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Coeliac Disease

In Coeliac disease, people are intolerant to Gliadin (component of Gluten), which is found in wheat, barley, and rye. It's more susceptible in those with HLA-DQ2 and HLA-DQ8. The pathophysiology that occurs here is:

  • Gluten is broken down into Gliadin, which then has its amino acids removed by Tissue Transaminases (TTG)

    • This deaminated Gliadin binds to APCs and is presented to Th cells, leading to cytotoxic T cell activity → Villous Atrophy

  • Crypts become larger to compensate for this decrease in surface area (see on biopsy)

  • Humoral response leads to production of Anti-TTG, Anti-Endomyseal, and Anti-Gliadin (good diagnostic markers)

Differentials - Non-coeliac gluten insensitivity (NCGS), Food allergy, IBD, IBS


Presentation:

GI symptoms - Abdominal pain, Diarrhoea, Steatorrhoea, Bloating, N+V


Systemic symptoms - Weight loss and Failure to thrive in children, Dermatitis Herpetiformis (pruritic papulovesicular lesions over the buttocks and extensor surfaces of the arms, legs, and trunk), Fatigue, Pallor

“Dermatitis herpetiformis” © Madhero88 (Licensed under CC-BY 3.0) https://creativecommons.org/licenses/by/3.0/


Investigations:

1st line tests - Total IgA and Anti-TTG IgA

  • Anti-TTG IgG should be checked instead if IgA deficient

  • Anti-Endomyseal should be checked if Anti-TTG weakly +ve


N.B. Some patients are IgA deficient, therefore will have a false negative Anti-TTG IgA.


Gold-standard diagnostic test - OGD and Duodenal/jejunal biopsy

  • Findings - Villous atrophy, Crypt hyperplasia, Intraepithelial lymphocytes


Bloods - FBC (for anaemia), U&E, Bone profile, LFT (for malabsorption of albumin), Ferritin, B12, Folate


N.B. May be worth doing a stool culture to rule out infection.


Management:

Lifelong Gluten-free diet!


N.B. Patients will require regular monitoring to check adherence to a gluten-free diet, and to screen for complications.


N.B. Dapsone is an antibiotic that can be given to help reduce pruritic symptoms of dermatitis herpetiformis.


Complications:

  • Anaemia - Iron, B12, and Folate deficiency

    • B12 deficiency may also cause a peripheral neuropathy

  • Osteoporosis - malabsorption of calcium (DEXA scan needed)

  • Functional hyposplenism - makes them susceptible to encapsulated organisms (will need -coccal vaccines)

  • Enteropathy-associated T cell lymphoma - directly proportional to the patient’s adherence to a gluten-free diet



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