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.