Coeliac Disease

Question 1

Define coeliac disease

Answer 1

Inflammatory disease of SMALL COLON caused by intolerance to gluten, causing chronic intestinal malabsorption

Question 2

Aetiology

Answer 2

Genetics - HLA-B8, DR3, DQW2
Sensitivity to gliadin component of gluten
Triggers immunological reaction in the small intestine, leading to mucosal damage and loss of villi

Question 3

Epidemiology

Answer 3

1/2000 in UK
1/300 in west of Ireland
Rare in east asia

Question 4

History/symptoms

Answer 4

Asymtomatic 
Abdo discomfort, pain, bloating 
Steatorrhoea/diarrhoea 
Tiredness, malaise, weight loss despite normal diet 
Failure to 'thrive' in children
Amenorrhoea in young adults

Question 5

Which three genetic markers are associated with coeliac disease?

Answer 5

HLA-B8
DR3
DQW2

Question 6

Explain the pathophysiology behind malabsorption

Answer 6

Sensitivity to gliadin component of gluten

triggers an immunological reaction in the small intestine, leading to mucosal damage and loss of villi

Question 7

Signs

Answer 7

Anaemia - pallor
Malnutrition - short stature, abdo distention, wasted buttocks in children
Vitamin/mineral deficiencies e.g. osteomalacia, easy bruising
Dermatitis herpetiformis - Intense itchy papulovesiclualr blisters on extensors e.g. elbows, knees or buttocks
?clubbing

Question 8

What would you look at as an indication of fat stores?

Answer 8

Triceps skinflap

Question 9

Explain the pathophysiology behind dermatitis herpetiformis

Answer 9

Normally, gliadin is de-amidated by tissue transglutaminase (tTG), however there is often a cross reaction where the antibodies produced against tTG also bind to epidermal transglutaminase and thus cause these herpes-like blisters!

Question 10

Initial investigations

Answer 10

FBC 
Serology
Stool culture
D-xylose test
Endoscopy

Question 11

What would you look at in an FBC for coeliac disease?

Answer 11

• low iron
• low folate
• low Hb
  U&Es
  Albumin (protein losing enteropathy)
  Calcium
  Phosphate

Question 12

What serological tests would you conduct?

Answer 12

Tissue transglutaminase (TTG)
IgG anti-gliadin (AGA)
IgA and IgG anti-endomysial transglutaminase

Question 13

What else must you do with serology?

Answer 13

Measure immunoglobulin levels as low IgA is common in coeliac disease

Question 14

What percentage of people have an IgA deficiency?

Answer 14

1/50

Question 15

Why do you do a stool test?

Answer 15

To exclude infection

To look at fat content (faecal fat tests for steatorrhoea)

Question 16

Explain a D-xylose test

Answer 16

You give a pt oral xylose

If there is reduced urinary excretion, it suggests malabsorption

Question 17

What would endoscopy show?

Answer 17

Flat, smooth mucosa and villous atrophy in small intestine

Question 18

What would a biopsy show of the:

• villi
• crypt
• epithelium
• lamina
• propria

Answer 18

Villous atrophy
Crypt hyperplasia of duodenum
Cuboidal appearance of epithelium (should be simple columnar)
Inflammatory infiltrate in lamina propria

Question 19

Management

Answer 19

Gluten avoidance
Avoid all types of wheat, rye and barley products

Vitamin and mineral supplements
Oral corticosteroids if disease does not subside with gluten withdrawal

Question 20

Complications

Answer 20

Iron, folate and B12 deficiency
Osteopenia/osteoporosis
Ulcerative jejunoileitis

Bacterial overgrowth
Rarely cerebellar ataxia
Small bowel lymphoma = EATL (enteropathy-associated T-cell lymphoma)

Question 21

Prognosis

Answer 21

With strict adherence to gluten-free diet, most patients make a full recovery.
Symptoms usually resolve within weeks. Histological changes may take longer to resolve. A
gluten-free diet needs to be followed for life.

Question 22

What might be seen on biopsy?

Answer 22

Villous atrophy
WBC infiltration
Cryptal hyperplasia

Question 23

Further investigations

Answer 23

Refer to:
Dietitians 
Biopsy 
Screening for first degree relatives 
Bone density scan

Question 24

What would you do if someone’s symptoms don’t improve with a gluten free diet?

Answer 24

Rerefer to dietitian to ensure diet is strictly adhered to

Repeat TTG/serology