Coeliac

Question 1

summarise the key points for coeliac disease?

Answer 1

IDA ( iron deficiency anaemia), steatorrhea, diarrhoea, cramps abdominal pain, bloating, N and V ( weight loss) , anti TTG and anti- endomysial antibodies ( recurrent mouth ulcers)

villus atrophy and crypt hyperplasia and raised intraepithelial lymphocytes ( infiltrating lamina propria)

Remember can be related to osteoporosis/osteomalacia and dermatitis herpetiformis (AI skin condition - papulovesiculorash - related with coeliac’s) and failure to thrive

Question 2

define coeliac disease?

Answer 2

an inflammatory disease caused by intolerance to GLUTEN causing chronic intestinal malabsorption

leads to subtotal villous atrophy and crypt hyperplasia

Question 3

Explain the aetiology of coeliac disease?

Answer 3

due to sensitivity of GLADIN component of the cereal protein, gluten

exposure to gliadin triggers an immunological reaction in the small intestine leading to mucosal damage and loss of villi- lose ability to absorb hence diarrhoea and weight loss

if gluten is removed from diet, villi can return and patient is asymptomatic- damage is REVERSIBLE

Question 4

what are the risk factors for coeliac disease?

Answer 4

10% risk of first- degree relatives being affected

clear genetic susceptibility associated with HLA- B8, HLA- DR3,

Question 5

summarise the epidemiology of coeliac disease?

Answer 5

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

Question 6

what are the presenting symptom of coeliac disease?

Answer 6

may be asymptomatic

abdominal discomfort, pain and distension

steatorrhea ( pale, bulky stool, with offensive smell and difficult to flush)

diarrohea

tiredness, malaise, weight loss ( despite normal diet)

failure to thrive in children

amenorrhea in young adults

Question 7

what are the signs of coeliac disease on physical examination?

Answer 7

signs of anaemia- pallor 
signs of malnutrition 
- short stature 
- abdominal distension 
- wasted buttocks in children 
- triceps skin fold thickness gives indication of fat stores 

signs of vitamin/mineral deficiencies: osteomalacia, easy bruising

intense, itchy bruising on elbows, knees or buttocks ( dermatitis herpetiormis)- lesions are papule and blisters up to 1cm in diameter, itchy on exterior surfaces

Question 8

outline the management plan for coeliac disease

Answer 8

advice- avoid gluten ( wheat, rye and barley products), education, dietary advice

medical- vitamin and mineral supplements, oral corticosteroids if disease does not subside with avoidance of gluten

Question 9

what are the possible complications of coeliac disease?

Answer 9

iron, folate and B12 deficiency

osteomalacia

ulcerative jejuneoileits

GI lymphoma ( particularly T cell ) if untreated coeliac

increased risk of gastric/oesophageal/ bladder/breast/brain malignancy

bacterial overgrowth

cerebellar ataxia ( rarely)

coeliac crisis- RARE- hypovol, water diarrhoea, hypocalcaemia, hypoalbunaemia

Question 10

what is a coeliac crisis?

Answer 10

RARE- hypovolaemia, v watery, diarrhoea, hypocalcaemia, hypoalbuniaemia

Question 11

summarise the prognosis for patients with coeliac disease?

Answer 11

full recovery in most patients who strictly adhere to a gluten free diet

symptom usually resolve within weeks-> though histological changes may take longer

gluten free diet must be followed for life

Question 12

what are the appropriate investigations for coeliac?

Answer 12

blood

serology

stool

d-xylose test

endoscopy

biopsy

bone scan

screening first degree relatives

Question 13

what do we look for in the bloods for coeliac?

Answer 13

FBC ( low Hb, iron, folate)

U and E

Albumin

calcium

phosphate

Question 14

why is a bone scan important when investigating coeliac?

Answer 14

osteopenia / osteoporosis is very common in patients who are newly diagnosed with coeliac disease and screening is recommended as they are likely not absorbing vitD

Question 15

what do we look for on serology when investigating coeliac?

Answer 15

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

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

Question 16

why is it important to investigate stool for coeliac?

Answer 16

culture to exclude infection, faecal fat tests for steatorrhoea

Question 17

why is the D-xylose test important?

Answer 17

reduced urinary excretion after oral xylose indicates small bowel malabsorption

Question 18

what do we look for on endoscopy when investigating coeliac?

Answer 18

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

Question 19

what will a biopsy show for coeliac?

Answer 19

It is important to confirm a diagnosis of coeliac disease with small bowel biopsy, which is most easily obtained during an OGD

○ will show villous atrophy and crypt hyperplasia in the duodenum

○ The epithelium adopts a cuboidal appearance - there is an inflammatory infiltrate of lymphocytes and plasma cells in the lamina propria

Small bowel changes completely resolve if you are adherent to a gluten-free diet, so it is important to get the biopsies before patients change their diet.

Question 20

why is screening first degree relative important for coeliac?

Answer 20

10% of their relatives will have / develop coeliac disease and so first degree relative screening is also recommended.

Question 21

what category of people should coeliacs be ruled out in?

Answer 21

Coeliac should be excluded in all those labelled as IBS