Coeliac Disease

# Not just a fad gluten-free diet


Coeliac Disease

Definition: A T-cell-mediated autoimmune disease of the small bowel in which prolamin intolerance causes villous atrophy and chronic intestinal malabsorption.

Prolamin: component of gluten; alcohol-soluble proteins in wheat, barley, rye +/- oats

                   Gliadin is the prolamin in wheat gluten

Aetiology/ risk factors:

-Sensitivity to prolamin triggers an immunological reaction in the small intestine leading to mucosal damage and loss of villi.

-Genetic association: HLA DQ2 in 95%; the rest are HLA DQ8

-Associated with other autoimmune disease and dermatitis herpetiformis

-Family history- 10% prevalence in 1st degree relatives and a 30% risk for siblings

Epidemiology:

Prevalence = 1 in 300-1500

Commoner in the Irish, rare in East Asia

Can present at any age but peaks in infancy and 50-60 years

Symptoms: 1/3 are asymptomatic

Diarrhoea

Weight loss

Anaemia: pale, tired

=Suspect coeliac in all with the above symptoms

Steatorrhoea– pale, foul-smelling, stools that float and are difficult to flush away (excess fat in stool due to fat malabsorption)

Abdominal pain

Bloating

Nausea & vomiting

Fatigue, weakness

Failure to thrive (children)

Amenorrhoea (young adult)

Signs:

Pallor (anaemia)

Aphthous ulcers

Image result for aphthous ulcer

Angular stomatitis/angular cheilosis– ulceration of the side of the mouth, in iron deficiency. Also a feature of vitamin B12 and B2 deficiency.

Image result for angular stomatitis

-Signs of malnutrition: children = short stature, abdominal distension, wasted buttocks

                                          reduced triceps skinfold thickness

Dermatitis herpetiformis– intense, itchy blisters on elbow, knees or buttocks. Despite the name, it is not associated with herpes. The blisters just look like those of herpes.

Image result for dermatitis herpetiformis

Investigations:

Bloods: Low Hb (anaemia)

               High RCDW (Red Cell Distribution Width)

               Low B12/folate

               Low ferritin

The anaemia in Coeliac’s may be of a mixed picture. You have both iron deficiency, which causes a microcytic anaemia (small RBCs) and folate/vitamin B12 deficiency, which causes a macrocytic anaemia (large RBCs). So, overall, the MCV (Mean Corpuscular Volume- i.e. RBC size) is within normal range. But, if you look at the RCDW, it is high, indicating that there is a large distribution of sizes of red blood cells i.e. there are small RBCs and large RBCs = a mixed picture anaemia.

Antibodies: anti α-gliadin, anti-transglutaminase, anti-endomysial (IgA Ab, most specific, 95% specific unless patient has IgA deficiency)

-As IgA deficiency is common (1 in 50 with coeliac disease), Ig levels should be measured to avoid false negatives.

Endoscopy + Duodenal biopsy: GOLD STANDARD for diagnosing Coeliac’s disease

Endoscopy shows villous atrophy in the small intestine, giving the mucosa a flat, smooth appearance.

Biopsy = Subtotal villous atrophy, increased intra-epithelial white blood cells + crypt hyperplasia

Image result for coeliac biopsy

Stool culture to exclude infection

Management:

-LIFELONG GLUTEN-FREE DIET (i.e. no prolamins).

= no wheat, barley, rye 

=rice, maize, soya, potatoes, oats (≤50g/d) and sugar are ok

-can prescribe gluten-free biscuits, flour, bread, and pasta

Image result for gluten free products uk

And here I thought Heinz only did baked beans. (This is not an advert. I am not promoting Heinz.)

 

-Symptoms, duodenal changes and antibodies reverse with gluten-free diet. Diet can be verified by testing endomysial antibodies.

-Vitamin and mineral supplements can be taken if needed.

-Oral corticosteroids may be used if the disease does not subside with gluten withdrawal.

Complications:

Iron, folate & Vitamin B12 deficiency

Anaemia

Secondary lactose intolerance

Ulcerative jejunoileitis

GI T-cell lymphoma (rare, suspect if refractory symptoms or weight loss)

Increased risk of malignancy- gastric, oesophageal, bladder, breast, brain

Myopathies

Neuropathies, cerebellar ataxia (rare)

Osteomalacia (softened bones, can lead to fractures, and bowing in children), Osteoporosis

Hyposplenism

Prognosis: with strict adherence to gluten-free diet, most patients make full recovery. Symptoms usually resolve within weeks. Histological changes may take longer to resolve. Gluten-free diet needs to be followed for life.

References: Cheese & Onion, Rapid Medicine

 

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One thought on “Coeliac Disease

  1. Jackie says:

    I love your outlines. I commented yesterday about FODMAPs. I have an aunt and cousin with seropositive, biopsy positive Celiac. I was having major health issues and despite testing negative and knowing gluten free is a fad, I tried eliminating gluten to see what would happen. I noticed some improvement in GI symptoms. As it turns out, I now know it’s because many foods with gluten also happen to be high FODMAP.

    Liked by 1 person

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