Coeliac Disease

Question 1

Define Coeliac Disease?

Answer 1

An inflammatory disease caused by intolerance to GLUTEN, causing chronic intestinal malabsorption
It leads to subtotal villous atrophy and crypt hyperplasia

Question 2

What is the aetiology of Coeliac Disease?

Answer 2

Due to sensitivity to the GLIADIN component of gluten
Exposure to gliadin triggers and immunological reaction in the small intestine leading to mucosal damage and loss of villi
10% risk of first-degree relatives being affected
Clear genetic susceptibility associated with HLA-B8, HLA-DR3 and HLA-DQW2 haplotypes

Question 3

What is the epidemiology of Coeliac Disease?

Answer 3

UK: 1/2000
West Ireland: 1/300
Rare in East-Asia

Question 4

What are the presenting symptoms of Coeliac Disease?

Answer 4

May be asymptomatic
Abdominal discomfort, pain and distention
Steatorrhoea
Diarrhoea
Tiredmess, malaise, weight loss (despite normal diet)
Failure to ‘thrive’ in children
Amenorrhoea in young adults

Question 5

What is Steatorrhoea?

Answer 5

Pale bulky stool with offensive smell and difficult to flush away

Question 6

What are the signs of Coeliac Disease on physical examination?

Answer 6

Signs of Anaemia
Signs of malnutrition
Signs of vitamin/mineral deficiencies
Dermatitis Herpetiformis

Question 7

What are the signs of anaemia you can see in Coeliac Disease?

Answer 7

Pallor

Question 8

What are the signs of malnutrition you can see in Coeliac Disease?

Answer 8

Short stature
Abdominal distension
Wasted buttocks in children
Triceps skinfold thickness gives indication of fat stores

Question 9

What are the signs of vitamin/mineral deficiencies you can see in Coeliac Disease?

Answer 9

Osteomalacia

Easy bruising

Question 10

What is dermatitis Herpetiformis?

Answer 10

Intense, itchy blisters on elbows, knees or buttocks

Question 11

What bloods would you do for Coeliac Disease?

Answer 11

FBC 
U&Es
Albumin
Calcium
Phosphate

Question 12

What do you look for specifically on a FBC for Coeliac Disease?

Answer 12

Low Hb, iron and folate

Question 13

What serology can you use to investigate Coeliac Disease?

Answer 13

IgG anti-gliadin antibodies, IgA and IgG anti-endomysial transglutaminase antibodies can be diagnostic

Question 14

What’s important to remember with Ig levels in Coeliac Disease?

Answer 14

IgA deficiency is quite common (1/50 with coeliac) so Ig levels should be measured to avoid false negatives

Question 15

Why do we do a stool culture for Coeliac Disease?

Answer 15

Exclude infection, faecal fat tests for steatorrhoea

Question 16

What is the use of the D-xylose Test?

Answer 16

Reduced urinary excretion after oral xylose indicates small bowel malabsorption

Question 17

Why do we do an endoscopy for Coeliac Disease?

Answer 17

Allows direct visualisation of villous atrophy in the small intestine (mucosa appears flat and smooth)

Question 18

What can we see on a Biopsy for Coeliac Disease?

Answer 18

Show villous atrophy and crypt hyperplasia in the duodenum
The epithelium adopts a cuboidal apperance - there is an inflammatory infiltrate of lymphocytes and plasma cells in the lamina propria

Question 19

What advice do you give to someone with Coeliac Disease?

Answer 19

Avoid gluten (wheat, rye, and barley products)

Question 20

What is the medical management plan for Coeliac Disease?

Answer 20

Vitamin and mineral supplements

Oral corticosteroids if disease doesn’t subside with avoidance of gluten

Question 21

What are the possible complications of Coeliac Disease?

Answer 21

Iron, folate and B12 deficiency
Osteomalacia
Ulcerative jejunoiletis
GI lymphoma (particularly T cell)
Bacterial Overgrowth
Cerebellar ataxia (rarely)

Question 22

What is the prognosis for patients with Coeliac Disease?

Answer 22

Full recovery in most patients who strictly adhere to a gluten-free diet
Symptoms usually resolve within weeks though histological changes may take longer
Gluten-free diet must be followed for life