Coeliac disease

Question 1

What is Coeliac disease

Answer 1

Immune mediated inflammatory condition provoked by gluten

Question 2

Clinical presentation of Coeliac disease

Answer 2

Range of possible symptoms, with onset at any age (two peaks; infancy and 5th decade). 
Persistent GI symptoms. 
Faltering growth. 
Prolonged fatigue. 
Unexplained weight loss. 
Severe mouth ulcers. 
Iron, B12 or folate deficiency (anaemia). 
IBS. 
Family Hx of Coeliac.

Question 3

Examination of Coeliac disease - what does DQ stand for

Answer 3

Dietary Query

Question 4

Pathophysiology of Coeliac disease

Answer 4

α-Gliadin is the toxic portion of gluten.
It is resistant to proteases in GI tract, and passes epithelial barrier of the small intestine
-> Deamination by tissue transglutaminase (increasing immunogenicity)
-> interacts with antigen presenting cells (macrophages) in the lamina propria via HLA DQ2 and DQ8 and deaminated gliadin is expressed on MHC2.
This activates gluten sensitive T cells
-> Inflammatory cascade and release of mediators
-> Cell damage (villous atrophy and crypt hyperplasia)

Question 5

Aetiology of Coeliac disease

Answer 5

Strong genetic association with HLA DQ2 and DQ8. Attacks caused by the presence of gluten in the diet.

Question 6

Epidemiology of Coeliac disease

Answer 6

1/100 in UK

common in Irish

Question 7

Diagnosis of Coeliac disease

Answer 7

Serology: IgA tissue transglutaminase antibodies (IgA-tTG blood test) have a very high sensitivity and specificity for Coeliacs. Also endomysial antibodies.
Then, Distal Duodenal Biopsy: Histological changes.

Question 8

Treatment fo Coeliac disease

Answer 8

Gluten free diet

Nutritional supplement as required

Question 9

Complications of Coeliac disease

Answer 9

Increased incidence of malignancy, reduced by gluten free e.g. GI t-cell lymphoma

Question 10

When would you suspect Coeliac disease

Answer 10

Diarrhoea + weight loss or anaemia

Question 11

FBC Coeliac disease

Answer 11

low Hb
high RCDW (Red blood Cell Distribution Width)
low B12
low ferritin
IgA levels

Question 12

Examples of gluten free food

Answer 12

Rice
Maize
Soya
Potatoes
Sugar

Question 13

Prescribe-able gluten free food

Answer 13

Gluten-free...
Biscuits
Flour
Bread
Pasta

Question 14

How does coeliac disease cause damage to the gut

Answer 14

Gliadin binds to secretory IgA in the mucosal membrane
The gliadin-IgA is transcytosed to the lamina propia
Gliadin binds to tTG and is deaminated
Deaminated gliadin is taken up by macrophages and expressed on MHC2
T helper cells release inflammatory cytokines and stimulate B cells
This causes gut damage.

Question 15

Symptoms

Answer 15

Bloating, failure to thrive, diarrhoea

Dermatitis Herpetiformis

Question 16

Describe the cell damage in Coeliac by reaction to gluten

Answer 16

Villous atrophy

Crypt Hyperplasia