1. Dr Nader Ghaderi, GPR

2. General information First described in ancient Greek by Aretaeus of Cappadocia The word Coeliac was first used in 19 th century in a translation and was derived from the Greek word koiliakos meaning abdominal. Many other names: Celiac disease, coeliac sprue, non- tropical sprue, gluten enteropathy, endemic sprue, ….

3. Coeliac disease Autoimmune disorder Heightened immunologic response to ingested gluten in genetically susceptible people More prevalent than previously thought: 2.4% in Finland, less in the UK and Germany Usually GI symptoms Other symptoms are increasingly being recognised Some patient may have no symptoms Often coexists with other conditions

4. Pathology: No signs or symptoms before starting gluten in diet Inflammatory reaction in small bowel following ingestion of gluten, caused by immune reaction to modified gliadin( the protein in gluten) by tTGA Villous atrophy caused by this autoimmune reaction Villous atrophy causes malabsorption The only effective life-long treatment is gluten-free diet

5. NICE recommendation: Offer serological testing to children and adults with any of the following signs, symptoms and conditions:

6. Signs and symptoms: Chronic or intermittent diarrhoea Failure to thrive or faltering growth in children Persistent or unexplained GI symptoms including nausea and vomiting Prolonged fatigue ( “tired all the time”) Recurrent abdominal pain, cramping or distension Sudden or unexpected weight loss Unexplained iron deficiency anaemia or other unspecified anaemia

7. Conditions: Autoimmune thyroid disease Dermatitis herpetiformis IBS DM type I

8. NICE recommends: Consider offering serological tests to children and adults with any of the following conditions: Addison’s disease Amenorrhoea Aphtous stomatitis ( mouth ulcers) Atuimmune liver conditions Autoimmune myocarditis Chronic thrombocytopaenic purpura Dental enamel defects

9. Also : Depression or bipolar disorder Down’s syndrome Epilepsy Low trauma fracture Lymphoma Metabolic bone disease such as rickets or osteomalacia Microscopic colitis Persistent or unexplained constipation Persistent raised liver enzymes with unknown cause

10. And: Polyneuropathy Recurrent miscarriage Reduced bone mineral density Sarcoidosis Sjogren’s disease Turner syndrome Unexplained alopecia Unexplained subfertility

11. Serological tests: IgA tTGA as first test EMA if above test equivocal IgA deficiency test if IgA tTGA negative If IgA deficient then IgG tTGA If serology positive refer to gastroenterologist for further investigations and biopsy If serology negative and high clinical suspicion refer to GI If serology negative and low clinical suspicion then coeliac disease is unlikely

12. Prior to serology or biopsy: To have an accurate test, patient should be taking gluten in diet: Should eat some gluten in more than one meal every day for at least 6 weeks before testing They should not start a gluten-free diet until the diagnosis is confirmed by biopsy.

13. Gluten containing food: Wheat Barley Rye Wheat subspecies like: semolina, spelt, durum, Small minority of patients may react to oat, likely due to contamination during food processing, pure forms are available.

14. Gluten free foods: Maize Wild rice Non-cereal carbohydrate rich foods like potatoes and bananas. Processed food available

15. Resources http://www.coeliac.org.uk/gluten-free-diet- lifestyle/food-on-prescription details the monthly quantities and types of gluten free foods a GP may can prescribe http://www.coeliac.org.uk/gluten-free-diet- lifestyle/food-on-prescription Lots of useful information from recipes to advice for healthcare professionals http://www.coeliac.org.uk/coeliac-disease http://www.coeliac.org.uk/coeliac-disease The review appointment checklist http://www.coeliac.org.uk/healthcare- professionals/management-of-coeliac-disease/review- appointment-checklist http://www.coeliac.org.uk/healthcare- professionals/management-of-coeliac-disease/review- appointment-checklist