Coeliac disease NICE Clinical Guideline 86, May 2009

Introduction Coeliac disease is an autoimmune disorder that involves a heightened immunological response to increased gluten in genetically susceptible people There is a variation in clinical symptoms Coeliac disease often coexists with other conditions

What are the signs and symptoms of coeliac disease?

Symptoms and signs of coeliac disease NICE Clinical Guideline 86, May 2009 Chronic or intermittent diarrhoea Failure to thrive or faltering growth (in children) Persistent or unexplained GI symptoms including nausea and vomiting Prolonged fatigue (TATT) Recurrent abdominal pain, cramping or distension Sudden or unexplained weight loss Unexplained iron deficiency anaemia, or other unspecified anaemia

What conditions are associated with coeliac disease?

Conditions associated with coeliac disease NICE Clinical Guideline 86, May 2009 Autoimmune thyroid disease Dermatitis herpetiformis IBS Type 1 diabetes First-degree relatives with coeliac disease

For what associated conditions should you offer serological testing?

Consider offering serological testing to children and adults with any of the following: NICE Clinical Guideline 86, May 2009 Addison’s disease Amenorrhoea Aphthous stomatitis (mouth ulcers) Autoimmune liver conditions Autoimmune myocarditis Chronic thrombocytopenic purpura Dental enamel defects Depression of bipolar disorder Down’s syndrome Epilepsy Low-trauma fracture Lymphoma Metabolic bone disease (rickets or osteomalacia) Microscopic colitis Persistent or unexplained constipation Persistent raised LFTs with unknown cause Polyneuropathy Recurrent miscarriage Reduced bone mineral density Sarcoidosis Sjogren’s syndrome Turner syndrome Unexplained alopecia Unexplained subfertility

What dietary advice should you offer before serological testing?

Dietary considerations before serological testing NICE Clinical Guideline 86, May 2009 Testing (serology and biopsy) are accurate only if they person follows a gluten-containing diet When following a gluten-containing diet the person should eat some gluten in more than one meal every day for at least 6 weeks before testing The person should not start a gluten-free diet until diagnosis is confirmed by intestinal biopsy

What else should be discussed prior to serological testing?

Other information before serological testing (1) NICE Clinical Guideline 86, May 2009 Inform people who are considering, or who have undertaken self-testing that any result needs to be discussed with healthcare professionals and confirmed by laboratory based tests Before serological testing explain: – What coeliac disease is – That serological tests do not diagnose but indicate whether further testing is needed – The implications of a positive test (referral for intestinal biopsy and implications for other family members) – The implications of a negative test (disease is unlikely but could be present and may arise later)

Other information before serological testing (2) NICE Clinical Guideline 86, May 2009 Inform people that delayed diagnosis or undiagnosed coeliac disease can result in: – Continuing ill health – Long term complications Osteoporosis Increased fracture risk Unfavourable pregnancy outcomes Modest increase in intestinal malignancy – Growth failure, delayed puberty and dental problems (in children)

What serological tests should be performed?

Serological tests NICE Clinical Guideline 86, May 2009 IgA tissue transaminase (tTGA) (1 st choice) Use IgA endomysial antibodies (EMA) testing if the result of the test is equivocal