Coeliac disease in adults

Question 1

What is coeliac disease?

Answer 1

Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten.

Question 2

What percentage of the UK population is thought to be affected by coeliac disease?

Answer 2

It is thought to affect around 1% of the UK population.

Question 3

What leads to malabsorption in coeliac disease?

Answer 3

Repeated exposure to gluten leads to villous atrophy, which in turn causes malabsorption.

Question 4

What skin condition is associated with coeliac disease?

Answer 4

Dermatitis herpetiformis, a vesicular, pruritic skin eruption.

Question 5

What autoimmune disorders are associated with coeliac disease?

Answer 5

Type 1 diabetes mellitus and autoimmune hepatitis.

Question 6

What HLA types are strongly associated with coeliac disease?

Answer 6

HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).

Question 7

What did NICE issue in 2009 regarding coeliac disease?

Answer 7

NICE issued guidelines on the investigation of coeliac disease.

Question 8

What are some signs and symptoms that should prompt screening for coeliac disease?

Answer 8

Chronic or intermittent diarrhoea, failure to thrive or faltering growth (in children), persistent gastrointestinal symptoms, prolonged fatigue, recurrent abdominal pain, sudden weight loss, unexplained anaemia, autoimmune thyroid disease, dermatitis herpetiformis, irritable bowel syndrome, type 1 diabetes, and first-degree relatives with coeliac disease.

Question 9

What are some complications of coeliac disease?

Answer 9

Anaemia (iron, folate, and vitamin B12 deficiency), hyposplenism, osteoporosis, lactose intolerance, enteropathy-associated T-cell lymphoma, subfertility, and unfavourable pregnancy outcomes.

Question 10

What rare malignancies are associated with coeliac disease?

Answer 10

Oesophageal cancer and other malignancies.

Question 11

What causes coeliac disease in children?

Answer 11

Coeliac disease is caused by sensitivity to the protein gluten.

Question 12

What leads to villous atrophy in coeliac disease?

Answer 12

Repeated exposure to gluten leads to villous atrophy, which causes malabsorption.

Question 13

At what age do children typically present with coeliac disease?

Answer 13

Children normally present before the age of 3 years, following the introduction of cereals into the diet.

Question 14

What is the incidence of coeliac disease?

Answer 14

The incidence of coeliac disease is around 1:100.

Question 15

Which HLA types are strongly associated with coeliac disease?

Answer 15

Coeliac disease is strongly associated with HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).

Question 16

What features may coincide with the introduction of cereals in coeliac disease?

Answer 16

Features may include failure to thrive, diarrhoea, and abdominal distension.

Question 17

How may older children present with coeliac disease?

Answer 17

Older children may present with anaemia.

Question 18

When are many cases of coeliac disease diagnosed?

Answer 18

Many cases are not diagnosed until adulthood.

Question 19

What is a key diagnostic test for coeliac disease?

Answer 19

A jejunal biopsy showing subtotal villous atrophy is a key diagnostic test.

Question 20

What are useful screening tests for coeliac disease?

Answer 20

Anti-endomysial and anti-gliadin antibodies are useful screening tests.

Question 21

What causes coeliac disease?

Answer 21

Coeliac disease is caused by sensitivity to the protein gluten.

Question 22

What are the consequences of repeated exposure to gluten in coeliac disease?

Answer 22

Repeated exposure leads to villous atrophy which in turn causes malabsorption.

Question 23

What conditions are associated with coeliac disease?

Answer 23

Conditions associated with coeliac disease include dermatitis herpetiformis and autoimmune disorders such as type 1 diabetes mellitus and autoimmune hepatitis.

Question 24

How is coeliac disease diagnosed?

Answer 24

Diagnosis is made by a combination of serology and endoscopic intestinal biopsy.

Question 25

What happens to villous atrophy and immunology on a gluten-free diet?

Answer 25

Villous atrophy and immunology normally reverses on a gluten-free diet.

Question 26

What guidelines did NICE issue regarding the investigation of coeliac disease?

Answer 26

NICE issued guidelines on the investigation of coeliac disease in 2009.

Question 27

What should patients do if they are already on a gluten-free diet before testing?

Answer 27

Patients should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing.

Question 28

What is the first-choice serology test for coeliac disease according to NICE?

Answer 28

Tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE.

Question 29

What is the purpose of endomyseal antibody testing?

Answer 29

Endomyseal antibody (IgA) is needed to look for selective IgA deficiency, which would give a false negative coeliac result.

Question 30

Are anti-gliadin antibody tests recommended by NICE?

Answer 30

Anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE.

Question 31

What is the 'gold standard' for diagnosing coeliac disease?

Answer 31

Endoscopic intestinal biopsy is the 'gold standard' for diagnosis.

Question 32

Where is the endoscopic intestinal biopsy traditionally performed?

Answer 32

Traditionally done in the duodenum but jejunal biopsies are also sometimes performed.

Question 33

What findings are supportive of coeliac disease?

Answer 33

Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes.

Question 34

Is rectal gluten challenge widely used?

Answer 34

Rectal gluten challenge has been described but is not widely used.

Question 35

What is the primary management for coeliac disease?

Answer 35

The management of coeliac disease involves a gluten-free diet.

Question 36

Which cereals contain gluten?

Answer 36

Gluten-containing cereals include wheat, barley, rye, and oats.

Question 37

What are examples of gluten-containing foods made from wheat?

Answer 37

Examples include bread, pasta, and pastry.

Question 38

Is whisky safe for patients with coeliac disease?

Answer 38

Whisky is made using malted barley, but proteins such as gluten are removed during the distillation process, making it safe to drink for patients with coeliac disease.

Question 39

What notable foods are gluten-free?

Answer 39

Gluten-free foods include rice, potatoes, and corn (maize).

Question 40

How can compliance with a gluten-free diet be checked?

Answer 40

Tissue transglutaminase antibodies may be checked to assess compliance.

Question 41

What vaccination is recommended for patients with coeliac disease?

Answer 41

All patients with coeliac disease are offered the pneumococcal vaccine.

Question 42

How often should patients with coeliac disease receive the pneumococcal vaccine booster?

Answer 42

Patients should have a booster every 5 years.

Question 43

What does Coeliac UK recommend regarding pneumococcal vaccination?

Answer 43

Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection.

Question 44

How is the influenza vaccine administered to patients with coeliac disease?

Answer 44

Current guidelines suggest giving the influenza vaccine on an individual basis.

Question 45

Answer 45

Duodenal biopsy from a patient with coeliac disease. Complete atrophy of the villi with flat mucosa and marked crypt hyperplasia. Intraepithelial lymphocytosis. Dense mixed inflammatory infiltrate in the lamina propria.

Question 46

Answer 46

Duodenal biopsy from a patient with coeliac disease. Flat mucosa with hyperplastic crypts and dense cellular infiltrate in the lamina propria. Increased number of intraepithelial lymphocytes and vacuolated superficial epithelial cell vacuolated superficial epithelial cells. Higher magnification image on the right.