Lecture 32 Flashcards
(28 cards)
Describe how Pippa first was recognised with coeliacs?
Pippa:
- Breastfed till 11mths, started solid. Within eating solids, starting getting grumpy, stools changed in colour and smell.
- Fat stomach and tiny bottom and lots of rash.
What is coeliacs disease?
Abnormal lining of the small bowel that improves after excluding wheat from the diet.
How was coeliacs diagnosed in the past?
When there was significant weight loss and multiple problems with absorption of nutrients (vitamins). The diagnosis was confirmed by a small bowel biopsy.
How else was coeliacs diagnosed in the past?
Blood tests using gliadin antibody tests, however there were problems with false positives and negatives.
What is an “iceberg” analogy of coeliac disease?
The overt reverse disease is at the top and mild or silent disease forming the majority below sea level.
What is the cause of coeliac disease?
There is a strong genetic component to the disease. 1:10 1st degree relatives will have coeliac disease. There are two genes: HLA DQ2 and DQ8. Common in people with northern european ancestry.
What is the pathogenesis of coeliac disease?
Gluten exposure required. Abnormal cellular and humeral response to gain ( a component of gluten) probably causes mucosal damage. Exposure of immunologically active epitope requires tissue transglutaminase (extracellular matrix enzyme).
What is the pathology of the coeliac disease?
Villous atrophy and hypertrophy of crypts, intraepithelial lymphocytes.
What is the pathophysiology of the coeliac disease?
Loss of brush border enzymes, loss of stimulus for pancreatic and bile secretion (low pancreozymin and secretin), exudation of protein across denuded mucosa.
Describe the antibodies affairs the enzyme transglutaminase?
They’re not cytotoxic. They are a by-product of the inflammation and damage caused by activated immune cells.
What is the Marsh cycle?
Stage 0: normal mucosa.
Stage 1: Increased number of intra-epithelial lymphocytes (IELs).
Stage 2: Crypt proliferation.
Stage 3: Partial or complete villous atrophy and crypt hypertrophy.
Stage 4: Hypoplasia of the SI architecture.
How does Coeliacs present in children?
1) Failure to thrive.
2) Diarrhoea, irritable and poor appetite.
3) May present as fe deficiency, short stature, abdominal distension or part of family screening.
How does coeliacs present in adults?
Silent during childhood.
1) Abdominal bloating and discomfort.
2) Iron deficiency with or with our anaemia is suggestive.
3) Additional finding of folate deficiency makes diagnosis highly likely.
4) Screening relatives:
-1:10 first degree relatives will be positive and 1:35 second degree relatives.
-Up to 25% of people with coeliacs are identified by screening method.
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What are coeliac antibodies?
1) Anti-TTG (tissue transglutaminase antibody) IgA - recommended.
2) Anti-EMA (endomysial antibody) IgA.
3) Anti-DGP (deaminated gliadin peptide) IgA.
Why can’t Anti-gliadin antibodies be used anymore?
Due to poor accuracy; replaced by newer generation deaminated form anti-DGP. The antibodies tested able by the lab are IgA, so may be falsely negative in IgA deficiency. If IgA deficiency, will need IgG form of the above antibodies.
Why should coeliac antibodies be requested?
1) Unexpected iron deficiency anaemia.
2) Folate and B12 deficiency.
3) Fatigue.
4) IBS with prominent bloating.
5) Early onset or severe osteoporosis.
6) Type 1 diabetes - taking insulin (4% positive).
7) Auto-immune thyroid disease.
How do you diagnose coeliacs disease?
1) Blood test for Anti-TTG IgA.
2) Testing family members using HLA DQ2 and HL:A DQ8.
3) If antibody test is positive - gastroscopy and duodenal biopsy (showing loss of small bowel villi).
How do you treat coeliacs disease?
Gluten-free diet. There is a rapid improvement in symptoms, but complete improvement takes 6-12 months.
Why has adherence to “gluten-free diet” become easier?
Wide range of commercially available gluten-free foods and the mandatory labelling of foods for gluten content.
Are dietary supplements required during the first 6-12 months of the diet?
No, except if there are nutritional deficiencies. Vitamin D supplements are appropriate.
What do coeliacs have an intolerance to?
Proteins fractions in wheat (gliadin), rye (secalins) and barley (hordeins). These grains contain a critical amino acid sequence that is involved in initiating the immune process.
What are other options for wheat?
Quinoa, millet, sorghum, buckwheat, amaranth.
What else can people with coeliacs eat?
Meat, fish, vegetables and fruit.
What are foods that coeliacs cannot eat due to contamination?
1) Wheat starch.
2) Distilled alcohol.
3) Distilled white vinegar.
4) Malt and malt extract.
