Coeliac disease is associated with chronic inflammation of the

small intestine which can lead to malabsorption of nutrients. 1 It is

an immune-mediated enteropathy caused by consuming gluten, a
mix of proteins found in wheat, barley and rye. 2 It is a permanent
condition

in

genetically

predisposed

individuals

causing

precipitation in small intestine as a result of ingestion of gluten. 3

Coeliac disease is common disorder among Caucasians of
European ancestry with estimated prevalence of 0.5% to 1%. 2 It
affects approximately 1 in a 100 in the European countries. 3
Gliadin is alcohol-soluble fraction of gluten which contains most of
disease-producing components.2 Gluten is digested by luminal and
brush-border enzymes into amino acids and peptides. 2 Both innate
and adaptive immune mechanism involved.2 Some gliadin peptides
induce epithelial cells to express IL-15 that triggers activation and
proliferation of CD8+ intraepithelial lymphocytes. 2 NKG2D, a
receptor for MIC-A and is expressed by the lymphocytes. 2 These
lymphocytes become cytotoxic and kill enterocytes with surface
MIC-A.2 Epithelial damage cause other gliadin peptides to cross
the epithelium to be deamidated by tissue transglutaminase. 2
Deamidated gliadin peptides will interact with HLA-DQ2 or HLADQ8 on antigen-presenting cells and they will presented to CD4+ T
cells.2 These T cells will produce cytokines causing tissue
damage.2
Patients blood test shows that she has low ferritin and folate level
but normal B12 level. Thus, the patient can be given folic acid and
iron.3 Additional blood tests that can be used are anti-endomysial
antibody (EMA) test and tissue transglutaminase (tTG) test. 3 In
EMA test, an antibody made up of immunoglobulin by the coeliac

disease patient reacts against an antigen, endomysium which is a

body tissue that supports and joins cells together.3 tTG test looks
for antibodies to tTG, an enzyme produced when coeliac-affected
gut repairs and remodels its tissues.3
DEXA scan is a type of X-ray scanning which measures density of
the bones.3 A T score of -2.6 shows that the patient has
osteoporosis. Treatment may include vitamin D tablets to
strengthen the bones.3 Regular exercise and stopping smoking
can help to improve bone health.3 Hormone replacement therapy
can be offered for postmenopausal women. 4 Another alternative is
bisphosphonates that inhibit bone resoprtion. 4 However, steroids
suppress circulating oestrogen and inhibit osteoblast maturation,
synthetic ability, calcium absorption and increase urinary loss. 4
Hormone replacement therapy can increase risk of breast cancer
after 5 years or 10 years treatment. 4

It is also reported that

bisphosphonates can cause nausea, diarrhoea and constipation. 4

Extra intestinal manifestation of coeliac disease in childhood are
delayed growth and delayed puberty, developmental abnormalities
of the enamel on teeth, anaemia and behavioural or learning
difficulties.3 Adults with coeliac disease may have osteoporosis,
joint or muscle pain, ataxia, arthritis, peripheral neuropathy,
dermatitis herpetiformis and hyposplenism.3
Problems with fertility can occur in untreated coeliac disease. 3
Adolescent girls will have late puberty and late menstrual periods. 3
Malnourished women with chronic, untreated disease have scanty,
irregular periods.3 Menopause may occur earlier than expected. 3
Pregnant women with untreated coeliac disease have an

increased risk of miscarriage and smaller babies. 3 The untreated

patient will also have a swollen abdomen, swollen ankles, weight
loss around upper body and weakness.3
The villi are absent or lack and there are openings into vestibules
at the top of the crypts.3 The microvilli are short and fragmented. 3
The coeliac mucosa looks flat in appearance or has a mosaic
pattern.3 The individual cells of enterocytes more cube-like or
flattened.3 The enterocytes are smaller and irregular.3 More
intraepithelial lymphocytes than normal.3
It is caused by nonresponsive coeliac disease which is a clinical
diagnosis defined by persistence of signs, symptoms typical of
coeliac disease despite adherence to a gluten-free diet at least 6
months.5 It is caused by refractory coeliac disease. 5 The patient
can be managed with nutritional supplementation and possibly low
level immunosuppressive therapy.5
Refractory coeliac disease is defined as the persistence of severe
villous atrophy on small intestinal biopsy despite strict gluten
withdrawal for at least 6 months with no evidence of other
pathology.5 The patients do not respond to treatment and they
remain clinically unwell.3 Specialist follow-up is needed for a more
serious progression.3 Steroids or immuno-suppressive drugs such
as azathiopine, nutritional replacement with special supplements
and additional vitamins and minerals are necessary.3 Sometimes,
surgery to look directly at the intestine is also done. 3
Guidelines for osteoporosis in coeliac disease and inflammatory
bowel disease

NICE guidelines : Coeliac disease: recognition, assessment and

management
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NICE guidelines : Coeliac disease: recognition, assessment and
management.

Because

it

recommends

how

heathcare

professionals can recognize, diagnose, treat patients with coeliac

disease.