Coeliac

Borders Ref Help Toolkit (in development)
NHS Borders

Background

Coeliac disease is common (affecting approximately 1% of the general population).

The condition is more common in those with:

  • A positive family history
  • Other autoimmune disease e.g. Type 1 Diabetes, thyroid disease
  • Chromosomal abnormalities e.g. Down Syndrome
  • Classical abdominal symptoms may be vague or absent.

Policy. In NHS Borders patients should be referred to both the Dietetics team and the Gastroenterology team.

NHS Borders has adopted a no-biopsy diagnosis for symptomatic adult patients with tTG ≥ 60 two occasions, with the recommendations of the British Society of Gastroenterology.

Please remember that when referring patients all patients must continue to eat adequate amounts of gluten until instructed otherwise by secondary care.

 

Who to refer:

  • Patients with tTG antibody >60AU on two occasions (no biopsy diagnosis)
  • Patients with tTG antibody 20-59AU (refer for upper GI endoscopy for consideration of duodenal biopsy)
  • Patients with tTG antibody <20AU consider watch and wait
  • All patients must continue to eat adequate amounts of gluten until instructed otherwise by secondary care
  • Patients can be provided with this information sheet on why and how they need to keep eating gluten until they have been told to stop by secondary care: PIL Continuing to eat gluten when a diagnosis of coeliac disease is being considered

Who not to refer: 

Patients with known coeliac disease who need further input for their condition should be referred to the dietetics service in the first instance.

How to refer:

Patients with tTG levels 20-59AU:

Borders General Hosptial -> Endoscopy -> Endoscopy B

For consideration of biopsy to obtain diagnosis via endoscopy

 

Patients with tTG levels >60AU

Refer patients to both Gastroenterology and dietetics with separate referrals via SCI Gateway using the following pathways:

Borders General Hospital -> Gastroenterology -> Borders General referral

Borders General Hospital -> Dietetics -> B Control IT

Whom to test:

Testing with coeliac serology is recommended for all patients presenting with:

  • Unexplained iron deficiency anaemia
  • Prolonged fatigue
  • Chronic or intermittent diarrhoea
  • Symptoms suggestive of Irritable Bowel Syndrome
  • Sudden or unexpected weight loss
  • Failure to thrive or faltering growth in children
  • Persistent or unexplained GI symptoms including nausea and/or vomiting

Testing should be considered in:

  • Unexplained recurrent aphthous mouth ulcers or angular stomatitis
  • Unexplained persistently raised liver enzymes
  • Persistent or unexplained constipation
  • Unexplained reduced bone mineral density or metabolic bone disease e.g. osteomalacia
  • Unexplained infertility
  • Unexplained neurological symptoms, especially ataxia
  • Lymphoma
  • Sjogren's Syndrome

A positive serological test for Coeliac Disease depends upon the interaction between dietary gluten and the small intestinal mucosa. Thus, if gluten is withdrawn from the diet, the tests become unreliable as a diagnostic tool.

All patients must continue to eat adequate amounts of gluten until instructed otherwise by secondary care.

Patients can be provided with this information sheet on why and how they need to keep eating gluten until they have been told to stop by secondary care: PIL Continuing to eat gluten when a diagnosis of coeliac disease is being considered

National resources:

bor.gastroenterology@borders.scot.nhs.uk

Editorial Information

Author(s): Jonathan Fletcher, Angus Wallace.

Author email(s): bor.gastroenterology@borders.scot.nhs.uk.