Coeliac

AKA Coeliac Sprue or Gluten Sensitive Enteropathy

  • inflammatory condition
  • small intestine mucosal inflammation
  • caused by ingestion of glutamin and proleine-rich proteins
  • in genetically sensitised individuals
  • 1 in every 90 people suffer in UK
    • 1:300 in italy & Spain
    • 1:18 in the Sahara
  • Prevalence is higher (1:10) in those who have a first degree relative with the disease

 

Coeliac and Cancer

  • Coeliacs who don’t adhere to the diet can be at increased risk of GI cancers and gut lymphoma
  • Once a sufferer has been gluten free for 3-5years risk of cancer decreases to that of person without coeliac

When to test for coeliac

  • persistent / unexplained gastrointestinal symptoms
  • faltering growth / prolonged fatigue
  • weight loss otherwise unexplained
  • mouth ulcers – recurrent
  • iron, B12 or folate deficiency
  • type 1 diabetes (at diagnosis)
  • Autoimmune thyroid disease
  • Irritable bowel syndrome
  • First degree relatives of coeliac sufferers

Management

Management of coeliac is a gluten free diet

Glutain containing cereals include:

  • wheat: bread, pasta, pastry
  • Barley – beer
  • Rye
  • Oats (though some coeliac sufferes will tolerate them – others will not)

Some foods which are gluten free are:

  • Rice
  • Potatoes
  • corn (maize)

Tissue transglutaminase antibodies may be checked to check compliance with a gluten free diet

Patients with coeliac often have a degree of functional hyposplenism.

So coeliac patients should be offered pneumoccal vaccine.

Current guidelines suggest giving flu vaccine on an individual basis.

Before Testing for Coeliac

  • Confirm person has eaten gluten-containing foods twice a day for the last six weeks
  • Emphasise that coeliac bloods don’t confirm diagnosis of coeliac, but indicate that further testing is needed

Coeliac Bloods:

Two Types of Antibody are tested for:

  • Endomysial antibodies (EMA)
  • Tissue Transglutaminase antiboties (tTGA) – these are produced in response to gluten ingestions. 

 

A normal test doesn’t entirely rule out Coeliac (coeliac patients are more likely to IgA deficient ant the general population so seronegative result doesn’t mean they don’t have coeliac)

A small bowel biopsy is still considered gold standard.

So still refer if high clincal suspcion

 

Young People and Adults

  • Total IgA & IgA tTG= Total Immunoglobulin A and Immunoglobulin A Tissue Transglutaminase
  • If IgA tTG then test IgA EMA (Immunoglobulin A Endomysial Antibodies)
  • If total IgA is deficient consider using:
    • IgG EMA
    • IgG DGP (deamidated gliamidin peptide)
    • IgG TtG
  • fds

Children

  • Same initially: Total IgA & IgA tTG
  • Then, if IgA is deficient:
    • IgG EMA,
    • IgG DGP or
    • IgG tTG
  • Don’t use HLA investigations in primary care.
  • It is used only specialist circumstances (eg in those not having a biopsy, those already on a limited gluten diet and choose not to have a gluten challenge)