Coeliac disease, also known as non-tropical sprue, is a T-cell mediated autoimmune chronic gluten intolerance condition characterised by a loss of villi in the proximal small bowel and gastrointestinal malabsorption (sprue).
It should always be considered as a possible underlying aetiology in cases of iron deficiency anaemia of uncertain cause.
Coeliac disease is relatively common in Caucasians, 1 in 200, but it is extremely rare in Asian and black people. There are two peaks of presentation, a small number of patients present early in childhood and the second, larger group of patients presents at 3rd and 4th decades.
Many patients have a paucity of symptoms with no GI upset. However, abdominal pain is considered the most common symptom. Other manifestations include:
- iron deficiency anaemia and guaiac-positive stools
- malabsorption, including fat-soluble vitamins
- weight loss
Coeliac disease is a chronic autoimmune disease induced in genetically susceptible individuals after ingestion of gluten. Small bowel mucosa is primarily affected (submucosa, muscularis and serosa remain unaffected), resulting in progressive degrees of villous inflammation and destruction. The disease tends to start in the duodenum and extends into the ilium, resulting in induction crypt hyperplasia. Loss of villi, which absorb fluid, and hypertrophy of crypts, which produce fluid, result in a fluid excess in the small bowel lumen 8.
The villous atrophy that occurs within the bowel also results in malabsorption of iron, folic acid, calcium and fat-soluble vitamins manifesting in a variety of signs, some of which may be non-specific.
The gold standard diagnostic test is a duodenal biopsy taken at endoscopy.
- total villous loss, initially blunting progressing to flattened mucosa
- hyperplasia of the crypts
- epithelial infiltration with T-cell lymphocytes
Additionally, serum antibodies may be raised:
- anti-tissue transglutaminase antibody (anti-tTG), IgA
- deamidated gliadin peptide (DGP) antibodies, IgA
- anti-endomysial antibodies (EMA), IgA class
- anti-reticulin antibodies (ARA), IgA class
Quantitative immunoglobulin A (IgA): measures the total level of IgA in the blood to determine if someone is deficient in the IgA class of antibodies. The IgG class of anti-tTG may be ordered for people who have a deficiency of IgA.
- idiopathic pulmonary haemosiderosis: as part of the Lane-Hamilton syndrome 4
- dermatitis herpetiformis
- IgA deficiency
- cavitating mesenteric lymph node syndrome 14
- small bowel lymphoma, in particular, enteropathy-associated T cell lymphoma, but also other non-Hodgkin lymphomas 11
- Down syndrome (trisomy 21) 12
- CEC syndrome (also known as Gobbi syndrome): coeliac disease, epilepsy and cerebral calcification 13
Features of small bowel barium studies are not sensitive enough for confident diagnosis, but the following changes may be seen:
- small intestinal dilatation due to excess fluid
- dilution of contrast
- multiple non-obstructing intussusceptions
- jejunoileal fold pattern reversal
- moulage sign
- mosaic pattern
Features present on CT enteroclysis may include 3,6:
- jejunoileal fold pattern reversal: thought to have the highest specificity is considered the most discriminating independent variable for the diagnosis of uncomplicated coeliac disease
- ileal fold thickening
- vascular engorgement
- prominent mesenteric lymph nodes may cavitate with a fluid-fat level
- submucosal fat deposition in long-standing cases
- other adjunctive features
Treatment and prognosis
- 1. Soyer P, Boudiaf M, Fargeaudou Y et-al. Celiac disease in adults: evaluation with MDCT enteroclysis. AJR Am J Roentgenol. 2008;191 (5): 1483-92. doi:10.2214/AJR.07.3646 - Pubmed citation
- 2. Reddy D, Salomon C, Demos TC et-al. Mesenteric lymph node cavitation in celiac disease. AJR Am J Roentgenol. 2002;178 (1): 247. AJR Am J Roentgenol (full text) - Pubmed citation
- 3. Lomoschitz F, Schima W, Schober E et-al. Enteroclysis in adult celiac disease: diagnostic value of specific radiographic features. Eur Radiol. 2003;13 (4): 890-6. doi:10.1007/s00330-002-1455-6 - Pubmed citation
- 4. Lane DJ, Hamilton WS. Idiopathic steatorrhoea and idiopathic pulmonary haemosiderosis. Br Med J. 1971;2 (5753): 89-90. - Free text at pubmed - Pubmed citation
- 5. La seta F, Salerno G, Buccellato A et-al. Radiographic indicants of adult celiac disease assessed by double-contrast small bowel enteroclysis. Eur J Radiol. 1992;15 (2): 157-62. - Pubmed citation
- 6. Barlow JM, Johnson CD, Stephens DH. Celiac disease: how common is jejunoileal fold pattern reversal found at small-bowel follow-through? AJR Am J Roentgenol. 1996;166 (3): 575-7. AJR Am J Roentgenol (abstract) - Pubmed citation
- 7. Soyer P, Boudiaf M, Dray X et-al. CT enteroclysis features of uncomplicated celiac disease: retrospective analysis of 44 patients. Radiology. 2009;253 (2): 416-24. doi:10.1148/radiol.2532090533 - Pubmed citation
- 8. Scholz FJ, Afnan J, Behr SC. CT findings in adult celiac disease. Radiographics. 2011;31 (4): 977-92. doi:10.1148/rg.314105215 - Pubmed citation
- 9. Bürgin-Wolff A, Gaze H, Hadziselimovic F et-al. Antigliadin and antiendomysium antibody determination for coeliac disease. Arch. Dis. Child. 1991;66 (8): 941-7. Free text at pubmed - Pubmed citation
- 10. Aster JC. Robbins & Cotran Pathologic Basis of Disease, 9e (Robbins Pathology). Saunders. ISBN:1455726133. Read it at Google Books - Find it at Amazon
- 11. Smedby KE, Akerman M, Hildebrand H et-al. Malignant lymphomas in coeliac disease: evidence of increased risks for lymphoma types other than enteropathy-type T cell lymphoma. Gut. 2005;54 (1): 54-9. doi:10.1136/gut.2003.032094 - Free text at pubmed - Pubmed citation
- 12. Gale L, Wimalaratna H, Brotodiharjo A et-al. Down's syndrome is strongly associated with coeliac disease. Gut. 1997;40 (4): 492-6. Free text at pubmed - Pubmed citation
- 13. Gobbi G. Coeliac disease, epilepsy and cerebral calcifications. Brain & development. 27 (3): 189-200. doi:10.1016/j.braindev.2004.05.003 - Pubmed
- 14. Bonnie J. Huppert, Michael A. Farrell, Akira Kawashima, Joseph A. Murray. Diagnosis of Cavitating Mesenteric Lymph Node Syndrome in Celiac Disease Using MRI. (2012) American Journal of Roentgenology. 183 (5): 1375-7. doi:10.2214/ajr.183.5.1831375 - Pubmed