Coeliac Disease

Overview

Sometimes you may feel bloating and gals in the abdomen, diarrhoea after eaten wheat, barley or rye. Those symptoms may be due to something wrong in your digestive system. Let’s look at around what is happening and why those symptoms are occurring.

Coeliac disease sometimes called coeliac sprue or gluten-sensitive enteropathy. This disease is due to an immune reaction to eating gluten. Gluten is a protein found in wheat, barley and rye.

Associations

HLA DQ2 in 95%, the rest are DQ8, Autoimmune disease, Dermatitis herpetiformis.

Prevalence

The prevalence is 1 in 100-300 persons( Commoner if Irish). Can occurs in any age group, but peak in childhood and 50-60 years of age. Male to female ratio is 1:1, relative risk in first degree relatives is having six (6) fold.

Definition

Coeliac disease is immune mediated enteropathy caused by a permanent sensitivity to gluten in genetically susceptible individuals. It is a unique autoimmune disorder with environmental trigger by gluten and the auto-antigen (tissue Transglutaminase)

Symptoms

The signs and symptoms are different between children and adults. Adult may present with, diarrhoea, fatigue, weight loss, abdominal pain, bloating and gas, nausea and vomiting, constipation.

Some patients have sings and symptoms unrelated to the digestive system. Those includes,

  • Anaemia, usually due to iron deficiency.
  • Osteoporosis (loss of bone density), Osteomalacia (softening of bone).
  • Mouth ulcers.
  • Headaches and fatigue.
  • Joint pain.
  • Feeling of numbness and tingling sensation in the feet and hands.

Children who is having coeliac disease are having following digestive symptoms,

  • Nausea and vomiting
  • Chronic diarrhoea
  • Swollen belly
  • Constipation
  • Pale, foul smelling stools

Children will present with symptoms and signs relating to the inability to absorb nutrients.

  • Weight loss
  • Anaemia
  • Irritability
  • Short stature
  • Delayed puberty
  • Failure to thrive in infants
  • Damage to the enamel

Diagnosis of Coeliac Disease

The diagnosis of coeliac disease is done by clinical features with the support of serological and histological features. Antibodies; anti: transglutaminase is single preferred test.

Serology has high estimation sensitivity in the most studies. Biopsy is only seropositive. Negative serology should not necessarily reassure the clinician. The biopsy is done while taking gluten containing diet.

Marsh I or infiltrative lesion

These are nonspecific. It is known as lymphocyte enteritis. Patients occasionally present with positive serology. This is the common presentation in latent Coeliac disease. It is often missed by pathologist.

Marsh II Hyperplastic lesion

This is very common form of IBS. Could present with symptoms.

Marsh IIIa or Partial Villous Atrophy ( Destructive)

This is a form of complex and prevalent variety of subgroups, easily missed. Negative in Serology 60% – 70% of the patients. It is very common presentation in First degree relatives. Patients with 20 % first degree relatives had Coeliac disease.

Marsh IIIb or Subtotal Villous Atrophy

This is less common and easier to recognise. About 70% of the patient presents with positive serology. This is very close to the classical presentation.

Marsh IIIc or Total Villous Atrophy

This is classical coeliac disease. Serology is positive in almost 100% if not IgA- deficient.

Seropositive with normal histology

Atypical localisation in Terminal ileum. False positive results will given in Liver diseases and Autoimmune diseases.

Endoscopy

Endoscopy should be done for entire small bowels. Normal duodenal biopsy do not exclude diagnosis. Segmental biopsy would be required.

Dermatitis herpetiformis

Gluten intolerance can cause itchy, blistering skin disease. This rash usually occurs on the elbows, knees, torso, scalp and buttocks. This condition is often associated with changes to the lining of the small intestine identical to those of celiac disease, but the skin condition might not cause digestive symptoms.

These patients can be treated with gluten- free diet or medication or both, to control the rash.

Treatment

These patients can be recommended lifelong gluten free diet. Rice, Maize, soya, potatoes and sugar are ok. Limited consumption of Oats (<50g/dl), may be tolerated in patients with mild disease. Gluten- free biscuits, flour, bread and pasta are recommended. We can monitor the response by symptoms and by repeating serology.

Complications

  • Because of poor nutrition, they can develop anaemia.
  • Dermatitis herpetiformis.
  • Osteopenia and Osteoporosis.
  • Hyposplenism.
  • T cell lymphoma.
  • There is a high risk of malignancy, such as lymphoma, gastric, oesophageal and colorectal.
  • Neuropathies.

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