Celiac Disease: Super Notes for Medical Students

In this post, we will cover Celiac disease short notes. We will introduce the topic with a concise summary first and then read in-depth about the topic.

Later, we will go into detail to discuss features, complications, diagnosis and differential diagnosis. Finally, we will conclude with the treatment of Celiac disease by giving the BROW mnemonic for a gluten-free diet.


Summary

  • Autoimmune + Malabsorption due to Gluten sensitivity
    • Gluten- BROWBarley, Rye, Oats, Wheat> Villous atrophy> IDA, Folic acid and Vitamin B12 deficiency, fat malabsorption
    • Features- Diarrhoea, Anaemia, Weight loss, APD, Atrophy of buttocks
    • Complications- IDA, Folic acid deficiency, Vitamin B12 deficiency, Osteoporosis, T-cell lymphoma (Intestinal lymphoma- consider when a patient with Celiac develops diarrhoea and weight loss), Dermatitis Herpetiformis (skin rash on extensors), DM 1, Autoimmune disease (Hypothyroidism)
    • Dx
      • Initial- TTG (Transglutaminase) and IgA
        • If IgA Deficiency is Present + TTG Negative- Request IgG instead
      • Others- Anti-Endomysial antibodies or Anti-Gliadin antibodies and Faecal Calprotectin
      • Confirmatory- Jejunal Biopsy- Re-introduce gluten in diet 6 weeks before the biopsy
        • Villous Atrophy
        • Crypt hyperplasia
        • Increased inter-epithelial lymphocytes
    • DDx
      • T-cell lymphoma- Lymphomatous Infiltrates on Biopsy
      • Tropical sprue- Flat villi
      • Whipple’s Disease- Stunted Villi and deposition of macrophages containing Periodic acid-Schiff (PAS) granules

Celiac disease: Manifestations

Features of celiac disease include the following:

  • Chronic or Intermittent Diarrhea
  • Steatorrhea
  • Stinking, bad-smell stools
  • Abdominal discomfort, Bloating, Nausea and Vomiting
  • Weight loss (Failure to thrive)
  • Iron deficiency anaemia (most common), followed by Folate defiance then Vitamin B12 deficiency
  • Manifestations of Anemia, e.g. Pallor, Fatigue

Complications

The complications of celiac disease are as follows:

  • IDA (read out guide on Anemia algorithm)
  • Folic acid deficiency
  • Vitamin B12 deficiency
  • Osteoporosis
  • T-cell lymphoma (Intestinal lymphoma- consider when a patient with Celiac develops diarrhoea and weight loss)
  • Dermatitis Herpetiformis (skin rash)
  • DM 1
  • Autoimmune disease (hypothyroidism)
Dermatitis Herpetiformins Complication of Celiac Disease

Diagnosis

The initial diagnosis of celiac disease is made by TG and IgA. The following are points worth noting for diagnosis:

  • Initial- TTG and IgA
  • Positive Endomysial Antibodies and Alpha-Gliadin Antibodies
  • After Positive TTG- Jejunal/Duodenal Biopsy
    • Villous Atrophy
    • Crypt Hyperplasia
    • Increased inter-epithelial Lymphocytes
  • Important: Re-introduce Gluten in the diet for 6 weeks before the biopsy

Differential Diagnosis

There are three differential diagnoses which should be kept in mind:

1. Lymphoma

This is a relatively rare complication of celiac disease. However, it should be suspected when:

  • Patient with known celiac disease with duodenal biopsy that shows lymphomatous infiltrates

2. Tropical Sprue

The following histopathological features of tropical sprue differentiate it from celiac disease:

  • Flattened villi
  • Presents with chronic diarrhoea
  • Vitamin b12 and folate deficiency (post-infectious in aetiology)

3. Whipple’s Disease

Finally, differentiating Whipple’s disease from celiac is based on a jejunal biopsy:

  • Jejunal biopsy shows Stunted Villi and deposition of macrophages containing Periodic acid-Schiff (PAS) granules

Treatment

The treatment of celiac disease revolves around a gluten-free diet alone. BROW mnemonic is used to remember the gluten diet which should be avoided:

BROW

  • Barley
  • Rye
  • Oats
  • Wheat

As of today, there is no permanent cure for the disease. People with celiac disease are advised to avoid triggers in their diet.

There is a whole list of triggers your physician will ask you to avoid. You can check the support page for gluten-free support here.

Is Gluten Allergy curable?

The management of Celiac disease is based on a gluten-free diet which involves barley, rye, oats and wheat. There is no permanent cure for the disease and only preventive measures are taken.

What is the pathogenesis behind Celiac disease?

People with Celiac disease have Gliadins in their intestines which are deamidated by tissue transglutaminase.

Upon consumption by macrophages, they cause a Type 4 hypersensitivity reaction along with the humoral response. All these lead to features of celiac disease:

1. Lymphocytes in lamina propria
2. Crypt hyperplasia
3. Blunting of the intestinal villa

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