Coeliac Disease

Question 1

What is Coeliac Disease

Answer 1

Coeliac disease is an Autoimmune T-cell response to gluten in the small bowel causing villous atrophy and malabsorption

Question 2

What will you find on a history taking of Coeliac Disease

Answer 2

Symptoms:
Steatorrhea
Diarrhoea
Abdominal Pain 
Bloating
Nausea and Vomiting 
Weight Loss
Fatigue 
Malnutrition – Anaemia, Bleeding problems (Fat soluble Vit K deficiency), Neurological symptoms like neuropathy (Vitamin B12 deficiency), Pica (Craving for non-food items due to severe Iron deficiency anaemia e.g. dirt)

Risk Factors:
Can present at any age, but most common in 20-40’s
Family History

Differentials:
Crohns Disease - Extra GI manifestations, Bloody Diarrhoea, Fever
Chronic Pancreatitis - Jaundice/Diabetes/Epigastric Pain radiating to back/Risk factors e.g. alcohol
Alcoholism - History of alcohol abuse

Question 3

Whatwill you find on examination of someone with Coeliac Disease?

Answer 3

End of the bed:
Dermatitis Herpetiform – Blistering skin condition affecting symmetrical extensor surfaces
Bruises - Vitamin K deficiency
Confusion - Beta deficiency
Muscle wasting/weight loss if malnourished
Hands:
Leukonychia - Hypalbuminaemia indicating protein Malnutrition
Koilonychia - Iron Deficiency Anaemia
Peripheral Neuropathy - B12 deficiency
Trousseau sign – Gripping of hand muscle when inflating cuff above systolic BP for 3 mins
Face:
Aphthous ulcers
Angular Stomatitis - Iron deficiency anaemia
Chvostek sign– Facial muscle spasm on tapping facial nerve at parotid (Seen In hypocalcaemia)
Abdomen:
Ascites - Protein Malnutrition
Splenomegaly - Anaemia
Legs:
Oedema - Protein Malnutrition
Restless Leg syndrome - Iron deficiency anaemia
Peripheral Neuropathy - B12 deficiency

Question 4

What are the investigations used for Coeliac Disease

Answer 4

Bloods:
FBC – Looking for Anaemia, Microcytic (Iron Deficiency), Macrocytic (B12/Folate Deficiency)
B12 – Levels can be reduced in malnutrition and cause neuropathies or anaemia
Total Iron Binding Capacity/Ferritin -Looking for Iron deficiency
Clotting screen – Vitamin K deficiency can cause impaired clotting
LFT’s – Looking for Hypalbuminaemia, Transaminase levels can be slightly raised, but this will return to normal on gluten free diet
Anti-transglutaminase antibody - First line investigation, if positive refer for duodenal biopsy
Serum Calcium – Can be low in chronic malnutrition

Special Tests:
Duodenal biopsy – Diagnostic test, done if Anti Tissue transglutaminase is positive or there is a very high level of suspicion. The patient needs to still be eating gluten to show changes (Sub Villous atrophy, increased intra epithelial WBC’s and crypt hyperplasia)
DEXA scan – Long term malnutrition can cause reduced bone density due to low serum calcium

Question 5

What are the treatments of Coeliac Disease

Answer 5

Lifelong Gluten free diet
Iron, folate and vitamin B12 supplements as required
Yearly review measuring height/weight and considering need for dietitian referral