Coeliac Disease: B-QuiCK

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Coeliac disease

Testing

Request a “coeliac screen” for patients with suspected coeliac disease, including those who are asymptomatic but at high risk. Serology testing should be done while the patient is still consuming gluten; a gluten challenge may be required (see below).
Exclude potential differential diagnoses and consider checking for and treating any nutritional deficiencies or abnormal biochemistries. If symptoms suggest, also check for laboratory evidence of autoimmune conditions. Investigations may include, full blood count, ferritin, folate, vitamin B12, calcium and phosphate, LFTs, TSH, CRP and faecal calprotectin.

Gluten challenge: necessary prior to testing if the patient is not consuming gluten

In general, advise adults to consume ≥ 5 g of gluten per day for three to eight weeks. E.g. a minimum of either two to four slices of wheat bread, two to four weetbix or half to one cup of cooked pasta per day
Selecting products lower in fermentable sugars, e.g. spelt flour-based breads, or consuming small amounts of gluten across multiple meals may make the gluten challenge more tolerable. If the patient experiences significant symptoms, they can reduce the amount they are consuming; if symptoms are intolerable, they may stop after a minimum of two weeks.
In children, a gluten challenge is only appropriate after age five years with supervision from a paediatric gastroenterologist, and should be avoided during pubertal growth spurts

Manage the patient according to the results of coeliac serology:
- Positive – advise the patient to continue consuming gluten and organise referral to a gastroenterologist for further assessment, which may include duodenal biopsy
- Negative – reconsider differential diagnoses, e.g. irritable bowel syndrome or inflammatory bowel disease. Or discuss with or refer to a gastroenterologist for further assessment. Check local HealthPathways for specific referral criteria.
If coeliac disease is still suspected despite normal biopsy results, consider re-referral to a gastroenterologist for further assessment if this has not already been organised
HLA typing (genetic testing) is not useful for diagnostic purposes but may be requested by a gastroenterologist to exclude coeliac disease in selected patients, e.g. if laboratory results are equivocal

Coeliac disease in children – click here for a diagnostic overview

Refer all children with suspected coeliac disease to a paediatric gastroenterologist for further assessment and diagnosis
Duodenal biopsy is not usually required in children if the following criteria are met:
- Anti-tTG IgA ≥ 10 × ULN; plus
- Confirmation with EMA-IgA (or DGP-IgG if IgA deficiency) and a positive anti-tTG result in a second serum sample.
  N.B. The tTG on the second sample does not need to be ≥ 10 × ULN.

Management

A life-long gluten-free diet is the only effective treatment for people with coeliac disease; offer referral to a dietitian and recommend registration with Coeliac New Zealand
Recommend that first-degree relatives be checked for coeliac disease
Regular follow-up, e.g. ideally every three to six months, is recommended while the patient becomes established on a gluten-free diet. Once symptoms have resolved after the patient is successfully established on a gluten-free diet, reviews can be conducted annually. At follow-up appointments:
- Calculate BMI or monitor growth in children
- Ask about new or persistent symptoms. If indicated, perform a physical examination.
- Check how the patient is coping with the gluten-free diet. If there are concerns about inadvertent exposure, repeat coeliac serology and consider re-engagement with a dietitian.
- Repeat a “coeliac screen” after 12 months of a gluten-free diet regardless of symptoms
- Repeat other laboratory tests, e.g. ferritin, folate, vitamin B12, particularly if there were abnormalities at diagnosis and if symptoms suggest, check for other laboratory evidence of autoimmune conditions, e.g. with LFTs, TSH. If nutritional deficiencies have not normalised or improved after one year of a gluten-free diet (or earlier as appropriate, e.g. older age), consider supplementation.
- Discuss ways to optimise bone health. Encourage an adequate intake of calcium and vitamin D. Bone densitometry scans can be requested on a case-by-case basis, e.g. aged > 55 years or with additional risk factors for osteoporosis.
Recommend pneumococcal vaccination (not funded); the benefit of other vaccinations such as Haemophilus influenzae type b (not funded), meningococcus (not funded) and influenza (funded) to people with coeliac disease is less clear, although they may be considered
If there is an inadequate response to a gluten-free diet after 12 months and other diagnoses have been excluded, consider non-responsive or refractory coeliac disease; discuss with or refer the patient to a gastroenterologist for further assessment