Coeliac disease, also known as coeliac sprue or gluten-sensitive enteropathy, is a permanent intestinal intolerance to gluten – a protein found in wheat, rye, barley, and oats. In these patients, gluten in the small bowel is enzymatically altered by tissue transglutaminase, which causes the immune system to cross react with the small bowel lining, causing inflammatory modification of the digestive barrier, characteristically flattening intestinal villi, alternating mucosal crypts, and recruiting immune cells (lymphocytes). This alteration to gut epitheleal architecture interferes with the absorption of dietary nutrients. Coeliacs malabsorption is also associated with small intestinal bacterial overgrowth (SIBO) and lactose intolerance, contributing to symptoms of fatigue and abdominal bloating and pain. Also, fat malabsorption causes the characteristic steatorrhoea of coeliacs disease, with foul, clay-coloured floating stools, often with diarrhoea.
Cause / Risk Factors
- Occurs in genetically predisposed patients, with as many as 10% of first –degree relatives affected.
- Common with Western European ancestry, rare in Asians and Africans
- Incidence peaks 8-12 months and 3rd -4th decade
- Incidence of coeliac disease is slightly higher in females than in males
Symptoms & Signs
- Chronic diarrhoea
- Steatorrhea (Clay-coloured floating stools)
- Abdominal bloating or cramps
- Weight loss
- Bleeding diathesis.
- Seizure disorders
- Stunted growth and failure to thrive
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Diet and Lifestyle
- Eliminate all gluten sources from the diet. This includes wheat, rye, barley and oat products. Gluten-free grains such as corn and rice are acceptable.
- An elimination/challenge trial may be helpful in uncovering other food sensitivities. Remove suspected allergens from the diet for two weeks. Re-introduce foods at the rate of one food every three days. Watch for reactions which may include gastrointestinal upset, mood changes, headaches, and exacerbation of symptoms. Do not perform a challenge if there is history of anaphylaxis.
- Consider a grain-free diet
- Reduce pro-inflammatory foods in the diet including refined foods, and sugar.
- Increase intake of fresh vegetables and fruits, protein, and essential fatty acids (cold-water fish, nuts, and seeds).
Full Blood count – Anaemia may result from iron, folate and B12 malabsorption. Low serum iron is common.
Immunoglobulins – Transglutaminase (endomysial) antibodies are more sensitive and specific for coeliac disease than are gliadin antibodies. Immunoglobulins G, A, M.
Small bowel biopsy- Coeliac disease primarily involves the mucosa of the small intestine. The submucosa, muscularis, and serosa are usually not involved. The villi are atrophic or absent, and crypts are elongated. The cellularity of the lamina propria is increased with a proliferation of plasma cells and lymphocytes. The number of intraepithelial lymphocytes per unit length of absorptive epithelium is increased.
Stool sample – The typical bulky, greasy appearance and rancid odour of stools often suggest malabsorption of fat.
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