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Coeliac Management
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Written by Dr Sebastian Zeki
MCQs for this page
Coeliac Management
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Written by Dr Sebastian Zeki
The value of these tests in monitoring adherence to a gluten-free diet is particularly
limited in three respects:
The test is useless if antibody levels are not elevated prior to therapy.
Decline in IgG
antigliadin
is more gradual than for IgA
antigliadin,
making it less useful in
monitoring recent dietary adherence.
IgA endomysial antibody levels are more costly and results are more difficult to quantify
than IgA
antigliadin
or IgA tTG.
Other-
Pneumococcal vaccination as hyposplenism.
Dietary advice:
-Refer to www.celiac.com.
-Wheat,
rye,
and
barley
containing foods should be avoided.
-Soybean or tapioca flours,
rice,
corn, buckwheat, and potatoes are safe.
-Be careful of stabilizers or emulsifiers that may contain gluten.
-Coeliacs can have secondary lactose intolerance so avoid lactose-containing products initially.
-Strict gluten avoidance is necessary.
Management of
Non-response
Nonresponse usually due to poor compliance.
Trace amounts of gluten is contained in products
that are labeled as gluten-free.
Gluten contamination of < 100 parts/million (up to
a total of 30 mg per day) does not result in
histologic injury.
Medications (pills) generally contain minimal
gluten and do not need to be avoided.
Nonre
-
sponders
Response
Patients with
refractory sprue
Prevalence -5% of
coeliac
Histology caused
by alternative
diagnoses
If compliance good
then 1 of 3 problems:
Check
compliance
Type 1
: Normal
population of
intraepithelial
lymphocytes
Type 2
: Aberrant or
premalignant
population of
intraepithelial
lymphocytes based
upon clonality
analysis of T-cell
receptors and
immunophenotyp
-
ing
Prognosis type 1> type
2.
Type 1 doesnt evolve
into type 2.
Subset of patients
develop subepithelial
collagen deposition
(="collagenous sprue".)
Monitoring adherence and response to gluten free diet
Exclusion of gluten from the diet results in a gradual decline in serum IgA
antigliadin
and IgA tTG
levels (half-life of six to eight weeks).
A normal baseline value is typically reached within three to twelve months depending upon the
pre-treatment concentrations.
If the levels do not fall as anticipated, the patient is continuing to ingest gluten either intentionally
or inadvertently.
Although the general patterns above can be helpful, the accuracy of these tests in establishing
compliance with a gluten free diet is unsettled .
70% improve in 2 weeks .
Improvement
3-6 months
Antibodies
3-4 months
Histology
Symp
-
2 weeks
3 Patterns of manifestations of Refractory Coeliac:
Only partial improvement on gluten-free diet.
No beneficial response to gluten-free diet.
Initial good response to gluten-free diet but relapse while still on this strict diet.
Death can also
be due to
malabsorption
Patients with ulcerative
jejunitis or
Enteropathy
associated T-cell lymphoma
(
5yr survival is 10%)
Nutritional considerations:
:Replace all deficiencies.
:Dietary
rice
bran and ispaghula husks to prevent constipation assoc with low bran diet.
:Bone loss is related to secondary
hyperparathyroidism,
which is probably due to vitamin D deficiency.
Monitoring the response to a gluten-free diet
Symptoms improve faster than histology.
Patients should demonstrate a histological improvement 3-4 months after treatment.
If there is no histological improvement but the patient feels better, then repeat biopsies in 6-9 months.
Gluten rechallenge can be used if the diagnosis is uncertain by advising the patient to eat 4 slices of regular
bread for 6 weeks.
Antibodies usually improve in 3-6 months.
Management of celiac disease in adults
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