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.
page revision: 3, last edited: 08 Jun 2017 20:34