Coeliac disease

Question 1

What is coeliac disease?

Answer 1

It is the most common autoimmune condition characterised by inflammation of the intestinal mucosa leading to a wide range of clinical manifestations

Question 2

What are the Oslo definitions for Coeliac disease?

Answer 2

1. Classical CD

• Symptoms and signs of GI malabsorption
• Positive coeliac antibodies and villous atrophy on duoedenal biopsy
  2. Non-classical CD
• Most common presentation
• Extraintestinal manifestations such as fatigue are predominant
• Patients have positive coeliac antibodies and villous atrophy on duodenal biopsy

   3. Subclinical CD

• No overt symptoms or signs
• Positive test for coeliac antibodies and intestinal damage on biopsy

   4. Potential CD (Latent CD)

• Positive coeliac antibodies but no histological evidence of intestinal damage

Question 3

What is the pathophysiology of coeliac disease?

Answer 3

• Gluten is the principal storage protein in wheat which has proline and glutamine rich proteins
• **Proline and glutamine **are highly resistant to digestion and in genetically predisposed individuals can trigger an immune response
• The prevalence is 1-2%
• It is mostly provoked by wheat, rye and barley

Question 4

What are the clinical features of coeliac disease?

Answer 4

• Varied presentations
• Classic tetrad of diarrhoea, weight loss, iron/folate deficiency and abdominal bloating
• Classial CD presents with malabsorption and GI symptoms
• Non classical is common which presents with malaise, lethargy, pallor and mucosal ulcers

Question 5

What are the risk factors?

Answer 5

• Genetic predisposition (1 in 10)-first degree
• Type 1 Dm and Downs Syndrome

Question 6

Who needs to be tested for coeliac disease?

Answer 6

• Chronic or intermittent diarrhoea
• Failure to thrive
• Irritable bowel syndrome
• Suddne or unexpected weight loss
• Autoimmune thyroid/Type 1 DM
• Dermatitis herpetiformis
• First degree relative with CD
  Recurrent nausea, vomiting, bloating or abdominal pain
• Other autoimmune disease
• Bone disease such as osteoporosis
• Mood disorders
• Unexplained alopecia

Question 7

How to diagnose Coeliac Disease?

Answer 7

• HLA DQ2/DQ8 can be helpful in certain circumstances
• >99% of patients with CD carry one of these, a negative test rules out CD
• FBC/iron studies/B12/folate/vitamin D and LFT ar eother tests undertaken

Question 8

How to manage patients with CD?

Answer 8

• Lifelong gluten free diet- refer to a dietitian
• Strict GFD reduced the risk of osteoporosis, other autoimmune diseases and small bowel lymphoma
• The adverse effects of GFD diet is constipation,weight gain and micronutrient deficiencies
• Uncontaminated oats can be added to the diet after consultation with the specialist and dietitian
• Treat micronutrient deficiencies (iron, vitamin B12, folate, calcium and vitamin D)
• Review for presence of other autoimmune conditions
• Review immunisation status and ensure are fully vaccinated including annual influenza and Strep.pneumoniae
• Evaluate BMD for hose with delayed diagnosis, post fragility #< post-menopausal women, men over 55 years)
• Join coeliac support group

Question 9

What does the follow-up involve?

Answer 9

At 3-6 months;

• Antibody leves should be falling
• Symptoms should be resolving
• Micronutrient deficiencies should be resolving
• Recommend screenign for first degree relatives

At 12 months;

• Review GFD adherence
• Review symptoms
• Review for complications
• If recovery inadequate, consider specialist referral