Coeliac disease

Question 1

What is coeliac disease?

Answer 1

Chronic immune mediated systemic disorder in genetically predisposed people, triggered by exposure to dietary gluten
Characterised by inflammatory small bowel enteropathy + presence of coeliac specific autoantibodies

Question 2

What is potential coeliac disease?

Answer 2

Symptomatic or asymptomatic with AB positivity for coeliac disease, but no villous atrophy on duodenal biopsy

Question 3

Non responsive vs refractory coeliac disease

Answer 3

Non responsive - persistent symptoms + enteropathy don’t respond after 6-12 months gluten free diet
Refractory - persisitent or recurrent of otherwise unexplained symptoms and villous atrophy on biopsy despite gluten free diet for 12 months

Question 4

What causes coeliac disease genes

Answer 4

Presence of HLA risk alleles is a factor, esp HLA-DQ2/8
Gluten exposure

Question 5

Complications of coeliac disease?

Answer 5

Depression, anxiety, eating disorders, reduced quality of life
Faltering growth and delayed puberty in children
Nutritional deficincies due to malabsorption
Anaemia - malabsoprtion of iron, folate, vit B12
Reduced bone mineral density - osteoporosis + osteopenia
Hyposplesism

Question 6

Symptoms of coeliac disease

Answer 6

Often non specific
-Persistent, unexplained GI symptoms eg acid reflux, diarrhoea, steatorrhea, weight loss, abdo paun, reduced appetitie, bloating and constipation
IBS
Prolonged fatigue or lethargy

Question 7

Signs of coeliac disease

Answer 7

Mouth ulcers = persistent or recurrent
Faltering gorwth, short stature, delayed puberty
Unexplained iron, B12 or folate deficiency that may cause anaemia
T1DM at diagnosis
Suspected dermatitis herpeteformis

Question 8

Ass diseases with coeliac

Answer 8

Autoimmune thyroid disease eg hashimotos thyroiditis
Autoimmune liver disease - primary biliary cholangutus, sclerosing cholangitis, autoimmune hepatitis
Slective IgA deficiency

Question 9

What is dermatitis herpeteformis?

Answer 9

Immune mediated cutaneous sign of coeliac disease
Symmetrical clusters of itchy blistering skin lesions
Eroisions, excoriations, hyperpigmentation

Question 10

What are some more atypical symptoms that can be associated with coeliac disease?

Answer 10

Unexplained
depression or anxiety
Osteomalacia, penia, porosis, fragility fractures
Peripheral neuropathy or ataxia
Recurrent miscarriage or subfertility
Persistently raised transaminases on LFTs
Dental enamel defects
Hyposplenism or asplenia
Downs, Turners or Williams syndrome

Question 11

History questions for coeliac fdisease

Answer 11

Symptoms of malabsorption - diarrhoea, steatorrhea, weight loss, unexplained acid reflux, abdo pain, bloat, constipation, fatigue
Family history
Risk factors
CLINICAL features of complications
Ass conditions - T1DM, autoimmune thyroid disease

Question 12

What does the patient have to do before they can have coeliac serology testing?

Answer 12

Eat gluten in more than one meal a day for at least 6 weejs before testing

Question 13

Investigations for coeliac disease

Answer 13

Coeliac serology - serum immunoglobulin (IgA) tissue transglutaminase antibody (tTGA) and total IgA (not diagnositc)
Check for IgG EMA, DGP or tTGA if no evidence of IgA deficiency
Referral to gastroenterologist
Endoscopic and intestinal biopsy confirms or excludes diagnososis - histologial changes in small bowel on biopsy

Question 14

Management of coeliac disease primary care

Answer 14

Refer to GE
Refer to dermatology if suspect dermatitis herpeteformis

Question 15

What does the diagnosis of coeliac disease rely on?

Answer 15

Combination of clinical, serological + histopathological findings following duodenal biopsy

Question 16

Serology results

Answer 16

Look up how to interpret

Question 17

Differnetials for coeliac disease

Answer 17

Non-coeliac gluten sensitivity
Food allergy
AIDS enteropathy
Gastroenteritis
Corhns
Micoroscopic colitis
IBS
Diverticular disease
Peptic ulcer disease
Malignancy
Intolerances
Pancreatic exocrine insufficinecy
Hepatobiliary abnormalitis
Small bowel bascterial overgrowth

Question 18

What is NCGS?

Answer 18

Non-coeliac gluten sensitivity
IBS like symptoms and extra intestinal manifestations hours or days after ingestion of gluten
Improves rapidly with gluten removal and relaspes after ingested
Coeliac serology tests and biopsy histology are normal

Question 19

How often should someone with coeliac disease be reviewd in primary care?

Answer 19

Annually

Question 20

What to assess in someone with coeliac disease routinely?

Answer 20

Adherence to non gluten diet
Nutritional defieinciencies - iron, folic acid, calcium, vit D, B12, + if need supplements
Assess risk of osteoporosis + need for DEXA scan in adults - FRAX
Assess for complications or associated conditions
Depression, anciety, eating disorders
Weight, height, BMI

Question 21

What bloods should be taken on annual monitoring coeliac disease?

Answer 21

Coeliac serology - assesses diet adherence
FBC
Ferritin
Thyroid function tests - autoimmune thyroid disease
LFTs - AI liver disease
Calcium, vit D, B12, folate

Question 22

What can thrombocytosis show in someone with coeliac disease?

Answer 22

Hyposplenism

Question 22

What can thrombocytosis show in someone with coeliac disease?

Answer 22

Hyposplenism

Question 23

When to refer to a dieticiain in coeliac disease

Answer 23

Intenitional or inadvertent gluten exposure
Unexplained or persisitent/recurrnet symptoms
Sus nutritional deficiencies and/or growth impairment

Question 24

What complication would require patients to get influenza, pneumococcal and meningococcal vaccinations?

Answer 24

Hyposplenism

Question 25

What foods contain gluten?

Answer 25

Wheat based - cereals, bread, flour, pasta, cakes, pastries, biskets
Wheat, barley or rye as fillers eg sausages, ready meals, soups
Contaminated with gluten in processing - oats, chips in same oul
Malt - most beers

Question 26

What is hyposplenism a risk factor for?

Answer 26

Ass with development of complications + other autoimmune diseases ass with coeliac
Encapsulated bacterial infections eg pneumococcus, H.influenzae + meningococcus infections and sepsis

Question 27

What malignancys are most commonly ass with coeliac disease?

Answer 27

Hodgkins and non-Hpdgkins lymphoma inl EATL (enteropathy ass T cell lymphoma)
Small bowel adenocarcinoma, pancreatic cancer

Question 28

What is ulcerative jejuoileitis a complication of?

Answer 28

Rare complication of refractory coeliac disease

Question 29

What cpmmon blood result can signal coeliac?

Answer 29

Anaemia due to iron or B12 malabsopriton

Question 30

Gold investigations for celiac

Answer 30

Blood test and endoscopy (OGD) and biopsy

Question 31

Where most likely to get positive biopsy in coeliac disease?

Answer 31

second part of duodenum (where get atrophy)

Question 32

Presentation of coeliac disease

Answer 32

• Persistent unexplained GI symptoms
  
  • Diarrhoea/steatorrhea
  • Abdo pain
  • Bloating
• lethargy
• Unexplained weight loss
• unexplained iron, B12, folate deficiency and anemia
• Recurrent mouth ulcers
• Children - failure to thrive, faltering growth
• Dermatitis herpetiformis
  
  • Blistering skin disoder - deposition of IgA in dermis → itchy, vesicular lesions on extensor surfaces

Question 33

What is coeliac disease ass with?

Answer 33

• T1DM
• Autoimmune thyroid disease
• First degree relative

Question 34

Coeliac disease pathology

Answer 34

• Small bowel enteropathy
• Villus atrophy - shorter

Question 35

Blood test for coeliac disease

Answer 35

Serum transglutaminase TTG