GASTROENTEROLOGY
‘Recurrent hypoglycaemia may be an indication of Coeliac disease in individuals with type 1 diabetes.’
disease, it is possible to have false negative results. Further investigations should therefore be carried out in patients whose symptoms are strongly suggestive of Coeliac disease. Patients with a positive blood test and those with negative antibodies, who are suspected to have Coeliac disease, should be referred to a gastroenterologist for a bowel biopsy to confirm diagnosis.
Delayed diagnosis Patients often have multiple investigations by multiple healthcare professionals, before they eventually receive a diagnosis and finally receive treatment that will improve their quality of life, Prof. Sanders pointed out.
“Simply from a health economics
perspective, earlier diagnosis would prove cost-effective, as this would reduce the number of tests and consultations being undertaken,”
Prof. Sanders pointed out that the
average presentation age is now 40-60 years old: “We have come a long way from the diagnosis of the small child with malabsorption. For every seven adult cases, there will be one paediatric case. This is a disease that is very much an adult disease that presents in an extremely varied manner. Healthcare professionals need to become more aware of this and be alert to the possibility of Coeliac disease in patients presenting with relevant symptoms.”
Testing In 2009, the National Institute of Health and Clinical Excellence (NICE) released a guideline on the recognition of Coeliac disease. The guideline outlines the symptoms and patients at risk of Coeliac disease, as well as evidence on how to identify people with the condition.1 If someone has symptoms or is at risk
of having Coeliac disease the first step is to carry out a blood test. Individuals with the condition produce endomysial antibodies(EMA) and tissue transglutaminase antibodies (tTGA) when gluten is ingested. Therefore, IgA tTGA and IgA EMA serological tests show high levels of sensitivity and specificity in the diagnostic process. However, it is important for patients to
continue having a normal gluten containing diet before considering diagnostic tests for Coeliac disease. The NICE guideline recommends that if the diet has been changed, foods that contain gluten should be eaten in at least one meal everyday for at least six weeks before testing. Although most negative results suggest that someone does not have Coeliac
MARCH 2012
he argued. He went on to suggest that including a condition such as Coeliac disease in the outcomes framework could have a significant difference: “If re-numeration was linked to targets based on a specified diagnostic rate, this would have a significant impact on case finding,” he commented. Prof. Sanders explained that delays in
diagnosis lead to patients experiencing increased morbidity and complications: “In patients with Coeliac disease, calcium malabsorption and subnormal levels of serum calcium result in damage to bone health. They are also more likely to develop problems associated with malabsorption of vitamins such as B12 and folate. Most worrying, however, is the fact that delays in detection can lead to an increased risk of developing certain cancers,” Prof. Sanders commented.
Complications Bone health: Studies have shown that more than 75% of adults with untreated Coeliac disease suffer from osteopenia or osteoporosis. Even in people with few symptoms of Coeliac disease, bone mineral density can be significantly lower than the general population.2
People with
Coeliac disease who are on a gluten-free diet show a lower level of bone loss than those who do follow a gluten-free diet, although research shows that bone mineral density may not return to that
‘NICE highlights the increased risk of non-Hodgkin’s and Hodgkin’s lymphoma, as well as small bowel cancer in undiagnosed Coeliac disease.’
THE CLINICAL SERVICES JOURNAL 39 seen in the general population.3-5 Early
diagnosis and diet change is crucial, therefore. Autoimmune conditions: Coeliac
disease is associated with an increased risk of developing other autoimmune conditions including diabetes and thyroid disease. The NICE guidance on Coeliac recognition states that 2% to 10% of people with the disease will also have type 1 diabetes and points out that recurrent hypoglycaemia may be an indication of Coeliac disease in individuals with type 1 diabetes. NICE recommends that anyone with type 1 diabetes should be screened for Coeliac disease – pointing out that a gluten-free diet can improve diabetic control, as well as having other clinical benefits. The link between Coeliac disease and
autoimmune thyroid disease is also well established. NICE states in the guideline that the prevalence of autoimmune thyroid disease in people with Coeliac disease is up to 7%.1
In fact, the
prevalence of Coeliac disease in patients with autoimmune thyroid disease has been shown to be 4 to 15 times greater than in the general population. One study found that, in a group of patients with Coeliac disease, 26.2% had autoimmune thyroid disease, compared to 10% of control subjects.6 Graves’ disease is the most common
form of hyperthyroidism. Around 30% of subjects with Graves’ disease have a member of the immediate family who also has an autoimmune condition. One study of 111 patients with Grave’s disease found that 4.5% of the participants also had Coeliac disease.7 Other associated autoimmune
conditions include autoimmune hepatitis
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