C - Coeliac

Question 1

typical presentation for coeliac

Answer 1

tiredness, muscle aches, weight loss
+/- GI symptoms

Question 2

TATT bloods

Answer 2

FBC
U&Es
LFTs
Glucose

Question 3

what type of anaemia is seen in coeliac

Answer 3

microcytic, hypochromic

Question 4

3 causes of microcytic anaemia

Answer 4

iron deficiency
thalassaemia trait
anaemia of chronic disease

Question 5

what things are you looking at on a blood film

Answer 5

cell types
number of each cell type
morphology of cells - ie shape
inclusions
colour (RBCs)

Question 6

what does a poikilocyte RBC indicate

Answer 6

iron deficiency

Question 7

what does anisopoikilocytosis

Answer 7

variation in shape and size

Question 8

what does anisopoikilocytosis on blood film indicate

Answer 8

iron deficiency

Question 9

what is basophilic stippling

Answer 9

aggregated ribosomal material of basophils

Question 10

what causes basophilic stippling

Answer 10

beta thalassaemia trait
lead poisoning
alcoholism
sideroblastic anaemia

Question 11

what does a hypersegmented neutrophil indicate

Answer 11

megaloblastic anaemia (impaired DNA synthesis)

Question 12

what causes hypersegmented neutrophils / megaloblastic anaemia

Answer 12

b12 deficiency
folate deficiency
drugs

Question 13

what do target cells indicate

Answer 13

iron deficiency
thalassaemia
hyposplenism
liver disease

Question 14

what are target cells aka

Answer 14

codocytes

Question 15

what is the SA:vol ratio like in target cells

Answer 15

high SA:vol ratio

Question 16

what are howell jolly bodies

Answer 16

nuclear remnants in RBC

Question 17

what do howell jolly bodies look like

Answer 17

dark dot in RBC

Question 18

what do howell jolly bodies indicate

Answer 18

hyposplenism

Question 19

causes of iron deficiency

Answer 19

blood loss
poor diet
malabsorption
combination of any of these

Question 20

causes of megaloblastic change

Answer 20

b12 deficiency
folate deficiency
poor diet
pernicious anaemia

Question 21

causes of hyposplenism

Answer 21

absent spleen
- trauma
- therapeutic
poor functioning spleen
- SLE
- IBD
- coeliac
- sickle cell

Question 22

what is the biochem of coealic

Answer 22

low Ca
high ALP, normal LFTs
low vit D
high PTH

Question 23

low Ca
high ALP, normal LFTs
low vit D
high PTH
what is this also the biochem of

Answer 23

secondary hyperparathyroidism (vitamin D deficiency)

Question 24

why is ALP high in coeliac

Answer 24

secondary hyperparathyroidism due to low vit D causes chronic low Ca –> osteoclasts take Ca from bone to maintain blood levels –> chronic bone loss

Question 25

DDx of coeliac

Answer 25

Crohns stress lesser: menorrhagia pancreatic disease lymphoma

Question 26

what blood levels would be different in crohns and coeliac

Answer 26

coealiac = low iron, b12, folate, fat, ca crohns = low b12, bile salts

Question 27

Ix for coeliac

Answer 27

CRP, ESR anti TTg and anti e upper GI endoscopy / duodenal biopsy foecal calprotectin

Question 28

what HLA do 90% of coeliacs have

Answer 28

HLA DQ2

Question 29

how is pathogenicity of crohns and coeliac different

Answer 29

crohns is autoinflam coeliac is autoimmune (therefore has auto ABs)

Question 30

what is coeliac

Answer 30

abnormal immune response to gluten

Question 31

what component of gluten causes the issue in coeliac

Answer 31

gliadin

Question 32

how are gliadin peptides broken down

Answer 32

deaminated by TTG

Question 33

what cell mediates the damage done in coeliac & how

Answer 33

gamma delta T cells expressing IEL --> damaging duodenal epithelial cells

Question 34

what type of ABs are anti TTG / anti e

Answer 34

IgA ABs

Question 35

how specific are anti TTG

Answer 35

95%

Question 36

what can cause a false negative with anti TTG ABs

Answer 36

if the patient is IgA deficient, the AB will be negative as they're anti TTG ABs

Question 37

when are the anti TTG ABs gone in coeliac

Answer 37

when gluten is avoided

Question 38

if the ABs come back positive, do you still need OGD? why / why not?

Answer 38

YES - need a baseline and need to confirm diagnosis

Question 39

gold standard diagnosis of coeliac

Answer 39

duodenal biopsy

Question 40

what is the normal villi:crypt ratio

Answer 40

4:1

Question 41

how many lymphocytes does a normal duodenal villus have per 100 epithelial cells

Answer 41

<20

Question 42

where should the duodenal biopsy be taken from in the duodenum & why

Answer 42

2nd part of duodenum - first contains Brunner's gland which can distort the architecture

Question 43

what is characteristic of coeliac on biopsy (3)

Answer 43

villous atrophy crypt hyperplasia >25 lymphocytes / 100 epithelial cells

Question 44

what other diseases look like coeliac on biopsy

Answer 44

Sprue enteropathy Giardia

Question 45

how can a pt have coeliac but have normal biopsy

Answer 45

if they're currently on a gluten free diet

Question 46

what can't you eat if you're on a gluten free diet

Answer 46

wheat barely rye some oats additives !!

Question 47

what are the long term complications of coeliac

Answer 47

lymphoma !! malabsorption osteoporosis / osteomalacia epilepsy hyposplenism cerebral calcification

Question 48

why do coeliacs need ongoing monitoring

Answer 48

ensuring adherence to diet

Question 49

what Ix are done for ongoing monitoring in coeliac

Answer 49

haem: FBC, iron, B12, folate, PT biochem: Ca, PO43, LFT, U&E anti TTG and anti e DEXA of hip and spine every 3-5yrs

Question 50

what can cause a persistent anti TTG AB+ in coeliac

Answer 50

not adherence to diet LYMPHOMA

Question 51

if coeliac is undiagnosed, what complications are they at risk of

Answer 51

low vit D, B12, folate, iron, K ++++ malignancy risk 2x mortality risk

Question 52

associated conditions with coeliac

Answer 52

dermatitis herpetiformis T1DM AI thyroid disease Down's all other AIDs

Question 53

what is the prevelance of dermatitis herpetiformis in coeliac

Answer 53

100%

Question 54

where is dermatitis herpetiformis

Answer 54

elbows

Question 55

what % of coeliacs have T1DM

Answer 55

7%

Question 56

when should you consider coeliac tests (4)

Answer 56

iron def anaemia chronic diarrhoea recurrent mouth ulcers IBS