Coeliac disease Flashcards
What is coeliac disease?
Chronic immune mediated systemic disorder in genetically predisposed people, triggered by exposure to dietary gluten
Characterised by inflammatory small bowel enteropathy + presence of coeliac specific autoantibodies
What is potential coeliac disease?
Symptomatic or asymptomatic with AB positivity for coeliac disease, but no villous atrophy on duodenal biopsy
Non responsive vs refractory coeliac disease
Non responsive - persistent symptoms + enteropathy don’t respond after 6-12 months gluten free diet
Refractory - persisitent or recurrent of otherwise unexplained symptoms and villous atrophy on biopsy despite gluten free diet for 12 months
What causes coeliac disease genes
Presence of HLA risk alleles is a factor, esp HLA-DQ2/8
Gluten exposure
Complications of coeliac disease?
Depression, anxiety, eating disorders, reduced quality of life
Faltering growth and delayed puberty in children
Nutritional deficincies due to malabsorption
Anaemia - malabsoprtion of iron, folate, vit B12
Reduced bone mineral density - osteoporosis + osteopenia
Hyposplesism
Symptoms of coeliac disease
Often non specific
-Persistent, unexplained GI symptoms eg acid reflux, diarrhoea, steatorrhea, weight loss, abdo paun, reduced appetitie, bloating and constipation
IBS
Prolonged fatigue or lethargy
Signs of coeliac disease
Mouth ulcers = persistent or recurrent
Faltering gorwth, short stature, delayed puberty
Unexplained iron, B12 or folate deficiency that may cause anaemia
T1DM at diagnosis
Suspected dermatitis herpeteformis
Ass diseases with coeliac
Autoimmune thyroid disease eg hashimotos thyroiditis
Autoimmune liver disease - primary biliary cholangutus, sclerosing cholangitis, autoimmune hepatitis
Slective IgA deficiency
What is dermatitis herpeteformis?
Immune mediated cutaneous sign of coeliac disease
Symmetrical clusters of itchy blistering skin lesions
Eroisions, excoriations, hyperpigmentation
What are some more atypical symptoms that can be associated with coeliac disease?
Unexplained
depression or anxiety
Osteomalacia, penia, porosis, fragility fractures
Peripheral neuropathy or ataxia
Recurrent miscarriage or subfertility
Persistently raised transaminases on LFTs
Dental enamel defects
Hyposplenism or asplenia
Downs, Turners or Williams syndrome
History questions for coeliac fdisease
Symptoms of malabsorption - diarrhoea, steatorrhea, weight loss, unexplained acid reflux, abdo pain, bloat, constipation, fatigue
Family history
Risk factors
CLINICAL features of complications
Ass conditions - T1DM, autoimmune thyroid disease
What does the patient have to do before they can have coeliac serology testing?
Eat gluten in more than one meal a day for at least 6 weejs before testing
Investigations for coeliac disease
Coeliac serology - serum immunoglobulin (IgA) tissue transglutaminase antibody (tTGA) and total IgA (not diagnositc)
Check for IgG EMA, DGP or tTGA if no evidence of IgA deficiency
Referral to gastroenterologist
Endoscopic and intestinal biopsy confirms or excludes diagnososis - histologial changes in small bowel on biopsy
Management of coeliac disease primary care
Refer to GE
Refer to dermatology if suspect dermatitis herpeteformis
What does the diagnosis of coeliac disease rely on?
Combination of clinical, serological + histopathological findings following duodenal biopsy
Serology results
Look up how to interpret
Differnetials for coeliac disease
Non-coeliac gluten sensitivity
Food allergy
AIDS enteropathy
Gastroenteritis
Corhns
Micoroscopic colitis
IBS
Diverticular disease
Peptic ulcer disease
Malignancy
Intolerances
Pancreatic exocrine insufficinecy
Hepatobiliary abnormalitis
Small bowel bascterial overgrowth
What is NCGS?
Non-coeliac gluten sensitivity
IBS like symptoms and extra intestinal manifestations hours or days after ingestion of gluten
Improves rapidly with gluten removal and relaspes after ingested
Coeliac serology tests and biopsy histology are normal
How often should someone with coeliac disease be reviewd in primary care?
Annually
What to assess in someone with coeliac disease routinely?
Adherence to non gluten diet
Nutritional defieinciencies - iron, folic acid, calcium, vit D, B12, + if need supplements
Assess risk of osteoporosis + need for DEXA scan in adults - FRAX
Assess for complications or associated conditions
Depression, anciety, eating disorders
Weight, height, BMI
What bloods should be taken on annual monitoring coeliac disease?
Coeliac serology - assesses diet adherence
FBC
Ferritin
Thyroid function tests - autoimmune thyroid disease
LFTs - AI liver disease
Calcium, vit D, B12, folate
What can thrombocytosis show in someone with coeliac disease?
Hyposplenism
What can thrombocytosis show in someone with coeliac disease?
Hyposplenism
When to refer to a dieticiain in coeliac disease
Intenitional or inadvertent gluten exposure
Unexplained or persisitent/recurrnet symptoms
Sus nutritional deficiencies and/or growth impairment
What complication would require patients to get influenza, pneumococcal and meningococcal vaccinations?
Hyposplenism
What foods contain gluten?
Wheat based - cereals, bread, flour, pasta, cakes, pastries, biskets
Wheat, barley or rye as fillers eg sausages, ready meals, soups
Contaminated with gluten in processing - oats, chips in same oul
Malt - most beers
What is hyposplenism a risk factor for?
Ass with development of complications + other autoimmune diseases ass with coeliac
Encapsulated bacterial infections eg pneumococcus, H.influenzae + meningococcus infections and sepsis
What malignancys are most commonly ass with coeliac disease?
Hodgkins and non-Hpdgkins lymphoma inl EATL (enteropathy ass T cell lymphoma)
Small bowel adenocarcinoma, pancreatic cancer
What is ulcerative jejuoileitis a complication of?
Rare complication of refractory coeliac disease
What cpmmon blood result can signal coeliac?
Anaemia due to iron or B12 malabsopriton
Gold investigations for celiac
Blood test and endoscopy (OGD) and biopsy
Where most likely to get positive biopsy in coeliac disease?
second part of duodenum (where get atrophy)
Presentation of coeliac disease
- Persistent unexplained GI symptoms
- Diarrhoea/steatorrhea
- Abdo pain
- Bloating
- lethargy
- Unexplained weight loss
- unexplained iron, B12, folate deficiency and anemia
- Recurrent mouth ulcers
- Children - failure to thrive, faltering growth
- Dermatitis herpetiformis
- Blistering skin disoder - deposition of IgA in dermis → itchy, vesicular lesions on extensor surfaces
What is coeliac disease ass with?
- T1DM
- Autoimmune thyroid disease
- First degree relative
Coeliac disease pathology
- Small bowel enteropathy
- Villus atrophy - shorter
Blood test for coeliac disease
Serum transglutaminase TTG
