Coeliac Disease- Malabsorption

07/05/2013 by admin | Gastroenterology
  1. Most common cause of malabs in the west
  2. Common, 1/150 (in Ireland), 1/300 (England), peak incidence 20-40yo
  3. Due to allergic reaction to the gliaden fraction of wheat germ. Initially causes an increase in intraepithelial lymphocytes in the small intestinal epitheliumprogresses to flattening of intestinal villi (villous atrophy), strong HLA (human leukocyte antigens) associations (DQ2/DQ8/DR3)
  4. p/c:
    1. o Iron deficient
    2. o Malabsorption – although rarely presents now with classic sprue (=diarrhoea, weight loss, and oedema)
    3. o Case finding: due to increasing recognition of genetic component – threshold for suspicion and diagnosis is lower than previously.
    4. o Dermatitis herpetiformis: characteristic blistering eruption may lead to diagnosis of coeliac disease
  5. Ix:
    1. o Endoscopy and distal duodenal biopsy: have replaced biopsy of jejunum! Traditionally this should be repeated after a period of gluten-free diet.
    2. o Antibodies: anti-gliaden antibodies, endomysial antibodies (EMA) – highly specific although will be negative in IgA deficiency
    3. o Bone densitometry: reduced at time of presentation
  6. Mx:
    1. o Gluten-free diet: usually completely reverses histological and nutritional changes
    2. o Vitamin and iron replacement: with iron, folate, vit B12
    3. o Osteopenia: should be monitored and treated early
  1. o Small intestinal cancers (enteropathy associated T-cell lymphoma and adenocarcinoma): rare, but do consider in refractory disease or those who relapse


Other causes of malabsorption:

  1. Small bowel bacterial overgrowth:
    1. o Due to structural or functional disorders which cause relative stasis (hypo- or achlorhydria, jejunal diverticulosis, post-surgical blind loops, intestinal strictures, autonomic neuropathy, scleroderma)
    2. o Diagnosis confirmed with a lactose breath test
    3. o Small bowel imaging for structural lesions in not usually needed
    4. o Tx: Abx (metronidazole and tetracycline)
  2. Giardiasis: persistent infection with Giardia lamblia = causing diarrhoea and malabsorption. Tx: metronidazole or tinidazole
  3. Hypolactasia: loss of lactase from small intestine brush border – maybe primary or secondary following a GI infection. Results in milk intolerance – causing bloating, nausea, wind, and diarrhoea.
    1. o Diagnosis confirmed with lactose breath test
    2. o Tx: low lactose diet
  4. Other disease: pancreatic exocrine failure, Crohn’s disease…


Complications of malabsorption:

  1. Osteomalacia (lack of Vit D): proximal myopathy, bone pain, malaise
  2. Vit K deficiency: easy bruising
  3. Glossitis
  4. Anaemia: low folate, iron, B12
  5. Impaired cognitive processes: lack of niacin (=pellagra), or low B12
  6. Scurvy (lack of Vit C): corkscrew hairs, perifollicular haemorrhage, swollen/bleeding gums, tooth loosening
  7. Cheilitis (=swollen lips)
  8. Beri-beri (lack of vitamin B1): ‘dry’ = neuropathy, ‘wet’ = cardiac failure
  9. Protein-calorie deficiency: muscle loss/weakness, subcutaneous fat loss, peripheral oedema. 
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