Coeliac disease

Question 1

What is coeliac disease? Where is gluten found?

Answer 1

An autoimmune systemic disorder that is triggered by gluten exposure.

Gluten is a complex protein that is found in wheat, barely, and rye.

Gluten is found in any food that contains those cereals, including:
- pasta
- cakes
- breakfast cereals
- most types of bread
- certain types of sauces
- some ready meals

Question 2

Complications of coeliac disease?

Answer 2

Reduced quality of life (because pts have to be very careful in what they eat as gluten is found in many food products, particularly processed food)

Depression, anxiety

Younger pts can have faltered growth and delayed puberty

Nutritional deficiencies
- malabsorption of iron, vitamin B12, folate, vitamin D, calcium from GI inflammation
- very common for coeliac disease pts to have osteopenia and osteoporosis as a result

Hyposplenism, asplenism (under performing function of spleen)

Increased risk of non-Hodgkin’s lymphoma, small bowel adenocarcinoma, pancreatic cancer

Question 3

Pathophysiology of coeliac disease?

Answer 3

Genetic predisposition
- associated with certainhuman leukocyte antigen(HLA) genotypes:
- HLA-DQ2
- HLA-DQ8

Immune-mediated
- when pt eats gluten, it triggers an immune response within the small bowel epithelium that absorbs the gluten. It develops coeliac-specific autoantibodies and lymphocytes come to the area, where both will destroy the villi (villous atrophy) within the small bowel that are responsible for nutrient absorption. Therefore, it leads to small bowel enteropathy with systemic symptoms.

Question 4

Presentation of coeliac disease?

Answer 4

• diarrhoea
• steatorrhoea (fatty stool, appears loose, fluffy and can float in water)
• constipation
• wt loss
• heartburn
• abdominal pain
• bloating
• flatulence (increase gas)
• fatigue
• rash
• abdominal tenderness, distention
• dermatitis herpetiformis (symmetrical/bilateral rash, pruritic -itchy, blistering-like lesions; commonly found in elbows, knees, shoulders, buttocks, sacral region, face) (herpes is unilateral rash)

Question 5

How is coeliac disease diagnosed?

Answer 5

Serum IgA tissue transglutaminase antibody (tTGA) and serum total IgA
- Before this test, pt must eat gluten for more than one meal a day for at least 6 wks.
- Does not confirm diagnosis, but to check if further assessment is needed.
- If elevated, refer for endoscopy for small bowel

Endoscopic intestinal biopsy
- confirms diagnosis
- villi might look smooth if it’s destroyed
- must eat gluten before procedure

Question 6

Management of coeliac disease?

Answer 6

Gluten-free diet.
- refer to dietician
- can eat CRAP: corn, rice, applesauce, potatoes

Assess nutritional deficiencies.
- provide supplementation if indicated
- iron, vitamin B12, folate, vitamin D, calcium

Assess the need for DEXA scan.

Annual blood monitoring
- coeliac serology
- FBC, ferritin
- TFTs (because coeliac is an autoimmune disease)
- LFTs
- Calcium
- vitamin D
- vitamin B12
- folate

Immunisation
- influenza
- meningococcal
- pneumococcal