Coeliac Disease

Question 1

What is coeliac disease?

Answer 1

A common disease affecting about 1 in 100 people in the UK.

It is due to an immunological reponse to the gliadin fraction of gluten leading to an immunological response.

It is a T-cell response to gluten (wheat, barley, rye) in the small bowel causing villous atrophy and malabsorption.

Question 2

Associations of coeliac disease.

Answer 2

HLA DQ2 in 95% of cases.

The rest are DQ8

Autoimmune disease

Dermatitis herpetiformis

Question 3

Epidemiology of coeliac disease.

Answer 3

1 in 100-300 and more common if Irish.

Any age, it peaks in childhood as well as 50-60 yo.

1:1 gender ratio

Relative risk in 1st degree relatives is 6 times.

Question 4

Clinical features of coeliac disease.

Answer 4

Stinking stools/steatorrhoea

Diarrhoea

Abdo pain

Bloating

N+V

Aphthous ulcers

Angular stomatitis

Weight loss

Fatigue

Weakness

OSteomalacia

Failure to thrive in children

Dermatitis herpetiformis.

Iron def. anaemia

Question 5

There may be no symptoms at all of coeliac disease.

How is it then picked up?

Answer 5

Found incidentally when investigation ID anaemia or due to a family history of coeliac disease.

Question 6

Investigations of coeliac disease.

Answer 6

Bloods - FBC, U&Es, B12, ferritin

Antibody serology (anti-tissue transglutaminase - Anti-TTG and endomysial antibodies (EMAs)

Duodenal biopsy while on a gluten containing diet.

Genotyping if there is still doubt.

Question 7

Diagnosis of coeliac disease

Answer 7

Investigations must be carried out whilst the patient remains on a diet containing gluten otherwise it may not be possible to detect antibodies or inflammation in the bowel.

Check total immunoglobulin A levels to exclude IgA deficiency before checking for coeliac disease-specific antibodies:

Raised anti-TTG antibodies (first choice)

Raised anti-endomysial antibodies

Endoscopy and intestinal biopsy show:

“Crypt hypertrophy”

“Villous atrophy”

Question 8

What antibody serology should be done when investigating coeliac disease.

Answer 8

anti-tissue transglutaminase (antibodies to tTG) is raised in most cases.

However it is an IgA antibody so check IgA levels to exclude subclass deficiency.

Question 9

What is the diagnostic test of coeliac disease?

Answer 9

Duodenal biopsy and oesophageal-gastro-duodenal biopsy.

Question 10

Findings on biopsy of coeliac disease.

Answer 10

Villous atrophy

Increased intra-epithelial WBCs

Crypt hyperplasia

Question 11

Treatment of coeliac disease.

Answer 11

Lifelong gluten free diet.

Rice, maize, sugar, soya and potatoes are OK.

Wheat, barley and rye should be avoided to all costs. Oats might be able to be introduced.

Question 12

Complications of untreated coeliac disease.

Answer 12

Anaemia

Dermatitis herpetiformis

Osteoporosis

Hyposplenism

GI T-cell lymphoma

Neuropathies like gluten ataxia and neuropathy

Small bowel lymphoma

Small bowel cancer