Introduction
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.
Epidemiology
- Incidence: 100.00 cases per 100,000 person-years
- Peak incidence: 30-40 years
- Sex ratio: 1:1
| Condition | Relative incidence |
|---|---|
| Irritable bowel syndrome | 20.00 |
| Coeliac disease | 1 |
| Giardiasis | 0.25 |
| Crohn's disease | 0.11 |
| Microscopic colitis | 0.10 |
| Whipple's disease | 0.0001 |
| <1 | 1-5 | 6+ | 16+ | 30+ | 40+ | 50+ | 60+ | 70+ | 80+ |
Aetiology
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 symptoms | Conditions |
|---|---|
|
|
Investigations
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.
Immunology
Duodenal biopsy*
Rectal gluten challenge has been described but is not widely used
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.
Immunology
- 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
Management
The management of coeliac disease involves a gluten-free diet. Gluten containing cereals include:
Some notable foods which are gluten-free include:
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
- 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
Complications
- 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