coeliac disease

Question 1

tell me about Coeliac disease

Answer 1

Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten. It is thought to affect around 1% of the UK population. Repeated exposure leads to villous atrophy which in turn causes malabsorption

Question 2

symptoms of coeliac disease

Answer 2

Chronic or intermittent diarrhoea

Failure to thrive or faltering growth (in children)

Persistent or unexplained gastrointestinal symptoms including nausea and vomiting

Prolonged fatigue (‘tired all the time’)

Recurrent abdominal pain, cramping or distension

Sudden or unexpected weight loss

Unexplained iron-deficiency anaemia, or other unspecified anaemia

Question 3

complications of coeliac disease

Answer 3

anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies

Question 4

conditions associated with coeliac disease

Answer 4

Autoimmune thyroid disease
Dermatitis herpetiformis
Irritable bowel syndrome
Type 1 diabetes
First-degree relatives (parents, siblings or children) with coeliac disease

Question 5

Symptoms of coeliac disease mnemonic

Answer 5

GI malabsoprtion
Lymphoma and carinoma
Immune association
Anaemia
Dermatalogical

Question 6

Symptoms of coeliac disease GI malabsorption

Answer 6

Carb: NVD, abdo distension, flatus, wt loss.
fat: steatorrhoea, hyperoxaluria (urine oxalate)
protein: protein losing enteopathy
heamatinics: reduce folate and fe –> anaemia
vitamins:
vitamin D and Ca, bone pain, osteoparosis
Vit K –> petechiae and increased INR
B2 (riboflavin) –> angular stomatitis
B1 & B6 –> polyneuropathy

Question 7

Symptoms of coeliac disease lymphoma and carcinoma

Answer 7

Enteropathy-associated T-cell lymphoma
Adenocarcinoma of small bowel
Other Ca: breast, bladder, breast

Question 8

Symptoms of coeliac disease immune

Answer 8

IgA deficiency
T1DM
PBC

Question 9

Symptoms of coeliac disease anemia

Answer 9

↑ or ↓ MCV

Hyposplenism: Howell-Jolly bodies, target cells

Question 10

Symptoms of coeliac disease dermatological

Answer 10

Dermatitis herpetiformis: 15-20%
Symmetrical vesicles, extensor surfaces
Esp. elbows
Very itchy
Responds to gluten-free diet or dapsone
Biopsy: granular deposition of IgA
Aphthous ulcers

Question 11

Investigations in coeliac disease

Answer 11

Bloods: FBC, LFTs (↓alb), INR, Vit D and bone, red cell
folate, serum B12
Abs
Anti-endomysial IgA (95% specificity)
Anti-TTG IgA
Both above ↓ c¯ exclusion diet
Anti-gliadin IgG persist c¯ exclusion diet)
IgA ↑ in most but may have IgA deficiency
Stools
Stool cysts and antibody: exclude Giardia
OGD and duodenal biopsy
Subtotal villous atrophy
Crypt hyperplasia
Intra-epithelial lymphocytes

Question 12

treatment of coeliac disease

Answer 12

Rx
Lifelong gluten-free diet
Avoid: barley, rye, oats, wheat
OK: Maize, soya, rice
Verify diet by endomysial Ab tests
Pneumovax as hyposplenic
Dermatitis herpetiformis: dapsone

Question 13

what things to consider when investigating coeliac disease

Answer 13

correct investigations are a paired tissue transglutaminase (TTG) and IgA. This is because TTG antibodies are IgA type, but IgA deficiency is very common. Therefore, without confirming that overall IgA levels are normal, it would not be possible to exclude coeliac disease.

However, when patients exclude gluten from their diet, their TTG antibody levels return to normal. Patients must eat gluten as part of their normal diet for at least 6 weeks before they are tested for coeliac disease. Therefore, this is the most appropriate course for the GP to follow.