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.

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