Celiac Disease

Casebank History
1

You are an FY2 in Medicine.

Mrs Kelsey Smith, aged 47, came to the hospital because of tiredness. She was prescribed Iron tablets by her GP for Iron Deficiency Anaemia. She had undergone some tests and she was found to have tissue transglutaminase 2 antibody test (tTGA2) positive. She was diagnosed with Coeliac Disease. She was planned for the Endoscopy and Duodenal Biopsy.

Please talk to the patient, assess her, and address her concerns.

D: How can I help you?
P: I was told I have Iron Deficiency Anaemia and my GP sent me here for Endoscopy.
D: May I know why you went to your GP?
P: I have been feeling tired from the last few weeks and I have tummy discomfort.
D: Tell me more about your tiredness?
P: I feel tired from the last few weeks. I went to my GP, he told me I have Iron Deficiency Anaemia, and gave me Iron Tablets.
D: Did you take those tablets regularly?
P: Yes
D: Tell me more about your tummy discomfort?
P: I have had diarrhoea since last few weeks.
D: Has it changed?
P: It is getting worse.
D: How frequently do you have to go?
P: 3 to 4 times a day.
D: How were your bowel habits before?
P: I used to go once a day.
D: What is the consistency?
P: It is watery.
D: Any blood or mucus?
P: No
D: Any alternating bowel habits?
P: No
D: Do you feel thirsty?
P: No
D: Any decrease in urine output?
P: No
D: Anything else?
P: No
D: Any tummy pain or bloating?
P: No
D: Any Nausea or Vomiting?
P: No
D: Any Fever or Flu like symptoms?
P: No
D: Any tingling or numbness in your hands and feet? (Peripheral Neuropathy)
P: No
D: Any loss of weight?
P: Yes, I lost half a stone in the last few weeks.
D: Is it intentional?
P: No
D: Any loss of appetite?
P: No
D: Any problem with your balance or speech? (Ataxia)
P: No
Please ask about the PMH, Lifestyle, Psychosocial History.

D: Are you sexually active?
P: Yes
D: Do you practice safe sex?
P: Yes

I would like to do a GPE, Vitals, and abdominal examination.

Iron deficiency anaemia is one of the most common findings of Coeliac disease. Coeliac disease is an autoimmune condition affecting mainly the small intestines because of dietary protein gluten. Classic symptoms include gastrointestinal problems such as chronic diarrhoea, abdominal distention, malabsorption. We have done a blood test for the antibodies which was found to be positive. However, we need to confirm the diagnosis by doing endoscopy and taking a biopsy, that is why your GP sent you here.

While being tested for coeliac disease, you will need to eat foods containing gluten to ensure the tests are accurate. You should also not start a gluten free diet until the diagnosis is confirmed by a specialist, even if the results of blood tests are positive

We may do some further blood tests to check the levels of other vitamins and minerals in your blood. We may consider doing a DEXA scan in some cases of coeliac disease if your GP thinks your condition may have started to thin your bones. It is a type of X-ray that measures bone density. It may be necessary in coeliac disease as a lack of nutrients caused by poor digestion can make bones weak and brittle.

P: Can it be cancer? D: Why do you think it is cancer? P: I am worried because I am losing weight and feeling tired.
D: Your blood test shows that it is coeliac disease and all these symptoms that you are experiencing explain it. But as I have already mentioned, we have to do an endoscopy to confirm the diagnosis.

Treatment:
Coeliac disease is usually treated by simply excluding foods that contain gluten from your diet. This prevents damage to the lining of your gut and the associated symptoms, such as diarrhoea and stomach pain.

If you have coeliac disease, you must give up all sources of gluten for life. Your symptoms will return if you eat foods containing gluten, and it will cause long-term damage to your health. Your symptoms should improve considerably within weeks of starting a gluten-free diet. However, it may take up to two years for your digestive system to heal completely.

When you’re first diagnosed with coeliac disease, you’ll be referred to a dietitian to help you adjust to your new diet without gluten. They can also ensure your diet is balanced and contains all the nutrients you need.
Your GP will offer you an annual review.

Differentials:
Coeliac Disease
Colon Cancer
Anaemia
Hypothyroid
HIV

1 Like
2

Who you are:
You are FY2 doctor in GP clinic.

Who the patient is:
Adam Smith, 30 years old , came with tiredness 2 months ago, blood tests showed that he has anaemia. He was given iron tablets but no improvements. A week ago transglutaminase test was ordered and it came back positive. He is scheduled for endoscopy and duodenal biopsy as coeliac
disease is suspected.

What you should do:
Talk to him and address his concern.

You don’t have to ask every single question in the Sx and complications, the patient is leaning towards a diagnosis and the main aim is to follow the patient’s concerns, explain the procedure and prepare him for it, after taking only the right amount of Focused Hx

D: Hello , I am one of the doctors here in the GP clinic. May I confirm your full name and your date of birth.
P: (Confirms details)
D: I can see from my notes that you are here for your test results , I have them here with me. If you do not mind, can we have a chat about your health first before we discuss these results to be able to explain things in a better way?
P: No problem doc.

❖ PAST:
D: Why did you have this test done in the first place ?
P: I was feeling tired in the last few weeks and I have been having tummy discomfort.

P1:

Tiredness ODIPARA:
D: Can you tell me more about your tiredness? (Open Q)
P: I have been feeling tired for the last few weeks, I went to my GP and there I had some tests done and he told me I have Iron Deficiency Anaemia. He gave me Iron Tablets.
D: Has it changed since it started?
P: It’s getting worse.
D: Have you noticed anything that makes it better or worse?
P: No.
D: After the Iron tablets did you feel any improvement?
P: Not really doctor.
D: Did you take those tablets regularly?
P: Yes.

Tummy discomfort
(SOCRATES very briefly)
D; What about this tummy discomfort, can you tell me more about it? (open Q)
P: It’s like a dull tummy pain or bloating and has been all around my tummy for a few weeks now!
D: Have you noticed anything that makes it better or worse?
P: I’m not sure.
D: Do you have anything else with it?

Coeliac disease Sx:
D: Any bowel changes like diarrhoea or constipation?
P: I have had diarrhoea the last few weeks.

ODIPARA
D: How did it start?
P: Gradually?
D: Has it changed since it started?
P: It is getting worse.
D: How frequently do you have to go?
P: 3 to 4 times a day.
D: How were your bowel habits before?
P: I used to go once in a day.
D: Is there anything that makes it better or worse?
P: No.

TRAC
D: What is the consistency?
P: It is watery.
D: Does it seem like stool that’s difficult to flush? (malabsorption)
D: Any blood or mucus?
P: No.
D: Any change in bowel habits?
P: No.

Any Skin changes? Dermatitis herpetiformis (DH)
P: No.

Red flags :
D: Any problems with your water works? Do you feel thirsty? (Dehydration)
P: No.

FLAWS: (GIT Lymphoma)
D: Any weight loss?
P: Yes. I lost half a stone in the last few weeks.
D: Was it intentional?
P: No.
D: Any loss of appetite?
P: No.
D: Any problem with your balance? Or unusual tingling sensation in your hands or feet? (Vit B Deficiency)
P: No.
D: Any bone pains? (Vit D deficiency and osteoporosis)

ICE:
D: Do you have any idea what might be going on?
P: I was told I have Iron Deficiency Anaemia and my GP sent me here for Endoscopy, because he is suspecting I might have something with my bowels. And I think it might be coeliac disease?
D: May I ask you how much you know about this condition?
P: My sister was diagnosed with coeliac disease when she was young.
D: Do you have any other specific concerns?
P: I would like to know more about endoscopy and how it is done? Do I have to prepare myself in anyway?
D: Thank you for bringing it up, I will explain everything you need to know in just a few moments. Just a few more questions about your health.

P2
D: Has it ever happened to you before?
P: No.
D: Have you ever been diagnosed with any medical condition in the past? (DM, thyroid or skin problems)
P: No.
D: Any previous hospital stays or surgeries?
P: No.

MAFTOSA
D: Are you taking any other medications apart from the iron tablets you told me about, including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.

(Family Hx: already mentioned, don’t repeat yourself, show active listening)

D: What do you do for a living? (Not important but can hint to IBS and since coeliac is the most possible Dx you can skip.)
D: Is your job stressful?

DESA Quickly
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Occasionally.
D: Tell me about your diet?
P: Good/Bad

Examination
− Observation
− Tummy

Provisional diagnosis:

❖ PRESENT
D: Do you know what test we did for you? Do you know what we are looking for?
P: I believe some markers for coeliac disease.
D: That’s right, your blood tests were screening for specific coeliac disease markers called (TTG) , and it came back positive. As your sister has it, do you know much about it?
P: From what I have seen with my sister I believe it’s an allergy to gluten. Am I correct? and I will have to stop eating it to feel better?
D: Yes, you are right. You seem like you are well informed. It is a condition where your immune system attacks your own tissue when you eat gluten so yes it’s a form of allergy in simple words. It causes damage to your gut so it becomes unable to take nutrients and that might be the cause of your tiredness, anaemia and diarrhoea as well like what you described.
− Gluten is present in wheat , barley , rye, etc.
– To confirm the diagnosis , we need to perform a special camera test called an endoscopy.

❖ FUTURE
Management:

  1. Refer you to gut specialist
  • To do an endoscopy , which is thin flexible tube with light and camera will be attached to your mouth and pass down to your gut. Especially to an area called duodenum and jejunum. We will need to take samples for analysis to check for specific inflammation markers of coeliac disease. In the meantime you will need to continue eating food containing gluten for about 6 weeks before performing the procedure otherwise the specific gut changes will not be there if you stopped gluten and that will result in false results. So may I request that you keep eating a gluten rich diet until the diagnosis is completed. I know it might be distressing but it’s essential at this step. Would that be OK?

Before the procedure we will need to prepare you. (similar to colonoscopy)
− You will need to fast for 6 hours before the procedure
− Then the following:

Before During After
You need to eat food that contains gluten for the test to be accurate. We will take a sample to examine it under microscopy to check it for signs of coeliac disease. Complications like nausea or vomiting or cramps are rare, however we will still do our best to prevent them.
You will be given local anaesthetic to numb your throat and medication to help you relax during the procedure. Procedure takes around 15-30 minutes

  1. Involve senior.

  2. Further tests and investigations:
    − to check level of vitamins and minerals especially iron profile, as they
    might be deficient due to coeliac disease.
    − bone scans (DEXA scan) to check bone strength.

  3. Management
    If diagnosis with coeliac disease is confirmed, the only treatment to follow is:
    − Gluten-free diet: Your symptoms should improve considerably within
    weeks of starting a gluten-free diet. However, it may take up to two
    years for your digestive system to heal completely.
    − We can refer you to dietician to adjust your diet without gluten.

  4. Safety netting:

  • If you have severe diarrhoea, dry mouth or do not urinating as usual, come to the hospital immediately, because that might need special attention. Or if you have FLAWS (Lymphoma) please report it to your GP.
  1. Leaflets: for Coeliac and gluten free diet and also about colonoscopy (What
    to expect and how to get ready.)

Do you have any other concerns?
P: Do I have to take time of work?

D: Yes you can take a few days off work until the effect of sedation wears away and you feel better and ready to work.
P: Can it be cancer?
D: Why you think it is cancer?
P: I am worried because I am losing weight and feeling tired.
D: Your blood test shows that coeliac disease is the most probable diagnosis, and all these symptoms that you are having indicate that too. However, as I have already mentioned we will have to do the endoscopy to confirm the diagnosis.
P: Can coeliac disease cause any complications:
D: Unfortunately, yes but with proper treatment we can avoid or at least delay these complications.
These complications include:

  • Anaemia
  • Bone diseases and osteoporosis
  • DM (as part of auto immune profile)
  • GIT Lymphoma (watch out for FLAWS we can avoid that by proper management)