Coeliac Disease

Presentation

• Persistent unexplained abdominal or gastrointestinal symptoms
• Faltering growth
• Prolonged fatigue
• Unexpected weight loss
• Severe or persistent mouth ulcers
• Iron deficiency anaemia

History warranting serological testing

Family history or coeliac disease
Past medical history:

• IBS
• T1DM at diagnosis
• Autoimmune thyroid disease, at diagnosis
• Unexplained iron, vitamin B12 or folate deficiency

Examination

• Alopecia
• Aphthous stomatitis
• Bruising
• Peripheral neuropathy
• Ataxia

Bedside tests

• Blood pressure
• ABG - to detect acidosis
• FBC and blood smear
  • Low Hb and microcytic red cells
  • Iron deficiency anaemia most common presentation of coeliac disease in adults

Differential Diagnosis

• Peptic duodenitis
• Crohn's disease

Laboratory investigations

Serological testing

• High IgA-tTG: Total immunoglobulin A (IgA) and IgA tissue transglutaminase (tTG)
• Test for IgA endomysial antibodies (EMA) if IgA tTG is weakly positive
• Explain that the test is accurate only if a gluten-containing diet is eaten during the diagnostic process

Radiological investigations

Endoscopy

• Atrophy and scalloping of mucosal folds; nodularity and mosaic pattern of mucosa may be evident but are not useful diagnostic indicators

Management

First line

• Dietary advice
  • information on which types of food contain gluten and suitable alternatives
  • Offer explanations of food labelling
  • How to manage social situations e.g eating out and travelling away from home
  • Advice on avoiding cross contamination in the home and minimising the risk of accidental gluten intake
  • Explain the role of national and local coeliac support groups
  • Calcium or vitamin D if their dietary intake is insufficient
    • Ergocalciferol (1000-2000 units orally o.d) and calcium carbonate (1000-1500 mg/day orally given in 3-4 divided doses)

Cases of Refractory coeliac disease

• Persistent severe diarrhoea
• Abdominal pain
• Sudden unexplained weight loss
• Gluten excluded as the cause of ongoing symptoms)

Management:

• Consider endoscopic intestinal biopsy if continued exposure to gluten has been excluded and: 1) serological titres are persistently high and show little or no change after 12 months OR

2) patient has persistent symptoms, including diarrhoea, abdominal pain, weight loss, fatigue or unexplained anaemia

• This is because RCD is associated with an increased risk of malignancy, especially enteropathy T-cell lymphoma
• Consider prednisolone for the initial management of RCD

Coeliac crisis

• Patients present with hypovolaemia, severe watery diarrhoea, acidosis, hypocalcaemia, and hypoalbuminaemia
• Rehydration and correction of electrolyte abnormalities
• Short course of glucocorticoid therapy (budesonide 9 mg orally o.d or prednisolone 40-60 mg orally o.d then taper)

Follow up

Refer to a nutritionist at diagnosis and yearly to instruct and monitor gluten-free diet adherence
DEXA scans due to risk of osteoporosis

Complications

Osteoporosis
Dermatitis herpetiformis
Malignancy

Prognosis

Good prognosis - most patients have complete and lasting resolution of symptoms on a gluten-free diet alone.