Related Subjects:
|Osteoporosis
There is an increased incidence of various bowel malignancies (lymphomas, squamous cancer of oropharynx/ oesophagus and adenocarcinoma of the small bowel - new symptoms should be regarded seriously
About
- Present at all ages including children 1 in 3000
- Gluten (alpha gliadin) Hypersensitivity causing malabsorption
- Gluten is found in wheat, rye and barley
- Commonest in West of Ireland 1 in 300 but UK is 1 in 2000
- Others rate it at 1% western society
- Can come on any time in life so retest if symptoms
Aetiology
- Chronic malabsorption due to subtotal villous atrophy in the small intestine
- T cell-mediated chronic inflammatory response to epitopes 57-75 of gliadin
- Gamma interferon-mediated intestinal wall damage
- 95% of patients are HLA-DQ2 or HLA-DQ8 positive
- Commoner in diabetics
Clinical
- Presents at any age but usually childhood and adolescence
- Infants/Children
- Failure to thrive, abnormal stools at 8-24 months
- Abdominal distension, wasted buttocks, short stature
- Anaemia, Irritability
- Abdominal pain, fatigue, arthralgia, headaches
- Malabsorption due to villous atrophy in the small intestine and loss of absorptive cross-sectional area
- Osteomalacia and osteoporosis
- Malabsorption of Fat-soluble vitamins (ADEK), Iron, Folate
- Steatorrhoea, Diarrhoea, altered bowel habit, Flatus
- Dermatitis herpetiformis - itchy blisters on arms and elbows and wrist
- Failure to thrive after the introduction of gluten from cereals
Investigations
- Microcytic anaemia - Iron deficiency - low Ferritin
- Macrocytic anaemia - Folate deficient (B12 deficiency uncommon)
- Dimorphic with features of both
- Low albumin
- Low calcium and phosphate and raised alkaline phosphatase (Vitamin D and Calcium malabsorption)
- Prolonged PT due to Vitamin K deficiency
- Howell-Jolly bodies due to splenic atrophy
- IgA anti tissue Transglutaminase (tTG) has 95% sensitivity and specificity. However, can be negative if patient has already started a GFD
- Anti-endomysial antibodies. If negative and disease suspected measure Immunoglobulins as IgA deficiency not uncommon.
- OGD - multiple distal duodenal biopsies needed as can be patchy and shows subtotal villous atrophy as well as lymphocytic and plasma cell infiltration of lamina propria.
Differential
- Tropical sprue, Cystic fibrosis, Milk protein enteropathy
- Giardiasis, Chronic pancreatitis, Abetalipoproteinaemia
Management
- Lifelong Gluten-free diet - no wheat rye or barley products
- Steroids have been used in severe cases
- Antibody levels fall with treatment which is a useful guide to adherence to a Gluten-free diet
- Some would re-endoscope to see if there has been a histological improvement
- Adherence to a gluten-free diet can reduce the risk of cancer
- Consider screening family members
Complications
- Infants - growth retardation, delayed puberty
- Osteopenia, Mortality x 2, Small bowel adenocarcinoma
- Hyposplenism, Oesophageal squamous cell,
- Non Hodgkin's Lymphoma, Decreased Breast cancer apparently