Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten. It is thought to affect around 1% of the UK population. Repeated exposure leads to villous atrophy which in turn causes malabsorption.


  • Incidence: 100.00 cases per 100,000 person-years
  • Peak incidence: 30-40 years
  • Sex ratio: 1:1
Condition Relative
Irritable bowel syndrome20.00
Coeliac disease1
Crohn's disease0.11
Microscopic colitis0.10
Whipple's disease0.0001
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+


Conditions associated with coeliac disease include dermatitis herpetiformis (a vesicular, pruritic skin eruption) and autoimmune disorders (type 1 diabetes mellitus and autoimmune hepatitis). It is strongly associated with HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).

Clinical features

In 2009 NICE issued guidelines on the investigation of coeliac disease. They suggest that the following patients should be screened for coeliac disease:

Signs and symptomsConditions


Diagnosis is made by a combination of immunology and jejunal biopsy. Villous atrophy and immunology normally reverses on a gluten-free diet.

NICE issued guidelines on the investigation of coeliac disease in 2009. If patients are already taking a gluten-free diet they should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing.

  • Tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE
  • Endomyseal antibody (IgA)
  • Anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE
  • Anti-casein antibodies are also found in some patients

Duodenal biopsy*
  • Villous atrophy
  • Crypt hyperplasia
  • Increase in intraepithelial lymphocytes
  • Lamina propria infiltration with lymphocytes

Rectal gluten challenge has been described but is not widely used


The management of coeliac disease involves a gluten-free diet. Gluten containing cereals include:
  • Wheat: bread, pasta, pastry
  • Barley*: beer
  • Rye
  • Oats**

Some notable foods which are gluten-free include:
  • Rice
  • Potatoes
  • Corn (maize)

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

Patients with coeliac disease often have a degree of functional hyposplenism. For this reason all patients with coeliac disease are offered the pneumococcal vaccine. Currrent guidelines suggest giving the influenza vaccine on an individual basis.

*whisky is made using malted barley. Proteins such as gluten are however removed during the distillation process making it safe to drink for patients with coeliac disease
**some patients with coeliac disease appear able to tolerate oats


  • Anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
  • Hyposplenism
  • Osteoporosis, osteomalacia
  • Lactose intolerance
  • Enteropathy-associated T-cell lymphoma of small intestine
  • Subfertility, unfavourable pregnancy outcomes
  • Rare: oesophageal cancer, other malignancies