Coeliac disease Flashcards
Define coeliac disease.
Inflammatory disease caused by intolerance to gluten, causing chronic intestinal malabsorption.
What kind of foods have gluten?
Cereals:
Wheat
Barley
Rye
Oats
What main clinical features should suggest coeliac disease as a diagnosis?
Diarrhoea
Weight loss
Anaemia (esp if iron/B12 is low)
What is the aetiology of Coeliac disease?
Sensitivity to the gliadin component of the cereal protein, gluten, triggers an immunological reaction in the small intestine leading to mucosal damage and loss of villi.
10% of 1st degree relatives being affected and there is a clear genetic susceptibility associated with HLA-B8, DR3, DQW2.
HLADQ2 in 95%; the rest are DQ8; autoimmune disease;
What are the HLA associations in Coeliac disease?
It is strongly associated with:
- HLA-DQ2 (95% of patients)
- HLA-DQ8 (80%)
How common is coeliac disease?
- Affects 1% of the population
- Commoner if Irish
- Rare in East Asia
- Any age but peaks in childhood and 50–60yrs
- M=F
- Relative risk in 1st-degree relatives is 6×.
What are the risk factors for coeliac disease?
- FH of coeliac
- IgA deficiency
- Other specific autoimmune diseases:
- Type 1 diabetes
- AI thyroid disease
- Down’s syndrome
Other: Sjogren;s, IBD, primary biliary cholangitis, psoriasis
Which type of skin condition is associated with Coeliac disease?
dermatitis herpetiformis.
What are the clinical features of Coeliac disease?
- Diarrhoea - chronic , intermittent
- Persistent GI symptoms e.g. N&V
- Prolonged fatigue (‘tired all the time’)
- Cramping
- Distension
- Abdominal discomfort, pain, bloating
- Dermatitis herpetiformis - specific
- Weight loss - sudden or unexpected
- Fe deficiency - otherwise unexplained
Mimics IBS
What are the signs of coeliac disease on examination?
- Anaemia
- Failure to thrive - short stature, abdominal distension, wasted buttocks in children. Triceps skin fold thickness givesn an indication of fat stores
- Vitamin/mineral deficiencies (e.g. osteomalacia, easy bruising)
- Apthous ulcers, angular stomatitis
- Dermatitis herpetiformis - intense, itchy blisters on elbows, knees or buttocks
Other:
- Dental enamel hypoplasia - due to abnormalities in mineralisation
- Peripheral neuropathy - either vitamin deficiencies (B12, E, or D; folate or pyridoxine) or autoimmune activity against neural antigens
What must you ensure before testing for Coeliac?
That the patient is currently ingesting gluten
What investigations would you do for coeliac disease?
Diagnosis:
- Anti-tTG (IgA)* - 1st line is tissue transglutaminase antibody testing according to NICE
- EMA - endomyseal antibody; more expensive than TTG but checks for false negative TTG.
- Endoscopic INTESTINAL biopsy - “gold standard” for diagnosis; usually in duodenum but sometimes jejunum.
NB: anti-gliadin are NOT recommended; anti-casein are found in some patients. *False negative in IgA deficiency.
Other:
FBC (low Hb, high RCDW, low B12, low ferritin), folate deficiency (and rarely B12) may cause macrocytic anaemia
What findings on biopsy are suggestive of Coeliac?
- villous atrophy
- crypt hyperplasia
- increase in intraepithelial lymphocytes
- lamina propria infiltration with lymphocytes
Which type of endocrine disorder is associated with Coeliac disease?
Type I diabetes
autoimmune thyroid disease
How do you manage coeliac disease?
Advice -
- withdrawal of gluten from diet i.e. wheat (bread, pasta, pastry), barley (beer), rye, oats (although some tolerate oats)
- NB rice, maize, soya, potatoes and sugar are okay
- Alternatives are sometimes prescribed
Referral to dietician/gastroenterologist
Coeliac Society
Medical -
- Vitamin and mineral supplements - Ca, Vit D +/- iron
- Pneumococcal vaccine - patients with Coeliac have a degree of hyposplenism; boosted every 5yrs
Coeliac crisis - rehydrate, correct electrolytes and give corticosteroids.
