Coeliac Disease

Introduction

  • Coeliac disease is a chronic autoimmune disorder triggered by the ingestion of gluten, a protein found in wheat, barley, and rye.
  • It causes inflammation and damage to the small intestine, leading to malabsorption of nutrients.
  • The only effective treatment is a lifelong gluten-free diet. Early diagnosis and adherence to treatment are critical to preventing complications.

Causes of Coeliac Disease

  1. Genetic Factors
    • Strongly associated with the HLA-DQ2 and HLA-DQ8 genes.
    • A family history of coeliac disease increases risk.
  2. Immune Response
    • Ingestion of gluten triggers an autoimmune reaction, damaging the intestinal lining (villi).
  3. Environmental Triggers
    • Early exposure to gluten or infections may contribute to disease onset.
  4. Other Autoimmune Disorders
    • Often associated with type 1 diabetes, thyroid disease, or autoimmune hepatitis.

Symptoms of Coeliac Disease

  1. Gastrointestinal Symptoms
    • Diarrhoea or constipation.
    • Abdominal pain and bloating.
    • Nausea or vomiting.
  2. Malabsorption Symptoms
    • Unintended weight loss.
    • Fatigue or weakness.
    • Iron-deficiency anaemia.
  3. Non-Gastrointestinal Symptoms
    • Dermatitis herpetiformis (itchy skin rash).
    • Joint pain or arthritis.
    • Neurological issues like numbness, tingling, or migraines.
  4. Symptoms in Children
    • Delayed growth and puberty.
    • Failure to thrive.
    • Behavioral issues or irritability.

Complications of Untreated Coeliac Disease

  • Malnutrition: Deficiencies in iron, calcium, vitamin D, and B12.
  • Osteoporosis: Due to calcium and vitamin D malabsorption.
  • Infertility and Miscarriage: In women of reproductive age.
  • Neurological Disorders: Ataxia or peripheral neuropathy.
  • Increased Cancer Risk: Small bowel lymphoma and other gastrointestinal cancers.
  • Other Autoimmune Disorders: Higher prevalence of type 1 diabetes, thyroid disease.

Diagnosis of Coeliac Disease

  1. Blood Tests
    • Anti-Tissue Transglutaminase Antibodies (tTG-IgA): Most common screening test.
    • Deamidated Gliadin Peptide Antibodies (DGP): Alternative test.
    • Total IgA levels to rule out IgA deficiency.
  2. Endoscopy with Biopsy
    • Gold standard for diagnosis; involves taking samples of the small intestine to check for villous atrophy.
  3. Genetic Testing
    • HLA-DQ2 and HLA-DQ8 testing may rule out coeliac disease if absent.
  4. Gluten Challenge
    • Reintroducing gluten before testing if a gluten-free diet has already been started.

Management and Treatment of Coeliac Disease

1. Gluten-Free Diet (Primary Treatment)

Foods to Avoid

  • Wheat, barley, rye, triticale, and oats (unless certified gluten-free).

Safe Foods

  • Fresh fruits, vegetables, meat, fish, poultry, eggs, rice, corn, potatoes, quinoa, and certified gluten-free products.

Hidden Sources of Gluten

  • Processed foods, sauces, soups, dressings, and medications.

Cross-Contamination Prevention

  • Use separate cooking utensils, toasters, and storage for gluten-free and gluten-containing foods.

2. Nutritional Support

  • Supplements for Deficiencies: Iron, calcium, vitamin D, and B12 as needed.
  • Lactose-Free Diet: Temporary in severe cases to aid digestion.

3. Medications and Therapies

  • Dermatitis Herpetiformis Treatment: Dapsone for skin symptoms, alongside a gluten-free diet.
  • Corticosteroids: For refractory coeliac disease with severe intestinal inflammation.

4. Monitoring and Follow-Up

  • Regular follow-ups with a gastroenterologist and dietitian.
  • Repeat blood tests to monitor antibody levels.
  • Bone density scans (DEXA) for osteoporosis risk assessment.
  • Address persistent symptoms or complications with additional evaluations (e.g., refractory coeliac disease or lymphoma).

5. Psychological Support

  • Address emotional challenges, such as dietary restrictions and social isolation.
  • Support groups or counselling for coping strategies.

Monitoring Parameters

  • Antibody Levels: Monitor tTG-IgA levels to assess dietary adherence.
  • Nutritional Status: Regular checks for deficiencies in iron, calcium, vitamin D, and B12.
  • Weight and Growth in Children: Ensure normal development.
  • Symptom Resolution: Monitor improvement in gastrointestinal and systemic symptoms.

Patient Counselling Points

  • Strict adherence to a gluten-free diet is essential, even if symptoms are mild or absent.
  • Learn to read food labels and recognize hidden sources of gluten.
  • Educate family members to prevent cross-contamination at home.
  • Maintain follow-up appointments and regular tests to monitor health.
  • Seek support groups for shared experiences and coping mechanisms.

Use in Children

  • Focus on a balanced, gluten-free diet to support growth and development.
  • Close monitoring for behavioural changes or irritability.

Use in Pregnancy

  • Ensure adequate intake of iron, folic acid, and calcium to prevent complications.

Use in Elderly

  • Monitor for osteoporosis and ensure dietary adherence to manage malabsorption-related issues.

FAQs About Coeliac Disease

Q1: What causes coeliac disease?

  • Genetic predisposition and an autoimmune reaction to gluten.

Q2: Can coeliac disease be cured?

  • No, but symptoms and complications can be managed with a lifelong gluten-free diet.

Q3: What foods should I avoid with coeliac disease?

  • Wheat, barley, rye, and any products containing these grains.

Q4: How soon will I feel better after starting a gluten-free diet?

  • Symptoms improve within weeks, but complete intestinal healing may take months to years.

Q5: Can I eat oats with coeliac disease?

  • Only certified gluten-free oats, as regular oats are often contaminated with gluten.

Q6: What are the long-term risks of untreated coeliac disease?

  • Malnutrition, osteoporosis, infertility, neurological issues, and certain cancers.

Q7: Is coeliac disease the same as gluten intolerance?

  • No, gluten intolerance does not involve an autoimmune response or intestinal damage.

Q8: Can children outgrow coeliac disease?

  • No, it is a lifelong condition requiring strict dietary management.

Q9: Can cross-contamination cause symptoms?

  • Yes, even trace amounts of gluten can trigger symptoms and intestinal damage.

Q10: What is refractory coeliac disease?

  • A rare condition where symptoms persist despite a strict gluten-free diet.

Q11: How is dermatitis herpetiformis related to coeliac disease?

  • It is a skin manifestation of coeliac disease, treated with a gluten-free diet and medications like dapsone.

Q12: Should family members of a coeliac patient be tested?

  • Yes, first-degree relatives have a higher risk and should be screened.

Q13: Is coeliac disease more common in women?

  • Yes, it is slightly more common in women than men.

Q14: Can coeliac disease cause weight gain?

  • Yes, especially after starting a gluten-free diet as nutrient absorption improves.

Q15: Are gluten-free products healthier for everyone?

  • Not necessarily; gluten-free products can be high in sugar and fat. They are essential for those with coeliac disease.