Coeliac Disease (2)

Question 1

What are pts intolerant to here?
→ Which foods is this found in?

Who is more susceptible to this?

What is its pathophysiology?

What are its differentials?

Answer 1

➊ Gliadin (component of Gluten)
→ Wheat, barley, rye

➋ Those with HLA-DQ2 and HLA-DQ8

➌ • Gluten is broken down into Gliadin, which then has its amino acids removed by Tissue Transaminases (TTG)
‣ This deaminated Gliadin binds to APCs and is presented to Th cells, leading to cytotoxic T cell activity → Villous Atrophy
• Crypts become larger to compensate for this decrease in surface area (see on biopsy)
• Humoral response leads to production of Anti-TTG, Anti-Endomyseal, and Anti-Gliadin (good diagnostic markers)

➍ • Non-coeliac gluten insensitivity (NCGS)
• Food allergy
• IBD
• IBS

Question 2

Presentation:
What are its GI symptoms?

What are its systemic symptoms?

Answer 2

➊ • Abdominal pain
• Diarrhoea
• Steatorrhoea
• Bloating
• N+V

➋ • Weight loss and Failure to thrive in children
• Dermatitis Herpetiformis (pruritic papulovesicular lesions over the buttocks and extensor surfaces of the arms, legs, and trunk)
• Fatigue
• Pallor

Question 3

Investigations:
What’s the 1st line test to do if coeliac is suspected?
→ What should be checked if IgA deficient?
→ What should be checked if Anti-TTG weakly +ve?

What’s its gold-standard diagnostic test?
→ What will this show?

What are the basic bloods to do?

Answer 3

➊ Total IgA and Anti-TTG IgA
→ Anti-TTG IgG
→ Anti-Endomyseal

N.B. Some pts are IgA deficient, therefore will have a falsely negative Anti-TTG IgA

➋ OGD and Duodenal/jejunal biopsy
→ Villous atrophy, Crypt hyperplasia, Intraepithelial lymphocytes

➌ • FBC - for anaemia
• U&E, Bone profile
• LFT - malabsorption of albumin
• Ferritin, B12, Folate

N.B. May be worth doing a stool culture to rule out infection

Question 4

How is it managed?

Answer 4

Lifelong Gluten-free diet

N.B. Pts will require regular monitoring to check adherence to a gluten-free diet and to screen for complications

N.B. Dapsone is an antibiotic that can be given to help reduce pruritic symptoms of dermatitis herpetiformis

Question 5

What are its complications?

Answer 5

• Anaemia - Iron, B12, and Folate deficiency
‣ B12 deficiency may also cause peripheral neuropathy
• Osteoporosis - malabsorption of calcium (DEXA scan needed)
• Functional hyposplenism - makes them susceptible to encapsulated organisms (will need -coccal vaccines)
• Enteropathy-associated T cell lymphoma - directly proportional to the pt’s adherence to a gluten free diet