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home - Small Bowel - Coeliac Disease - Coeliac Management Written by Dr Sebastian Zeki

Coeliac Management

Written by Dr Sebastian Zeki The value of these tests in monitoring adherence to a gluten-free diet is particularly limited in three respects:The test is useless if antibody levels are not elevated prior to therapy.Decline in IgG antigliadin is more gradual than for IgA antigliadin, making it less useful in monitoring recent dietary adherence.IgA endomysial antibody levels are more costly and results are more difficult to quantify than IgA antigliadin or IgA tTG. Other- Pneumococcal vaccination as hyposplenism. Dietary advice: -Refer to, rye, and barley containing foods should be avoided.-Soybean or tapioca flours, rice, corn, buckwheat, and potatoes are safe.-Be careful of stabilizers or emulsifiers that may contain gluten.-Coeliacs can have secondary lactose intolerance so avoid lactose-containing products initially.-Strict gluten avoidance is necessary. Management of Non-responseNonresponse usually due to poor compliance.Trace amounts of gluten is contained in products that are labeled as gluten-free.Gluten contamination of < 100 parts/million (up to a total of 30 mg per day) does not result in histologic injury.Medications (pills) generally contain minimal gluten and do not need to be avoided. Nonre-sponders Response Patients with refractory spruePrevalence -5% of coeliac Histology caused by alternative diagnoses If compliance good then 1 of 3 problems: Check compliance Type 1: Normal population of intraepithelial lymphocytes Type 2: Aberrant or premalignant population of intraepithelial lymphocytes based upon clonality analysis of T-cell receptors and immunophenotyp-ing Prognosis type 1> type 2. Type 1 doesnt evolve into type 2. Subset of patients develop subepithelial collagen deposition (="collagenous sprue".) Monitoring adherence and response to gluten free dietExclusion of gluten from the diet results in a gradual decline in serum IgA antigliadin and IgA tTG levels (half-life of six to eight weeks).A normal baseline value is typically reached within three to twelve months depending upon the pre-treatment concentrations.If the levels do not fall as anticipated, the patient is continuing to ingest gluten either intentionally or inadvertently.Although the general patterns above can be helpful, the accuracy of these tests in establishing compliance with a gluten free diet is unsettled . 70% improve in 2 weeks . Improvement 3-6 months Antibodies 3-4 months Histology Symp- 2 weeks 3 Patterns of manifestations of Refractory Coeliac: Only partial improvement on gluten-free diet.No beneficial response to gluten-free diet.Initial good response to gluten-free diet but relapse while still on this strict diet. Death can also be due to malabsorption Patients with ulcerative jejunitis or Enteropathy associated T-cell lymphoma (5yr survival is 10%) Nutritional considerations: :Replace all deficiencies.:Dietary rice bran and ispaghula husks to prevent constipation assoc with low bran diet.:Bone loss is related to secondary hyperparathyroidism, which is probably due to vitamin D deficiency. Monitoring the response to a gluten-free dietSymptoms improve faster than histology.Patients should demonstrate a histological improvement 3-4 months after treatment.If there is no histological improvement but the patient feels better, then repeat biopsies in 6-9 months.Gluten rechallenge can be used if the diagnosis is uncertain by advising the patient to eat 4 slices of regular bread for 6 weeks.Antibodies usually improve in 3-6 months. Management of celiac disease in adults

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