Coeliac Disease

 

Coeliac disease is a life-long inflammatory condition of the gastrointestinal tract that affects the small intestine.Treatment involves a strict gluten-free diet that excludes wheat, rye and barley. 

Introduction

Definition:
Coeliac disease (CD) may be defined as an inflammatory condition of the small intestinal mucosa, which improves when gluten is removed from the diet.  Recent evidence suggests CD has a prevalence of less than 1 in 200 people.  .  CD presents at all ages.  Patients may present with clinical symptoms or iron deficiency anaemia.

Symptoms:
The peak incidence of diagnosis in adults is age 20-30.  In some patients it is a co-incidental finding when being investigated for other clinical problems. Of those that have symptoms:

- 80-90% have general tiredness.
- 75-80% have diarrhoea. 
- 15-30% have vitamin D deficiency.

There is often a delay of several years before the diagnosis is made. 

Investigations

Diagnostic Tests

  1. Antibody Studies: Blood tests can be performed for antibodies to tTG, gliadin and endomysium.  IgG and IgA anti-tTG antibodies can be measured easily and cheaply, using blood tests.  They are highly sensitive markers, being present in 90% of patients with untreated disease, and are relatively specific. 
  2. Intestinal Biopsy: Diagnosis usually requires a small intestinal biopsy, the current usual practice being for endoscopic biopsies to be taken from the first part of the small bowel. A biopsy is when a small piece of tissue is taken with a pair of tiny forceps at the time of endoscopy. 


Supportive Investigations

A number of routine blood tests should be carried out to identify nutritional deficiencies including haemoglobin, B12, folate, iron, serum albumin, and calcium.These should be measured at diagnosis, during symptomatic relapse, and during pregnancy. 


Treatment

Dietary Treatment

(a) Gluten Exclusion: The cornerstone of therapy is adherence to a gluten free diet (GFD).  This means the exclusion of foods containing wheat, rye, barley and oats, although the role of oats in CD is still debated.  The avoidance of these cereals is a formidable task as they are found in bread, biscuits, cakes, pastries, breakfast cereals, pasta, beer, and most soups, sauces and puddings . 

Patients may supplement their diet with commercial gluten-free products that are available from supermarkets and also some products on prescription by general practitioner.  from supermarkets and include gluten-free flour, bread, biscuits, and pasta.

(b) Total vs Partial Gluten Exclusion: The risk of developing small intestinal lymphoma (a rare type of cancer) is increased in patients with CD who ingest a diet that contains gluten.  Nutritional deficiencies are also more likely to occur.  It has been shown that early introduction of a gluten-free diet decreases the subsequent risk of developing autoimmune disorders, particularly diabetes mellitus.

(c) Dietary Supplements: Many patients will be found to be suffering from dietary deficiencies at the time of diagnosis, the commonest being  iron, folic acid, calcium and vitamin B12.  Although these usually resolve spontaneously once on a GFD, it seems reasonable to ensure correction with appropriate supplements.

(d) Bone Abnormalities: Many individuals have osteopenia (an early stage of bone thinning prior to osteoporosis).  It is usual practice to consider bone densitometry scanning on presentation which may be repeated after one to two years of dietary therapy if the initial value is low.  Osteoprosis in post-menopausal women may warrant hormone replacement therapy and the use of bisphosphonates in some individuals.  Calcium supplementation may be considered.


Further information

The Coeliac Society of the UK, PO Box 220, High Wycombe, Bucks, HP11 2HY 
Tel: 01494 437278  Fax: 01494 474349