coeliac disease

Last edited 03/2023 and last reviewed 09/2023

Coeliac disease (coeliac sprue’ or ‘gluten-sensitive enteropathy) is an inflammatory condition of the small intestine mucosa caused by ingestion of glutamine-rich and proline-rich proteins in genetically susceptible individuals (related to possession on particular HLA class II molecules) (1,2)

• the mucosal lesions seen on upper GI biopsy are the result of an abnormal, genetically determined, cell-mediated immune response to gliadin, a constituent of the gluten found in wheat (gluten is not found in rice and maize).
• a similar response occurs to comparable proteins found in rye and barley.

Coeliac disease was first identifed by Samuel Gee in 1888. However, it was W. Dicke in the 1950s who identified the dietary link, noting that patients with this condition were apparently cured by the deprivations of World War II, but relapsed when rationing was abolished.

Note the threshold amount of gluten in 'gluten-free' products that can be tolerated by people with coeliac disease is unclear:

• the amount of tolerable gluten varies among people with coeliac disease. Although there is no evidence to suggest a single definitive threshold, a daily gluten intake of <10 mg is unlikely to cause significant histological abnormalities (3)

With respect to screening for Coeliac disease, NICE have suggested (4):

• Offer serological testing for coeliac disease to:
  
  
  • people with any of the following:
    • persistent unexplained abdominal or gastrointestinal symptoms
      
    • faltering growth prolonged fatigue
      
    • unexpected weight loss
      
    • severe or persistent mouth ulcers
      
    • unexplained iron, vitamin B12 or folate deficiency
      
    • type 1 diabetes, at diagnosis
      
    • autoimmune thyroid disease, at diagnosis
      
    • irritable bowel syndrome (in adults)
      
      
  • first-degree relatives of people with coeliac disease
    
    
• Consider serological testing for coeliac disease in people with any of the following:
  
  
  • metabolic bone disorder (reduced bone mineral density or osteomalacia)
    
  • unexplained neurological symptoms (particularly peripheral neuropathy or ataxia)
    
  • unexplained subfertility or recurrent miscarriage
    
  • persistently raised liver enzymes with unknown cause
    
  • dental enamel defects
    
  • Down's syndrome
    
  • Turner syndrome

  Healthcare professionals should have a low threshold for re-testing people identified in recommendations if they develop any symptoms consistent with coeliac disease

Notes:

• study evidence showed that individuals with coeliac disease had a lower prevalence of traditional cardiovascular risk factors but had a higher risk of developing cardiovascular disease than did people with no coeliac disease (5)

Reference:

• (1) British Society of Gastroenterology (BSG) 2010. The management of adults with coeliac disease
• (2) Di Sabatino A, Corazza GR. Coeliac disease. Lancet. 2009;373(9673):1480-93. 
• (3) Akobeng AK et al. Systematic review: tolerable amount of gluten for people with coeliac disease. Aliment Pharmacol Ther. 2008 Jun 1;27(11):1044-52.
• (4) NICE (September 2015). Coeliac disease: recognition, assessment Coeliac disease: recognition, assessment and management.
• (5) Conroy M et al. Association between coeliac disease and cardiovascular disease: prospective analysis of UK Biobank data.BMJ Medicine 2023;2:e000371. doi: 10.1136/bmjmed-2022-000371