Coeliac, CMPA and Toddler's diarrhoea

Question 1

What is coeliac disease?

Answer 1

Enteropathy in which the gliadin faction of gluten provokes a damaging immunological response in the proximal small intestinal mucosa.

Question 2

Epidemiology, RF + PPx of Coeliac?

Answer 2

• Age at presentation is influenced by the age of introduction of gluten into diet. Occurs at 8-24 months following the introduction of wheat-containing food - nowadays presents less acutely in later childhood.
• Immune drive resulting in VILLOUS ATROPHY, CRYPT HYPERPLASIA, and INTRAEPITHELIAL LYMPHOCYTES - contributing to MALABSORPTION.
• RF: Other autoimmune: DMT1/thyroid disease, breast feeding, IgA deficiency

Question 3

Clinical presentation of Coeliac?

Answer 3

1) Failure to thrive/short stature
2) Abdominal pain
3) Diarrhoea
4) Abdominal distention
5) Stinking/fatty stools (steatorrhoea)

Question 4

Ddx of Coeliac?

Answer 4

1) IBD

Question 5

Diagnosis of Coeliac?

Answer 5

1) Should maintain gluten in diet 6 weeks before testing to get true results.
2) Serum antibody testing - NOT DIAGNOSTIC:
- IgA tTG (tissue transglutaminase antibodies)
- endomysial antibody
3) Endoscopy with duodenal biopsy - DIAGNOSTIC
- see villous atrophy, crypt hyperplasia and increased intra-epithelial lymphocytes (these are reversed with a gluten free diet)

Question 6

Treatment of Coeliac?

Answer 6

1) Lifelong gluten free diet
2) When patients present before 2 years a gluten challenge is required in later childhood to demonstrate continued susceptibility of the small intestinal mucosa to gluten damage - take serum antibodies (negative under GF diet), introduce gluten and antibodies should give a positive test.

Question 7

Aetiology of CMPA?

Answer 7

• Occurs in 3-6% of all children and typically presents in the first 3 months of FORMULA-FED INFANTS - rarely it is seen in exclusively breast-fed infants.
• Multi-system disease affecting GI, respiratory (only in IgE mediated) and skin, some exclusively have GI Sx, some GI + skin etc.
• IgE mediated - associated with atopy - eczema, asthma etc. - symptoms occur immediately after ingestion.
• Non-IgE mediated - delayed presentation of symptoms

Question 8

Clinical presentation of CMPA?

Answer 8

1) Colic symptoms - crying, drawing up knees and passage of excessive flatus
2) Can cause GORD, blood/mucus in stools and can result in faltering growth

Question 9

Diagnosis of CMPA?

Answer 9

1) Clinical - symptoms improve after eliminating CMP from diet.
2) Skin prick/patch testing
3) Total IgE and specific IgE (RAST) for CMP

Question 10

Treatment for CMPA?

Answer 10

• In exclusively breastfed babies - tell mother to exclude cows milk protein from her diet.
• In formula-fed babies - change to hypoallergenic extensively hydrolysed or amino acid formula
• Most tend to outgrow by 5 years

Question 11

What is the commonest cause of persistent loose stools in preschool children?

Answer 11

Toddler’s diarrhoea/chronic non-specific diarrhoea

Question 12

How does toddler’s diarrhoea present?

Answer 12

• Stools are varying consistency - sometimes well-formed and other times explosive/loose present with undigested vegetables.
• Affected children are well and thriving - no precipitate dietary factors
• Children tend to outgrow symptoms by 5 years

Question 13

What is the ppx of toddler’s diarrhoea?

Answer 13

• Thought to resell from underlying maturational delay in intestinal motility - leading to intestinal hurry - loose stool NOT from malabsorption

Question 14

How do you treat Toddler’s diarrhoea?

Answer 14

• Symptom relief achieved through ensuring diet contains adequate fat (slows gut transit) and fibre (FAT + FIBRE)
• Children tend to outgrow symptoms by 5 years