Coeliac Disease

Question 1

A 12 month old boy presents with chronic diarrhoea since 6 months of age. He has never had any vomiting or fevers. He was thriving for the first 6 months of life, after which his weight gain has plateaued. This change coincided with the introduction of solids. He is pale, with a protuberant abdomen and wasted buttocks.

Answer 1

Impression
Given chronic diarrhoea and now FTT temporally related to introduction of solids, am concerned about coeliac disease in this 12 month old boy.

DDx include;
- Infective: C.Diff, Giardia lamblia infection
- autoimmune causes (IBD - rare in this age group)
- Food intolerances: lactose intolerance, CMPI/FPIES
- GI pathology: CF
- other: Toddlers diarrhoea, dietary causes.

Question 2

Coeliac disease - History

Answer 2

History
- sx: characterise diarrhoea: frequency, related to eating? quantity, characteristic (floats, mucousy, etc), abdo discomfort ,distension, etc, urinary changes, diet and nutrition
- extra-intestinal manifestations: neuro, developmental delay, poor growth, irritability, rashes (autoimmune)
- RISKS: fam history, other autoimmune disease
- paeds history, obstetric history

Question 3

Coeliac disease - Examination

Answer 3

Examination
- general appearance
- growth parameters
- abdo: distension, pain/tenderness/discomfort

Question 4

Coeliac disease - Investigations

Answer 4

Investigations
key/diagnostic
- coeliac serology (total IgA + tissue transglutaminase (tTG) IgA). Anti-endomysial antibodies if tTG is equivocal.
- need to be on gluten diet for 2 weeks, endoscopy with intestinal biopsy (upper) looking for crypt hyperplasia, lymphocytes at the borders, intestinal villous atrophy

• Bedside: stool OCP + MCS for infective causes, faecal calprotectin
• Bloods: UEC, LFT, CRP/ESR, FBC, iron studies

Question 5

Coeliac disease - Management

Answer 5

Management
supportive
- adherence to gluten free diet: avoiding all foods containing gluten
- regular review for compliance to diet, monitoring growth parameters
- because thyrogastric cluster
o BSL (T1DM)
o TFTs
o coeliac serology
o micronutrients, haematinics
- correct any nutritional deficiencies
- join parent and coeliac support groups
- regular follow-up to assess symptoms and adherence

Complications;
- infertility
- thyrogastric cluster
- Non-hodgkins lymphoma