GASTROENTEROLOGY
‘If a family member has the condition, there is a 1 in 10 chance of a close relative developing Coeliac disease.’
with earlier onset of menopause. In addition to sub-fertility, untreated
Coeliac disease is also associated with adverse pregnancy outcomes. There is evidence that undiagnosed maternal Coeliac disease has a negative effect on intrauterine growth and birth weight, and is associated with increased preterm birth and caesarean section rates. An increased incidence of miscarriage among women with untreated Coeliac disease has also been reported. Studies have suggested that, following a gluten-free diet, the miscarriage rate among women with untreated Coeliac disease is significantly reduced.14
and primary biliary cirrhosis. Prevalence of Coeliac disease in people with autoimmune hepatitis has been found to be 6.4%,8
while research has shown that
there may be at least a threefold increase in the risk of primary biliary cirrhosis in people with Coeliac disease.9 The NICE guideline recommends that
people with autoimmune liver conditions should be considered for screening of Coeliac disease.1
Crucially, treatment with
a gluten-free diet in patients with both Coeliac disease and liver disease can lead to prevention of hepatic failure – even in severe cases where liver transplantation is being considered.10 People with Addison’s disease should
also be considered for screening, according to NICE. Addison’s disease affects more women than men and, in around 70% of all cases, is caused by autoimmune adrenalitis. An endocrine condition, in which the adrenal gland does not produce enough steroid hormones, patients require lifelong, steroid replacement therapy. There is a similar immunogenetic background to Coeliac disease, with both diseases being associated with the DR3-DQ2 allele. The incidence of Addison’s disease in people with Coeliac disease is between 7% and 12%.11,12 Other autoimmune diseases that have
been shown to have an increased incidence in people with Coeliac disease include Sjogren’s syndrome and Sarcoidosis.
Cancer: Evidence reviewed for the
NICE guideline highlights the increased risk of non-Hodgkin’s and Hodgkin’s lymphoma, as well as small bowel cancer in undiagnosed Coeliac disease. However, after three to five years of following a gluten-free diet, the risk of malignancy is reduced to that of the general population.13 The cause of gut malignancies is
unknown, but there are several local and general mechanisms that could be involved: • Mucosal lesions are pre-malignant prior to presenting with symptoms of Coeliac disease.
• Carcinogens may be able to pass through the mucosa when the gut lining is damaged.
• The mucosa may be deficient in carcinogen-detoxifying enzymes when the gut lining is damaged.
• The immune systemis disturbed which may allow cancerous cells to develop.
• HLA status (presence ofHuman Leukocyte Antigen genes) may predispose to malignancy.
Pregnancy and fertility: Untreated Coeliac disease is also associated with an increased prevalence in unexplained infertility. Amenorrhoea is more common in patients with the condition, compared to the general population, while studies have found that menarche is significantly delayed in people with untreated Coeliac disease. The condition is also associated
Treatment Prof. Sanders highlighted the importance of referral to a dietitian once a positive diagnosis is confirmed. He explained that a life-long gluten-free diet is the only treatment for Coeliac disease. Once gluten is eliminated from the diet, the damage to the gut can begin to heal. Depending on the individual, this process can take between six months and two years. Ultimately, the health risks associated with Coeliac disease can be minimised, providing the patient adheres to a gluten-free diet. “Unfortunately, the area of dietetics is
woefully underfunded and there is a need for improved access to dietitians within the NHS,” he commented. “There also needs to be increased funding in order to build on the promising research underway, into tackling this disease,” he commented. Prof. Sanders reported that research is
underway to investigate the use of a ‘fingerprint’, point-of-care test. It is hoped that this will increase diagnostic rates, by making testing easier and more accessible. Research efforts are also being targeted at the development of a vaccine, aimed at preventing the immune response to gluten; an enzyme drink that breaks down gluten before it reaches the gut; and a Zonulin blocker which prevents gluten reaching the bowel. Other possible approaches may include the creation of genetically modified, ‘gluten-free’ wheat, he revealed. “We are yet to see how these novel
approaches may evolve in the future. What we know already, however, is the fact that Coeliac disease is a condition
‘Screening studies suggest that 1 in 100 people in the UK have Coeliac disease, yet only 10% to 15% of these have been diagnosed.’
40 THE CLINICAL SERVICES JOURNAL MARCH 2012
www.sxc.hu
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