia osteopenia/osteoporosis;

ulcerative jejunoileitis

gastrointestinal lymphoma (particular T cell) - suspect if refractory symptoms/weight loss

bacterial overgrowth

cerebral ataxis

dermatitis herpetiformis

hyposplenism - so give flu and pneumococcal vaccinations

increased risk of malignancy - lymphoma, gastic, oesohpageal, colorectal

neuropathies

Question 13

Px of coeliac

Answer 13

With strict adherence to gluten-free diet, most patients make a full recovery.

Symptoms usually resolve within weeks.

Histological changes may take longer

A gluten-free diet needs to be followed for life.