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Coeliac disease (coeliac sprue or gluten allergy)

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Coeliac disease (coeliac sprue or gluten allergy)

Written by Dr Jocelyn S Fraser, specialist registrar in gastroenterology

What is coeliac disease?

Term watch Coeliac disease is also known as gluten enteropathy or coeliac sprue.

How does gluten damage the bowel?

The small bowel contains villi, which are tiny finger-like projections that are only visible under a microscope.

They provide a large surface area over which we absorb nutrients such as vitamins, folic acid, iron and calcium.

If you have coeliac disease, a reaction occurs when gluten comes into contact with the lining of the small bowel.

The villi are attacked by the immune system and are eventually destroyed.

This results in nutrients from food going down the gut without being absorbed (malabsorption), leading to diarrhoea, vitamin and mineral deficiencies, anaemia and thin bones (osteoporosis).

Who is at risk?

It used to be thought that coeliac disease affected about 1 in 1500 people. More accurate diagnosis through blood tests has shown that the condition affects up to 1 in 300 people in the United Kingdom, Europe and the USA.

It is more common in some areas of the world, particularly on the west coast of Ireland, where 1 in every 100 people are thought to have coeliac disease.

Coeliac disease can affect you at any age. It was thought to be more common in men, but probably occurs equally in men and women.

Coeliac disease is sometimes associated with other conditions. People with Type 1 diabetes, thyroid problems and ulcerative colitis have an increased chance of developing coeliac disease.

One definite risk factor is a history of the condition in your family. Coeliac disease occurs in people who are genetically prone to it.

If you have a parent, sibling or child with coeliac disease, you have a 10 per cent chance of also developing it. If you have an identical twin with coeliac disease, your chances increase to more than 70 per cent.

What are the symptoms?

Coeliac disease has many and varied symptoms, and symptoms in adults are different to those in children.

Childhood symptoms In childhood symptoms do not appear until gluten-containing foods (bread, cereal) are introduced into the diet.

Poor appetite, irritability and a failure to gain weight are usually the first symptoms.

Pale, bulky stools that smell nasty.

Vomiting and diarrhoea, which can lead to a wrong diagnosis of gastroenteritis.

Swollen stomach.

Arm and leg muscles may become wasted and thin.

Adult symptoms

In adults symptoms include:

weight loss with pale, offensive diarrhoea

constipation

abdominal bloating with wind.

Half of adults with coeliac disease do not have any of these bowel symptoms. They approach their doctor because of:

extreme tiredness â€“ which is a sign of anaemia

psychological problems like depression

bone pain and sometimes even fractures â€“ which are due to thinning of the bones

ulcers in the mouth

a blistering, itchy skin rash mostly on the elbows and knees, called dermatitis herpetiformis.

In one neurology clinic, several patients who, for no apparent reason, had difficulty walking and coordinating (ataxia) were tested for coeliac antibodies in the blood. A significant number were found to have coeliac disease, although many of them did not have any gut symptoms.

How is coeliac disease diagnosed?

Your GP will ask about your symptoms. Don't feel embarrassed about questions on the frequency and colour of your bowel motions.

Your doctor may also want to know whether you have lost weight or whether you have symptoms of anaemia (tiredness, exhaustion, pallor). The doctor may:

examine your abdomen

look for a blistering rash on your skin

check for mouth ulcers.

Blood tests are then usually requested.

Your doctor will check for anaemia, testing the levels of iron, folic acid and calcium in your blood.

Another blood test detects antibodies that are often found in coeliac disease. Several antibodies are linked to the condition, but the most specific is anti-endomysial antibody. If this is present in the blood, you are very likely to have coeliac disease.

An endoscopy test is needed to diagnose coeliac disease. Your doctor should arrange this test at the endoscopy unit at your local hospital.

You can usually choose to have the test under general anaesthetic (sedation) or have a local anaesthetic that numbs the throat with a spray.

Endoscopy and biopsy

A thin flexible tube with a tiny camera and clipper at its end is put into your mouth.

The camera is guided down the oesophagus (gullet) into the stomach and then the small bowel.

The clipper can be used to remove a small piece of the bowel lining during the procedure. This is called a biopsy. You will not feel any discomfort.

The whole procedure takes about 10 minutes.

The biopsy specimen will be sent to the laboratory to examine the size and shape of the villi. This will confirm diagnosis.

It is usual to repeat this test after several months on a gluten-free diet, to check that the lining has recovered.

What else could it be?

Diarrhoea and weight loss can be due to several other causes.

A bowel infection caused by parasites called Giardia lamblia and Strongyloides. If your symptoms start after a tropical holiday, one of these infections may be to blame.

Overgrowth of bacteria in the small intestine.

Lactose (milk) intolerance.

Whipple's disease (a rare disease in men that prevents nutrients and fat being absorbed).

Intestinal lymphoma (a type of cancer).

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