This pathway provides guidance to support the diagnosis, referral and optimal management of coeliac disease in adults in Gloucestershire.
Please see the Coeliac disease in children pathway here.
Please click the relevant flowchart box to be taken directly to textual information.
Coeliac disease is an autoimmune condition associated with chronic inflammation of the small intestine. The auto-immune response is activated by gluten, a protein present in wheat, barley and rye, which can lead to systemic symptoms and malabsorption of nutrients. Coeliac disease can present with a wide range of clinical features, both gastrointestinal (such as indigestion, diarrhoea, abdominal pain, bloating, distension or constipation) and non-gastrointestinal (such as fatigue, anaemia (either iron deficiency or megaloblastic) dermatitis herpetiformis, osteoporosis, infertility, recurrent miscarriage or reproductive problems, neuropathy, ataxia or delayed puberty). Although some people present with the symptoms listed above, others will initially experience few or no symptoms.
Coeliac disease is a common condition, but is underdiagnosed. Population screening studies suggest that 1% of the population in the UK are affected. People with conditions such as type1 diabetes, autoimmune thyroid disease, Down's and Turner syndromes are at a higher risk than the general population of having coeliac disease. First-degree relatives of a person with coeliac disease also have an increased likelihood of having the condition with risk rising to approx.10 percent in this group. Complications of coeliac disease include malabsorption of nutrients such as calcium, iron and Vitamin D, osteoporosis, infertility, hyposplenism and malignancy (intestinal lymphoma), so delayed diagnosis is of concern. With strict and ongoing gluten exclusion from the diet, clinical and histological improvements usually occur.
Diagnosis is via serological testing: Immunoglobulin A (IgA) endomysial antibody (EMA) and tissue transglutaminase (tTG). In cases of total IgA deficiency, immunoglobulin G (IgG) tTG may be used as an alternative serological measure. Diagnosis should be confirmed by oesophago-gastro-duodenoscopy (OGD) and duodenal biopsy.
The treatment of coeliac disease is a strict, lifelong gluten-free (GF) diet. This is challenging, so specific education, information and support; including advice on suitable foods in the diet to maintain a healthy and varied intake, provided by a health care professional with expert knowledge on the condition can increase the probability of dietary adherence and a positive prognosis.
Consider the conditions below in your differential diagnosis; please see the IBS pathway for further information.
Ensure your patient has been following a gluten containing diet for at least 6 weeks (at least 2 slices of bread daily or equivalent) prior to serology testing and continues to consume gluten throughout the entire diagnostic process.
Refer directly to endoscopy services for oesophago-gastro-duodenoscopy (OGD) with duodenal/ jejunal biopsies to confirm diagnosis. It is not necessary to refer to gastroenterology consultant unless there are additional symptoms or the patient has other medical issues that might preclude the investigation. Ensure your patient remains on a gluten containing diet whilst awaiting OGD.
Following confirmed coeliac diagnosis (biopsy demonstrating features of coeliac disease such as villous atrophy, significant presence of lymphocytes plus positive serology):
Patients will be managed by the dietetic-led coeliac clinic (DLCC) as follows:
DEXA is indicated for those at increased risk only e.g. 2 or more of:
Consider the following actions in people with coeliac disease who have persistent symptoms despite advice to exclude gluten from their diet:
Refractory coeliac disease can be diagnosed if the original diagnosis of coeliac disease has been confirmed, and exposure to gluten and any coexisting conditions have been excluded as the cause of continuing symptoms.
Refer those with possible refractory coeliac disease to a specialist centre for further investigation.
Prednisolone may be considered for the initial management of the symptoms of refractory coeliac disease in adults while waiting for specialist advice.
NICE Coeliac disease: quality standard [QS134] (October 2016) states ‘health care professionals should help people who may need support to find suitable gluten-free foods on prescription to enable them to maintain a gluten-free diet.’
NHS Gloucestershire CCG have recommended the cessation of gluten-free prescribing unless under exceptional circumstances from 30 November 2016. Please see the ‘Prescribing’ section of the pathway for further information.