Celiac disease

Coeliac disease (also sometimes termed as non tropical sprue ⁶) is a condition of gastrointestinal malabsorption (sprue) that results from the small intestine's response to dietary gluten.

It should always be considered as the possible underlying aetiology in cases of Iron deficiency anaemia of uncertain cause.

Demographics and clinical presentation

Many patients have paucity of symptoms with no GI upset and while the condition is relatively common (1 in 200 of the general population), the majority of patients will be adult when the diagnosis is made. There may a slight female predilection.

Pathology

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 normal), resulting in progressive degrees of villous inflammation and destruction (which starts in duodenum and extends into ilium) with resulting of induction crypt hyperplasia. Loss of villi, which absorbs fluid, and hypertophy of crypts, which produce fluid , result in 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 vitamin resulting in a variety of signs, some of which may be non-specific.

The gold standard diagnostic test is a duodenal biopsy taken at UGIE. Histological features include total villous loss (initially blunting progressing to flattened mucosa). Additionally, serum endomysial antibodies may be raised.

Associations

• idiopathic pulmonary haemosiderosis -:  as part of the Lane Hamilton syndrome ⁴

Radiographic features

Fluoroscopy (Barium(barium follow through)

Features of small bowel barium studies are not sensitive enough for confident diagnosis, but some changes may be seen:

• small intestinal dilatation due to excess fluid 
• dilution of contrast
• non-obstructing intussusception
• ileojejunal fold pattern reversal (including jejunalisation of the ileum)
• moulage sign
• mosaic pattern
• flocculation
• segmentation

CT enterocolysis

Features present on CT enterocolysis may include ^3,6:

• reversed jejunoileal fold pattern: 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
• other adjunctive features
  • splenic atrophy

Complications

• increased risk of malignant conditions such as small bowel lymphoma(mainly T cell type) and small bowel adenocarcinoma.
• hyposplenism ¹
• ulcerative jejuno ileitis ¹
• increase risk of development of carcinoma of oesophagus
• cavitatory lymph node syndrome^1-2