diagnosis and management of adult coeliac disease

Quality in Practice Committee

Diagnosis and Management of Adult Coeliac DiseaseAUTHOR: Dr Audrey Russell Dr Eamonn Shanahan Professor Eamonn Quigley

Original Publication: 2015

Next Review Date: 2018

DISCLAIMER AND WAIVER OF LIABILITYWhilsteveryefforthasbeenmadebytheQualityinPracticeCommitteetoensuretheaccuracyoftheinformationandmaterialcontainedinthisdocument,errorsoromissionsmayoccurinthecontent.ThisguidancerepresentstheviewoftheICGPwhichwasarrivedataftercarefulconsiderationoftheevidenceavailableattimeofpublication.

Thisqualityofcaremaybedependentontheappropriateallocationofresourcestopracticesinvolvedinitsdelivery.Resourceallocationbythestateisvariabledependingongeographicallocationandindividualpracticecircumstances.Thereareconstraintsinfollowingtheguidelineswheretheresourcesarenotavailabletoactioncertainaspectsoftheguidelines.Thereforeindividualhealthcareprofessionalswillhavetodecidewhetherthestandardisachievablewithintheirresourcesparticularlyforvulnerablepatientgroups.

Theguidedoesnothoweveroverridetheindividualresponsibilityofhealthcareprofessionalstomakedecisionsappropriatetothecircumstancesofindividualpatientsinconsultationwiththepatientand/orguardianorcarer.

Guidelinesarenotpolicydocuments.Feedbackfromlocalfacultyandindividualmembersoneaseofimplementationoftheseguidelinesiswelcomed.

EVIDENCE-BASED MEDICINEEvidence-basedmedicineistheconscientious,explicitandjudicioususeofcurrentbestevidenceinmakingdecisionsaboutthecareofindividualpatients.

Inthisdocumentyouwillseethatevidenceandrecommendationsaregradedaccordingtolevelsofevidence(Level1–5)andgradesofrecommendations(GradesA–C)respectively.ThisgradingsystemisanadaptationoftherevisedOxfordCentre2011LevelsofEvidence.

LEVELS OF EVIDENCE

Level1: Evidenceobtainedfromsystematicreviewofrandomisedtrials

Level2: Evidenceobtainedfromatleastonerandomisedtrial

Level3: Evidenceobtainedfromatleastonenon-randomisedcontrolledcohort/follow-upstudy

Level4: Evidenceobtainedfromatleastonecase-series,case-controlorhistoricallycontrolledstudy

Level5: Evidenceobtainedfrommechanism-basedreasoning

GRADES OF RECOMMENDATIONS

A Requiresatleastonerandomisedcontrolledtrialaspartofabodyofliteratureofoverallgoodqualityandconsistencyaddressingthespecificrecommendation.(Evidencelevels1,2).

B Requirestheavailabilityofwell-conductedclinicalstudiesbutnorandomisedclinicaltrialsonthetopicofrecommendation.(Evidencelevels3,4).

C Requiresevidenceobtainedfromexpertcommitteereportsoropinionsand/orclinicalexperienceofrespectedauthorities.Indicatesanabsenceofdirectlyapplicableclinicalstudiesofgoodquality.(Evidencelevel5).

ICGP QUALITY IN PRACTICE COMMITTEE 2015DrPaulArmstrong,DrPatriciaCarmody,DrHarryComber,DrMaryKearney,DrNiamhMoran,DrMariaO’Mahony,DrMargaretO’Riordan,DrBenParmeter,DrPatrickRedmond,DrPhilipSheeranPurcell.

CORRESPONDENCE [email protected]

© 2015 ICGP

QUALITYINPRACTICECOMMITTEE–Diagnosis and Management of Adult Coeliac Disease

TABLE OF CONTENTS

1. Introduction1.1 Background 11.2 Aimsofthedocument 1

2. Subtopics2.1 Clinicalpresentationandcomplications 22.2 Whototest 32.3 Investigationsfordiagnosis 52.4 Managementatinitialdiagnosis 62.5 Followupofpatients 72.6 Noncoeliacglutensensitivity 9

3. References 10

4. AppendicesAppendix1–Dietaryadvice 14Appendix2–Diagramofpatientfollowup 19

QUALITYINPRACTICECOMMITTEE–Diagnosis and Management of Adult Coeliac Disease |1

© 2015 ICGP

1. Introduction

1.1 BackgroundCoeliacdiseaseisaheightenedimmuneresponsetoingestedglutenandoccursin0.5–1%oftheIrishpopulation.Currentlycoeliacdiseaseisunderdiagnosed.Ithasastronggeneticcomponentwitha10%chanceofoccurrenceinafirstdegreerelative.Theonlytreatmentisadherencetoaglutenfreediet.Studieshaveshownthatdietarycomplianceisoftenpoorrangingfrom45–87%.Long-termhealthriskswithpoorcomplianceincludeincreasedriskofmalignancy,nutritionaldeficienciesandreducedbonemineraldensity.Researchhasshownthatdietarycompliancepositivelycorrelateswithregularfollowupandknowledgeofthedisease.

Currentlythereareanumberofguidelinespublishedonthemanagementofcoeliacdisease.However,alloftheseguidelineshavebeendevelopedoutsideoftheRepublicofIreland.ThisguidelinehasbeendevelopedforusewithinthecontextoftheIrishHealthcaresystemandputsinplaceaframeworkforthediagnosisandmanagementofpatientswithcoeliacdisease.Structured,comprehensivecareforpatientswithcoeliacdiseaseisnecessaryforlong-termfollowup.ThiscarriesfinancialandresourceimplicationsforGPpractices.

1.2 Aims of the documentTheaimofthisdocumentistoprovideIrishgeneralpractitionerswithanuptodate,easytofollow,evidencebasedguidancedocumentonthediagnosis,initialmanagementandfollowupofpatientswithcoeliacdisease.


© 2015 ICGP

2. Subtopics

2.1 Clinical presentation and complicationsCoeliacdiseasecanpresentatanyageandhasawidespectrumofclinicalmanifestations(1,2).Themajorityofsymptomaticpatientspresentwithgradualonsetofgastrointestinalsymptoms,however,therearestillanumberofpatientswhoremainasymptomatic(3,4).

Table 1 – Clinical Presentations of Coeliac Disease

Gastrointestinal symptoms due to malabsorption

DiarrhoeaSteatorrhoeaAbdominalcrampsAbdominalbloatinganddistensionBorborygmiExcessiveflatulenceWeightlossbutpatientsmayalsobeoverweightorobese

Gastrointestinal Symptoms due to dysmotility

HeartburnRegurgitationDysphagiaVomitingEpigastricPainConstipation

Haematological(5) Iron/B12/FolatedeficiencyThrombocytopeniaThrombocytosisThromboembolismLeukopenia/neutropeniaVitaminKmalabsorptionleadingtocoagulopathyHyposplenismIgAdeficiencyLymphoma

Hepatological AbnormalLFTs–AST/ALTSkin DermatitisHerpetiformis

AlopeciaOral(6) Aphthousmouthulcers

GlossodyniaDefectivetoothenamel

Rheumatological ArthralgiaBone Osteopenia

OsteoporosisOsteomalacia

Gynaecological(7) LatemenarcheEarlymenopauseInfertilityRecurrentmiscarriage

Neurological(8) AtaxiaPartialseizuresMigrainePeripheralneuropathy

Psychological DepressionChronicfatigue‘Muzzyhead’


© 2015 ICGP

Glutenfreedietistheonlyavailabletreatmentandnonadherencecanleadtocomplicationsofthediseasesuchas:

Table 2 – Complications of Coeliac Disease

Osteopenia

Osteoporosis

Malignancy:oropharyngealsquamouscellcarcinoma,Enteropathy-associatedT-celllymphoma,Adenocarcinomaofjejunum

IronDeficiencyAnaemia

SplenicAtrophy

Infertility

RecurrentAbortion

UlcerativeJejunoileitis

Neurologicaldisorders

DermatitisHerpetiformis

2.2 Who to test

Patients with symptoms, signs or laboratory evidence suggestive of malabsorption such as chronic diarrhoea or steatorrhea should be tested for coeliac disease (9) Level 1 Grade ACoeliacdiseaseresultsininjurytotheliningofthesmallintestinecausingvillousatrophywithsubsequentlossofmucosalsurfaceareaandimpairedabsorption.Theresultantinflammationleadstoexcessfluidsecretioncausingdiarrhoeawithabdominalpainandbloating.(10)CoeliacdiseaseisonethemostcommoncausesofmalabsorptionintheWesternworld.

Patients with a first degree relative with coeliac disease should be tested if they have signs or symptoms consistent with coeliac disease (9) Level 3 Grade BThefrequencyofcoeliacdiseaseissubstantiallyincreasedinpatientswithapositivefamilyhistory.AlargecommunitybasedstudyintheUSAin2003(11)foundthattheprevalenceofcoeliacdiseasewas;

• Atrisk,first-degreerelatives:1in10• Atrisk,second-degreerelatives:1in39• Atrisk,symptomaticpatients:1in56• Groupsnotatrisk:1in100

Newlydiagnosedpatientswithcoeliacdiseaseshouldbeinformedoftherisksandfamilialscreeningshouldbeadvised.


© 2015 ICGP

Patients with a first degree relative with coeliac disease should be considered for testing even if they are asymptomatic(9) Level 3 Grade BEveniffirstdegreerelativesareasymptomaticitisreasonabletoconsiderscreeningthesepatients.Studiesinpatientswhohavebeendiagnosedonthebasisofscreeningreportimprovementsinqualityoflifeandimprovedhealth(12)withadherencetoaglutenfreediet.

Patients with Type 1 DM should be tested for coeliac disease if there are any digestive symptoms (9) Level 3 Grade CCoeliacdiseaseissubstantiallymorecommoninpatientswithtype1DMthaninthegeneralpopulation.Theprevalenceratesofcoeliacdiseaseinchildrenwithtype1diabetesareestimatedtobebetween1.7and12%.(13)Screeningstudieshaveshowntheprevalenceamongadultswithtype1diabetestobesimilar,between1.3and6.4%,whichis10timestheprevalenceinthegeneralpopulation.(14)

Population screening is currently not recommended for coeliac disease (15) Level 3 Grade BThecurrentviewisthatthereisnotenoughevidencetosupportadecisiontocarryoutmassscreeningofthegeneralpopulation.Despitethefactthatcoeliacdiseasefulfils5oftheWHOcriteriaforascreeningtestthisstillremainscontroversialduetocosteffectivenessissues(15)andpotentialharm(16).

ActivecasefindingmayincreasedetectionofthosewithcoeliacdiseasewhoareattendingaGPsurgery(17).5%ofpatientswithirritablebowelsyndromehavecoeliacdisease.Symptomaticpatientsorthosewithcloselyrelatedconditionsshouldbeconsideredfortesting.

Table 3 – Conditions Associated with an increase prevalence of coeliac disease (9) (15) (18)

Type1DiabetesMellitus

AutoimmunethyroidDisease

Metabolicbonedisease/earlyosteoporosis

Irritableboweldisease

Primarybiliarycirrhosis

Autoimmunehepatitis

Sjogren'ssyndrome

Addison'sdisease

Downsyndrome

Turnersyndrome

SelectiveIgAdeficiency

AbnormalAST/ALT


© 2015 ICGP

2.3 Investigations for diagnosisInitial diagnosis is by a single blood test for Immunoglobulin A (IgA) anti tissue transglutaminase (9) Level 1 Grade BTheIgAtTGAisrelativelysensitiveandspecificfordiagnosingcoeliacdiseasemakingitthepreferredtestfordetection.Manystudiesdemonstrateaspecificityof>95%andasensitivityintherangeof90–96%.(2)(19)(20)

Measurement of IgA antiendomysial antibodies should be used as a confirmatory test in the case of elevated anti tTG antibodies (21) Level 5 Grade CMeasurementofantiEMAisnearly100%specificforactivecoeliacdiseaseandhas>90%sensitivity(2).ItshouldbeusedasaconfirmatorytestwhenantiTTGisborderlineortoruleoutfalsepositiveresults.AfalsepositiveantiTTGcanoccurinotherautoimmuneconditionssuchasautoimmunehepatitis(22)andtype1Diabetesmellitus(23).

If IgA deficiency is suspected then Ig A level should be checked and where a deficiency exists then IgG based tests should be performed. Level 4 Grade CIgAdeficiencyismorecommonincoeliacdiseasethaninthegeneralpopulationandoccursin2-3%ofpatientswithcoeliacdisease.MeasurementofserumIgAlevelisanappropriatenextstepifIgAbasedtestingisnegativeandthereisastrongclinicalsuspicionofcoeliacdisease.FiguresforIgGtTGsensitivityandspecificityvarywidelywhileIgGDGP(deaminatedgliadinpeptide)hasasensitivityandspecificityof>90%.(24)IfanIgAdeficiencyexiststhenIgGbasedtTGshouldberequestedfromthelaboratory.

All diagnostic serological testing should be performed while the patient is on a gluten diet. (9, 21)Level 4 Grade CFalsenegativetestresultswilloccuriftestingisperformedonaglutenfreediet.

HLA-DQ2/DQ8 testing should not be done routinely in the diagnosis of coeliac disease (2) (9) Level 2 Grade BTheadditionofHLA-DQtypingtoserologicaltestsdoesnotimprovetheaccuracyofbloodtestalonefordiagnosis(25).IncaseswheretherearestilldoubtsregardingthediagnosisafterhistologyorinsomeotherspecificclinicalsituationsthenHLA-DQ2/DQ8genotypingshouldbeconsidered(9).Suchtestinghasahighnegativepredictivevaluemeaningthosewhotestnegativeareveryunlikelytodevelopthedisease.(26)

The confirmation of coeliac disease is based on upper GI endoscopy with multiple biopsies of the duodenum (9) Level 3 Grade BApositivecoeliacdiseasespecificserologyinpatientswithvillousatrophyonendoscopyconfirmsthediagnosisofcoeliacdisease(27).


© 2015 ICGP

2.4 Management at initial diagnosisPatients with Coeliac disease should adhere to a gluten free diet for life (9) Level 2 Grade A (See Appendix 1)Thereiscurrentlynoothertreatmentavailableforcoeliacdiseaseandsopatientsmustexercisestrictavoidanceofallproductscontainingglutenincludingwheat,barleyandrye.Itisdifficulttoavoidglutencompletelyduetoglutencontaminationoffood.

Itisunclearwhetherpatientswithcoeliacdiseaseshouldavoidoats.Themajorityofpatientscantolerateamoderateamountofrawoatsbutsideeffectscanoccurinsomepatients.Foradultsupto70g/dayissafe(28).Thereisstillneedforcautionwhenintroducingoatsduetothepossibilitythatcommercialoatsmaybecontaminatedwithgluten.

Aglutenfreedietwillleadtoresolutionofsymptomsandrepairofvillousdamageovertime.

Otherbenefitsofaglutenfreediet:

• Riskofmalignanciesisreduced(smallboweladenocarcinoma,BcellandTcelllymphoma)(29)

• Improvedbonemineraldensityandreducedfractures(30)

• Reducesriskofinfertility,spontaneousabortions,pretermdeliveriesandlowbirthweightinfantstothatofthegeneralpopulation(31)(32)

Patients with coeliac disease should be referred to a dietician (9, 33) Level 4 Grade CImprovedpatientknowledgeofthediseaseisassociatedwithbettercompliancewithaglutenfreediet(34).ManyGPsdonothaveadequateknowledgeortherequiredtimetoevaluateandeducatepatientsregardingtheirdiet.Dieticianscanperformtheinitialassessmentandadviseonglutenfreedietaswellasconductlong-termfollowupforongoingcompliance.

People with newly diagnosed coeliac disease should be tested for B12/folate/iron deficiency. Vitamin D testing should also be considered (9) Level 3 Grade BCoeliacdiseaseisassociatedwithiron,B12,folateandothervitamindeficiencies(35,36).ItisthoughtthatlowVitaminDlevelsarerelatedtolowbonemineraldensity.

All patients should have a DXA scan at presentation. Females with normal bone mineral density at presentation should be reassessed after the menopause and males at age 55 years (37). Level 2 Grade AOsteopeniaandosteoporosishavebeenreportedinalmosthalfofnontreatedcoeliacdiseasepatients(36).ManycurrentguidelinesrecommendaDXAscanatdiagnosistoreverseearlyosteopeniaandalsobecausethelatentperiodtodiagnosismaybelonginsomecasessignifyingalongerperiodofcalciummalabsorption(33).Despitethis,somecontroversyremainsastothecostbenefitofroutinelyperformingDXAscanatdiagnosis(38).


© 2015 ICGP

Becausecoeliacdiseaseisanindependentriskfactorforosteoporosisthenperi-menopausalwomenandmenover55yearsareatincreasedriskdespitetreatmentwithaglutenfreediet.

All individuals with coeliac disease should be advised to consume 1500mg calcium per day ideally from dietary sources. Calcium supplementation should only be used if dietary intake is inadequate. Patients should be advised regarding usual care conservative measures to reduce osteoporosis risk (37) Level 5 Grade C

If calcium intake is adequate then Vitamin D replacement is not routinely needed unless in special circumstances such as the elderly or housebound (37) Level 5 Grade C

2.5 Follow up of patients(Seediagram–Appendix2)

Patients with coeliac disease should have an annual review (37). Level 3 Grade BMostofthecurrentlypublishedguidelinesrecommendanannualfollowupreviewofpatients(39).

At the annual review patients should be assessed for BMI, symptomatology, compliance with diet and complications of their disease (37). Level 4 Grade C

If there are concerns regarding compliance Coeliac serology should be taken (37). Level 4 Grade CMonitoringofadherencetodietshouldbebasedonhistoryandIgATTGorIgADGP(deaminatedgliadinpeptide)antibodies.(40)ThetTGtakelongertonormaliseonaGFDalthoughtheyhavebeensuggestedtobettercorrelatewiththedegreeofvillousatrophy(41).

Patients should be investigated for micronutrient deficiencies if diet is poor and any previously abnormal blood tests should be repeated (9). Level 5 Grade C

Patients with coeliac disease should receive vaccination against encapsulated organisms (37). Level 4 Grade CCoeliacdiseaseisassociatedwithsplenicatrophyandissufficientlyseveretocauseperipheralbloodchangeinapproximately25%patients(37).Thereisnoeasilyappliedtechniquethatreliablyidentifiesthosewithhyposplenism.Noristhereadefineddegreeofhyposplenismthatcanbeusedtodecidewhenapersonisatincreasedriskofsepsis.Asoverwhelmingsepsiscanoccurrapidly,itisadvisablethatthefollowingvaccinesshouldbeconsideredforthosewithcoeliacdisease-PCV13,PPV,Hib,MenACWY,MenBandannualinfluenzavaccines

(42).Patientsshouldbeeducatedregardingtheinfectiouscomplicationsassociatedwithhyposplenism.Patientswhoshowsignsofovertsplenicatrophysuchasacanthocytes,HowellJollybodiesortargetcellsonbloodfilmshouldbetreatedinasimilarfashiontoasplenicpatients(5).


© 2015 ICGP

If symptoms persist after 6 months on a gluten free diet patients should be referred to a dietician with expertise in coeliac disease to assess dietary compliance (21). (Level 5 Grade C)Ifsymptomspersistdespiteaglutenfreedietotherconditionsshouldbeconsidered:

• Lactoseintolerance• Pancreaticinsufficiency• Wheat/maltintolerance• Lymphoma• Microscopiccolitis• Bacterialovergrowth• Irritablebowelsyndrome• Refractorycoeliacdisease

LactoseIntoleranceisassociatedwithcoeliacdiseaseandcanbeapresentingfeatureoralatecomplicationofnon-compliancewithaglutenfreediet.Villousatrophyandthesubsequentdamagetotheintestinalbrushbordercausesasecondarydisaccharidasedeficiencyleadingtolactoseintolerance(43).Patientspresentwithbloating,stomachpainand/orcramps,diarrhoea,flatulenceandnausea.Referraltoadieticianisnecessarybothfordiagnosisandongoingfollowupasthesepatientsareathighriskofcalciumdeficiency.Lactoseintoleranceimproveswithadherencetoaglutenfreediet.

Thereisaclearassociationbetweencoeliacdiseaseandintestinalnon-Hodgkinslymphoma.ThislymphomaisknownasEnteropathy-typeTcelllymphoma.Thesearerarelymphomasandaccountfor<1%ofallnonHodgkinslymphomas.CurrentepidemiologicalstudiesreporttherelativeriskofdevelopingNHLintherange3–6(5).Theriskofadenocarcinomaofthesmallintestineisalsoincreasedinpatientswithcoeliacdisease.However,theabsoluteriskofthiscancerisstillquitelowgivenitsrarity(44,45).Atpresentroutinescreeningformalignancyinpatientswithcoeliacdiseasecannotbejustified.

Referral to a gastroenterologist for repeat endoscopy or further investigation should be considered if there is: (37)

• Poor response to gluten free diet• Weight loss on a gluten free diet• Blood in stools• Onset of unexplained abdominal pain• Abnormalities in blood results

Level 5 grade C Thereiscurrentlynoconsensusonfollowupendoscopyforsurveillanceinasymptomaticpatients(46).


© 2015 ICGP

2.6 Non coeliac gluten sensitivityNonCoeliacGlutenSensitivity(NCGS)isemergingasamorefrequentlyencounteredconditioninclinicalpractice.Itwasrecognisedasfarbackas30yearsago(47)butitisonlyinrecentyearsthattheincreasingprevalenceofthisconditionhasbeenrecognised.ItisthoughtthattheprevalenceismuchhigherthanthatofcoeliacdiseasewithoneUSstudydocumentingaprevalenceof6%(48).

Glutensensitivityisdefinedasareactiontogluteninwhichallergicandautoimmunemechanismshavebeenexcluded.Patientshavenegativecoeliacserologyandnormalduodenalmucosabuthaveresolutionofsymptomsonadherencetoaglutenfreediet.

NCGSislargelyadiagnosisofexclusion.Afteradherencetoaglutenfreedietwithresolutionofsymptomsaglutenchallengemaybeperformedtomakeadefinitivediagnosis(49).

Theaetiologyofthisconditioniscurrentlyunknownandfurtherstudyisneededtoelucidateanylongtermcomplicationsthatmayresultfromthiscondition.


© 2015 ICGP

3. References1. MurrayJA,WatsonT,ClearmanB,MitrosF.Effectofagluten-freedieton

gastrointestinalsymptomsinceliacdisease.TheAmericanJournalofClinicalNutrition.2004April;79(4):669-73.

2. RostomA,MurrayJA,KagnoffMF.AmericanGastroenterologicalAssociation(AGA)Institutetechnicalreviewonthediagnosisandmanagementofceliacdisease.Gastroenterology2006;131(6):1981-2002.

3. TursiA,GiorgettiG,BrandimarteG,RubinoE,LombardiD,GasbarriniG.Prevalenceandclinicalpresentationofsubclinical/silentceliacdiseaseinadults:ananalysisona12-yearobservation.Hepatogastroenterology.2001Mar-Apr;48(38):462-4.

4. SaleemA,ConnorHJ,ReganPO.AdultcoeliacdiseaseinIreland:acaseseries.IrishJournalofMedicalScience.2012Jun;181(2):225-9.doi:10.1007/s11845-011-0788-z.Epub2011Dec28.

5. HalfdanarsonTR,LitzowMR,MurrayJA.HaematologicManifestationsofCeliacDisease.Blood2007109(2):412-421.

6. LuccheseA,GuidaA,SerpicoR.Glossodyniaandcoeliacdisease.ImmunopharmacologyandImmunotoxicology.2012Apr;34(2):247-9.

7. SherKS,MayberryJF.Femalefertility,obstetricandgynaecologicalhistoryincoeliacdisease.ACasecontrolstudy.Digestion1994;55(4):243-6.

8. HadjivassiliouM,SandersDS,GrünewaldRA,WoodroofeN,BoscoloS,AeschlimannD.Glutensensitivity:fromguttobrain.TheLancetNeurology.2010;9(3):318-330.

9. Rubio-TapiaA,HillID,KellyCP,CalderwoodAH,MurrayJA.ACGClinicalGuidelines:DiagnosisandManagementofCeliacDisease.TheAmericanJournalofGastroenterology.2013May;108(5):656-76.

10. DiSabatinoA,CorazzaGR.Coeliacdisease.Lancet.2009Apr25;373(9673):1480-93.

11. FasanoA,BertiI,GerarduzziT,NotT,CollettiRB,DragoS,ElitsurY,GreenPH,GuandaliniS,HillI,PietzakM,VenturaA,ThorpeM,KryszakD,FornaroliF,WassermanSS,MurrayJA,HorvathK.Prevalenceofceliacdiseaseinat-riskandnot-at-riskgroupsintheUnitedStates:alargemulticenterstudy.ArchivesofInternalMedicine.2003Feb10;163(3):286-92.

12. KinosS,KurppaK,UkkolaA,CollinP,LähdeahoML,HuhtalaH,KekkonenL,MäkiM,KaukinenK.Burdenofillnessinscreen-detectedchildrenwithceliacdiseaseandtheirfamilies.JournalofPediatricGastroenterologyandNutrition.2012Oct;55(4):412-6.

13. BareraG,BonfantiR,ViscardiM,BazzigaluppiE,CaloriG,MeschiF,BianchiC,ChiumelloG.Occurrenceofceliacdiseaseafteronsetoftype1diabetes:a6-yearprospectivelongitudinalstudy.Pediatrics.2002May;109(5):833–8.


© 2015 ICGP

14. LiVoonChongJS,LeongKS,WallymahmedM,SturgessR,MacFarlaneIA.Iscoeliacdiseasemoreprevalentinyoungadultswithcoexistingtype1diabetesmellitusandautoimmunethyroiddiseasecomparedwiththosewithtype1diabetesmellitusalone?DiabeticMedicine.2002Apr;19(4):334-7.

15. WorldGastroenterologyOrganisationPracticeGuidelines:CeliacDisease.2007.[Online]Availablefrom:http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/04_celiac_disease.pdf[AccessedMay12th2015]

16. UkkolaA,MakiM,KurppaK,CollinP,HuhtalaH,KekkonenL,KaukinenK.Dietimprovesperceptionofhealthandwell-beinginsymptomatic,butnotasymptomatic,patientswithceliacdisease.ClinicalGastroenterologyandHepatology.2011Feb;9(2):118–23.

17. CatassiC,KryszakD,Louis-JacquesO,DuerksenDR,HillI,CroweSE,BrownAR,ProcacciniNJ,WonderlyBA,HartleyP,MoreciJ,BennettN,HorvathK,BurkM,FasanoA.Detectionofceliacdiseaseinprimarycare:amulticentercase-findingstudyinNorthAmerica.TheAmericanJournalofGastroenterology.2007July;102(7):1454–60.

18. BarkerJM,LiuE.CeliacDisease:Pathophysiology,clinicalmanifestationsandassociatedautoimmuneconditions.AdvancesinPediatrics.2008;55:349-65.

19. ZintzarasE,GermenisAE.PerformanceofAntibodiesagainstTissueTransglutaminasefortheDiagnosisofCeliacDisease:Meta-Analysis.ClinicalandVaccineImmunology.2006Feb;13(2):187-192.

20. vanderWindtDA,JellemaP,MulderCJ,KneepkensCM,vanderHorstHE.Diagnostictestingforceliacdiseaseamongpatientswithabdominalsymptoms:asystematicreview.JAMA2010May5;303(17):1738-46.

21. ClinicalResourceEfficiencySupportTeam(CREST).GuidelinesfortheDiagnosisandManagementofCoeliacDiseaseinAdults.May2006.[Online]Availablefrom:http://www.gain-ni.org/index.php/guidelines-for-the-diagnosis-and-management-of-coeliac-disease-in-adults[Accessed14thMay2015]

22. GermenisAE,YiannakiEE,ZachouK,RokaV,BarbanisS,LiaskosC,AdamK,KapsoritakisAN,PotamianosS,DalekosGN.PrevalenceandClinicalSignificanceofImmunoglobulinAAntibodiesagainstTissueTransglutaminaseinPatientswithDiverseChronicLiverDiseases.ClinicalandDiagnosticLaboratoryImmunology.August2005.12(8):941-8.

23. MaglioM,FlorianF,VecchietM,AuricchioR,PaparoF,SpadaroR,ZanziD,RapacciuoloL,FranzeseA,SblatteroD,MarzariR,TronconeR.Majorityofchildrenwithtype1diabetesproduceanddepositanti-tissuetransglutaminaseantibodiesinthesmallintestine.Diabetes.2009Jul;58(7):1578-84.

24. FasanoA,CatassiC.ClinicalPractice:CeliacDisease.NewEnglandJournalofMedicine.2012Dec20;367(25):2419-26.

http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/04_celiac_disease.pdf

http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/04_celiac_disease.pdf

http://www.gain-ni.org/index.php/guidelines-for-the-diagnosis-and-management-of-coeliac-disease-in-adults

http://www.gain-ni.org/index.php/guidelines-for-the-diagnosis-and-management-of-coeliac-disease-in-adults

http://www.ncbi.nlm.nih.gov/pubmed/19401430


© 2015 ICGP

25. HadithiM,vonBlombergBM,CrusiusJB,BloemenaE,KostensePJ,MeijerJW,MulderCJ,StehouwerCD,PeñaAS.AccuracyofserologictestsandHLA-DQtypingfordiagnosingceliacdisease.AnnalsofInternalMedicine.2007Sep4;147(5):294–302.

26. KarellK,LoukaAS,MoodieSJ,AscherH,ClotF,GrecoL,CiclitiraPJ,SollidLM,PartanenJ;EuropeanGeneticsClusteronCeliacDisease.HLAtypesinceliacdiseasepatientsnotcarryingtheDQA1*05-DQB1*02(DQ2)heterodimer:resultsfromtheEuropeanGeneticsClusteronCeliacDisease.HumanImmunology.2003April;64(4):469-77.

27. LefflerDA,SchuppanD.Updateonserologictestinginceliacdisease.TheAmericanJournalofGastroenterology.2010Dec;105(12):2520–4.

28. RashidM,ButznerD,BurrowsV,ZarkadasM,CaseS,MolloyM,WarrenR,PulidoO,SwitzerC.Consumptionofpureoatsbyindividualswithceliacdisease:apositionstatementbytheCanadianCeliacAssociation.CanadianJournalofGastroenterology.2007Oct;21(10):649-51.

29. HolmesGK,PriorP,LaneMR,PopeD,AllanRN.MalignancyinCeliacDisease–effectofaglutenfreediet.Gut.1989Mar;30(3):333–8.

30. BlazinaS,BratanicN,CampaAS,BlagusR,OrelR.Bonemineraldensityandimportanceofstrictgluten-freedietinchildrenandadolescentswithceliacdisease.Bone.2010Sep;47(3):598-603.

31. CiacciC,CirilloM,AuriemmaG,DiDatoG,SabbatiniF,MazzaccaG.Celiacdiseaseandpregnancyoutcome.TheAmericanJournalofGastroenterology.1996Apr;91(4):718–22.

32. SoniS,BadawySZ.CeliacDiseaseandItsEffectonHumanReproduction:AReview.TheJournalofReproductiveMedicine.2010Jan-Feb;55(1-2):3-8.

33. CiclitiraPJ,DewarDH,McLaughlinSD,SandersDS.TheManagementofAdultswithCoeliacDisease.London:BritishSocietyofGastroenterology;2010.[Online]Availablefrom:http://www.bsg.org.uk/sections/small-bowel-nutrition-articles/bsg-guidance-on-coeliac-disease-2010.html[Accessed14thMay2015]

34. ButterworthJR,BanfieldLM,IqbalTH,CooperBT.Factorsrelatingtocompliancewithagluten-freedietinpatientswithcoeliacdisease:comparisonofwhiteCaucasianandSouthAsianpatients.ClinicalNutrition.2004Oct;23(5):1127-34.

35. WierdsmaNJ,vanBokhorst-devanderSchuerenMA,BerkenpasM,MulderCJ,vanBodegravenAA.Vitaminandmineraldeficienciesarehighlyprevalentinnewlydiagnosedceliacdiseasepatients.Nutrients.2013Sep30;5(10):3975-92.

36. CarusoR,PalloneF,StasiE,RomeoS,MonteleoneG.Appropriatenutrientsupplementationinceliacdisease.AnnalsofMedicine.2013Dec;45(8):522–31.

37. PrimaryCareSocietyforGastroenterology.TheManagementofAdultswithCoeliacDiseaseinPrimaryCare.London:PrimaryCareSocietyforGastroenterology;May2006.


http://www.bsg.org.uk/sections/small-bowel-nutrition-articles/bsg-guidance-on-coeliac-disease-2010.html

http://www.bsg.org.uk/sections/small-bowel-nutrition-articles/bsg-guidance-on-coeliac-disease-2010.html



© 2015 ICGP

38. LewisNR,ScottBB.Shouldpatientswithcoeliacdiseasehavetheirbonemineraldensitymeasured?EuropeanJournalofGastroenterology&Hepatology.2005Oct;17(10):1065-70.

39. SilvesterJA,RashidM.Long-termfollow-upofindividualswithceliacdisease:Anevaluationofcurrentpracticeguidelines.CanadianJournalofGastroenterology.2007Sep;21(9):557–564.

40. NachmanF,SugaiE,VázquezH,GonzálezA,AndrenacciP,NiveloniS,MazureR,SmecuolE,MorenoML,HwangHJ,SánchezMI,MauriñoE,BaiJC.Serologicaltestsforceliacdiseaseasindicatorsoflong-termcompliancewiththegluten-freediet.EuropeanJournalofGastroenterologyandHepatology.2011Jun;23(6):473-80.

41. PietzakMM.Followupofpatientswithceliacdisease:Achievingcompliancewithtreatment.Gastroenterology.2005Apr;128(4Suppl1):S135-41.

42. HSE.ImmunisationGuidelinesforIreland.2013.[Online]Availablefrom:http://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/[Accessed14thMay2015]

43. PlotkinGR,IsselbacherKJ.SecondaryDisaccharidaseDeficiencyinAdultCeliacDisease(NontropicalSprue)andOtherMalabsorptionStates.NewEnglandJournalofMedicine.1964Nov12;271:1033-37.

44. GreenPH,FleischauerAT,BhagatG,GoyalR,JabriB,NeugutAI.Riskofmalignancyinpatientswithceliacdisease.TheAmericanJournalofMedicine.115(3);2003Aug15:191-5.

45. LoftusCG,LoftusEVJr.Cancerriskinceliacdisease.Gastroenterology.2002Nov;123(5):1726-9.

46. LübbersH,MahlkeR,LankischPG,StolteM.Follow-UpEndoscopyinGastroenterology:WhenIsItHelpful?DtschArzteblInt.2010Jan;107(3):30–39.

47. CooperBT,HolmesGKT,FergusonR,ThompsonRA,AllanRN,CookeWT.Glutensensitivediarrhoeawithoutevidenceofceliacdisease.Gastroenterology.1980Nov;79(5Pt1):801-6.

48. SaponeA,BaiJC,CiacciC,DolinsekJ,GreenPH,HadjivassiliouM,KaukinenK,RostamiK,SandersDS,SchumannM,UllrichR,VillaltaD,VoltaU,CatassiC,FasanoA.Spectrumofgluten-relateddisorders:consensusonnewnomenclatureandclassification.BMCMedicine.2012Feb11;10:13.

49. HolmesG.NonCoeliacGlutenSensitivity.GastroenterologyandHepatologyfromBedtoBench.2013Summer;6(3):115-119.

http://journals.lww.com/eurojgh/toc/2005/10000



http://www.hse.ie/eng/health/immunisation/hcpinfo/guidelines/

http://www.sciencedirect.com/science/journal/00029343/115/3

http://www.sciencedirect.com/science/article/pii/S0016508502003050

http://www.sciencedirect.com/science/article/pii/S0016508502003050

http://www.sciencedirect.com/science/journal/00165085/123/5

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3292448/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3292448/


© 2015 ICGP

4. Appendices

Appendix 1 – Dietary adviceAdaptedwithpermissionfromPatientwebsite,http://www.patient.co.uk/health/coeliac-disease-diet-sheet©2015,EgtonMedicalInformationSystemsLimited.Allrightsreserved.

SinceSeptember2012glutenfreefoodsarenolongeravailableonthegeneralmedicalschemeordrugspaymentscheme.TheonlyfinancialsupportforthosewithcoeliacdiseaseistaxreimbursementattheendofthetaxyearbyfillinginaMed1Form.

GlutenfreefoodsareavailableinallmajorsupermarketsandhealthfoodshopsinIreland.

Reading labels and identifying gluten in foodsBylaw,ifafoodcontainsglutenitmustbelistedonthelabel.Youmayseeanallergenadviceboxsaying‘containsgluten’.Manyprocessedfoodscontaingluten,asitisusedasanadditiveorfoodsbecomecontaminatedduringtheproductionprocess.Therefore,itisimportanttocheckthelabelswhenoutshopping.

Avoidproductsthatcontainanyofthefollowing:

• Wheat• Barley• Rye• Spelt

• Oats(contaminatedoats)• Maltandmaltedbarley(foundin

breakfastcereals,vinegar,sauces,picklesandconfectionary)

Notallfoodsthataregluten-freewillmentionthisonthelabel,soalwayschecktoseewhetheritcontainsgluten.Thecrossedgrainsymbolisusedbymanymanufacturerstohighlightthataproductisgluten-free.Somemanufacturersmayusetheirownsymbol.Otherproductsmaysimplystateitonthepackaging.Forexample,youmaysee:

• Gluten-free• Suitableforcoeliacs• Freefromgluten

Foods that contain glutenCheckingthelabelsisusefulwhenidentifyingfoodsthatcontaingluten.However,itishelpfultohaveageneralideaofwhatfoodstoavoidandwhatfoodsareallowed.

http://www.patient.co.uk/health/coeliac-disease-diet-sheet

http://www.patient.co.uk/health/coeliac-disease-diet-sheet


© 2015 ICGP

FOOD GROUP FOODS ALLOWED FOODS TO AVOIDCereals and flour

Cornflour,polenta,potato,cassava,beanandlentilflour,splitpeaflour,millet,quinoa,buckwheat,rice(alltypes),maize,arrowroot,sorghum,teff,amaranth.

Breakfastcerealsallowedare:somebrandedandequivalentsupermarketbrandsofcornorricebasedcerealse.g.cornflakes,ricesnaps,honeynutcornflakes.(Alwayscheckthelabelassomevarietiesmaynotbegluten-free.)

Wheat,rye,barley,bulgarwheat,spelt,durumwheat,triticale,khorasanwheat(Kamut®),wheatflour,wheatstarch,wheatbran,oatbran,semolina,couscous,maltandmaltedbarley,bale.

Avoidallwheat-basedbreakfastcerealsandmuesli.

Breads, cakes and biscuits

Gluten-freeproductsspeciallymanufactured(supermarketshavespecialisedranges):eg,breads,biscuits,pizzabases,flourmixes,cakes.Productsmadefromcerealsorfloursfromtheallowedlist.Productsmadewithoutflour(checkthelabelforotherglutensources)orwithgluten-freeflour.

Allbreadandbreadproducts-e.g.,croissants,bagels,pittabread,chapatti,naanbread,crispbreads,crackers,matzos,muffins,scones,croutons,pancakes,pizza,yorkshirepuddings,wafersandicecreamcones,pastriesandpies.

Pasta, rice and noodles

Alltypesoffreshrice.Ricenoodles(checkthelabel).Gluten-freepasta,cornpasta.

Anyfresh,driedortinnedpasta,andnoodles.Processedricefoundinsaladsorreadymeals.

Potatoes Allfreshpotatoes.Somecrisps(checkthelabel).Home-madechipsmadefromfreshpotatoes.

Processedpotatoes-e.g.,potatosalad,waffles,somechips,instantmash,crispsorpotatosnacks

Meat, fish and poultry

Allfreshmeat,fishandpoultry.Tinnedfish-e.g.,tuna/salmon.Smoked,kipperedordriedfish.Gluten-freesausages.Gluten-freefishfingers.

Someprocessedmeatsorproductscoatedinbatterorbreadcrumbs.Pies,puddings,suet,stuffing,fishfingers,chickennuggets,fishcakes,sausages,burgers,haggis,taramasalata,rissoles,Quorn®.

Milk, dairy, eggs and dairy alternatives

Naturalplaincheese,freshmilk,cream,condensedmilk,yoghurts,fromagefrais,soyamilk,goat’smilk,coconutmilk,almondmilk,ricemilk,driedskimmedmilkpowder,eggs.

Checkthelabelsofprocessedcheese,low-fatcheesespreads,artificialcreamandyoghurts.Yoghurtscontainingmuesliorcereals.Scotcheggs.


© 2015 ICGP

Fats and oils Vegetableoil,oliveoil,butter,lard,reducedfat/low-fatspreads(checkthelabels).

Suet,somebrandsoflow-fatspreads.

Fruit, vegetables, nuts and pulses

Fresh,driedortinnedfruit,vegetables,nuts,beans,pulsesandseeds.Checklabelsofsomebakedbeanbrands.

Processedfruitandvegetablesthatarecoatedinbreadcrumbs/orinsauces.Somebrandsofnuts

Desserts and puddings

Meringues,sorbets,icecreams,jelly,mousses,custardpowders,milkpuddingsmadewithgluten-freeingredients.Alwayschecklabelsofthesefoodproducts.

Trifles,spongepuddings,semolina,tarts,andpuddingsmadefromfloursinthe‘foodstoavoid’list.

Snack foods Prawncrackers,ricecakes,poppadoms,home-madepopcorn,glutenfreecrispbreadsandcrackers.

Pretzels,Bombaymix,snacksmadefromfloursinthe‘foodstoavoid’list.

Confectionary, sweets and preserves

Sugar,goldensyrup,icingsugar,treacle,molasses,jam,honey,marmalade,peanutbutter,boiledsweetsandjellies.

Somechocolatebars,toffeesandsweets(alwayschecklabels).

Soups, sauces and seasonings

Freshsaltandpepper,herbs,spices,vinegars(e.g.,ricewine,balsamic),homemadefreshsoups,gluten-freesoups,saucesandseasonings.

Maltvinegar,packetsoupsandsauces,gravies,soysauce,ketchups,mayonnaise,saladdressings,picklesandchutneys,stuffingandstuffingmixes,stockcubes,bouillon,Worcestershiresauce(somebrandsmaybegluten-free).

Drinks and alcohol

Tea,coffee,fizzydrinks,squashes,cordials,freshjuices,milk,somecocoapowders,cider,spirits,wines,liqueurs,sherry,port.

Barleydrinksorsquashes,cloudyfizzydrinks,maltedmilkdrinks,instantvendingmachinedrinks,somemilkshakesandsportsdrinks,beer,lager,stout,ale.

Other Bicarbonateofsoda,freshanddriedyeast,marzipan,yeastextracts,tofu,foodcolouringsandflavourings,gelatine.

Bakingpowder,somemedicinesandvitamins.

Foods naturally free from glutenIffoodsarebeingexcludedfromthediet,itisimportanttoensureyouarestillhavingabalanceddiettogetallthenutrientsyouneed.Foodsnaturallyfreefromglutenincludefruit,vegetables,meat,fish,rice,potatoes,beans,pulses,nuts,eggs,milkanddairy.Stickingtoagluten-freedietcanbedifficult,soincludingplentyoftheseinthedietwillmakeiteasier.


© 2015 ICGP

Gluten-free alternativesLivingwithadietfreefromglutencanbedifficult,andsothereareproductsavailabletohelpkeepthedietvariedandeasiertomaintain.Theseproductswillalsohelptoprovideyouwiththeenergyandnutrientsyouneed.

Thereisawiderangeofgluten-freeproductsavailable.It’slikelythatyou’llfindgluten-freealternativesofmostfoods.Productsavailableincludethebasicssuchasgluten-freebread,pasta,flour,plainbiscuitsandcakes,crackers,crispbreadsandpizzabases.Luxuryproductsincludebiscuits,cakes,muesli,muffins,stuffingmix,confectionary,cerealbars,fishfingers,chickennuggetsandotherconveniencefoods.

Manyofthesupermarketchainshavegluten-freeranges.Somecompaniesthatprovidegluten-freeproductsinclude:

• FreeFrom• Juvela• Glutafin• Genius• Ener-G• DS-glutenfree• Warburtons• Proceli• Barkat

Somecompaniesofferfreestarterpacks,soyoucantryarangeofproductsandfindonesthatyouprefer.Somegluten-freeproductscontainCodexwheatstarch,whichimprovesthetasteandtextureoftheseitems.Thiscontainsaverylowlevelofgluten,whichhasbeenshowntobetoleratedbymostofthosewithcoeliacdisease.However,asmallpercentageofpeoplewhoarehighlysensitivetoglutenmayfindthatsymptomsoccurandsochoosingproductswithoutCodexwheatstarchmaybemoreappropriate.

OatsOatscanbepartofabalanceddietinmostpeoplewithcoeliacdisease,withoutcausingdamageorsymptoms.Thesemustbepure,uncontaminatedoatsandsosomeproductsavailableonsupermarketshelvesmaynotbesuitable.

Oatscanbeausefuladditiontothediet,astheyareavaluablesourceoffibreandimprovevarietyinthediet.Thismakesiteasiertocomplywithagluten-freediet.However,oatsshouldbeexcludedforthefirstsixmonthsafterdiagnosis.Thisallowsyourbodytobecomeusedtoagluten-freediet.Oatscanthenbegraduallyintroducedbutshouldbedonewiththeassistanceofadieticianincaseyoureacttopureoats.

Overall balance of the dietOnceyouhavesuccessfullyachievedagluten-freediet,itisimportanttoconsiderotheraspectsofyourdiettokeepyouhealthy.Adietinlinewiththe‘eatwellplate’


© 2015 ICGP

willprovideyouwithallthenutrientsandenergyyouneed.Aftercommencingagluten-freediet,theliningoftheintestinewillrepair,restoringnormalabsorptionofnutrients.Thismeansthatdeficienciessuchasiron-deficiencyanaemiashouldbegintoresolveandimprove.

CalciumThosewithcoeliacdiseasearemoreatriskofweakbones(osteoporosis).Thisispartlyduetohavingpoorabsorptionofcalciumwhenglutenhasbeenincludedinthediet.Thosewithcoeliacdiseasehaveahigherrequirementforcalcium.Anintakeof1,000mg–1,500mgeachdayisrecommended.Sourcesofcalciuminclude:

Glassofmilk/soyamilkenrichedwithcalcium(200ml) 245mgCheese(30g) 216mgYoghurt/soyayoghurt(onepot) 225mgGluten-freebreadfortifiedwithcalcium(twoslices) 300mgSardineswithbones(100g) 460mgTofu(100g) 510mgDriedfigs(100g) 250mgBroccoli 50mgBakedbeans(halfatin) 100mg

Youmayneedasupplementifyouareunabletomeetyourcalciumrequirementsthroughdiet.Additionally,vitaminDisnecessarytohelpabsorbcalciumfromfood.WemainlygetourvitaminDfromsunlight,asitisnotinmanyfoods.AskyourGPordieticianwhetheryouneedcalciumorvitaminDsupplements.

IronItcanbehelpfultoincludeiron-richfoodsinyourdiettohelpyouachievenormalironlevels.Animalsourcesarebetterabsorbedbythebody,butironisfoundinplantsourcestoo.VitaminCcanhelptoabsorbiron,soyoumaywanttohaveaglassoforangejuicewithmeals,eatapieceoffruitafteramealorincludefruitandvegetablesatmealtimes.

Ironisfoundin:• Redmeatsuchasbeeforlamb• Othermeatincludingchickenandturkey• Fishandshellfish-e.g.,sardines,mackerel,salmon,prawns,mussels• Liver,kidney,pâté• Beansandpulses-e.g.,lentils,chickpeasandbakedbeans• Greenleafyvegetables-e.g.,broccoli,cabbage,spinach• Nutsandseeds-e.g.,Brazilnuts,almonds,peanutbutter• Driedfruit-e.g.,raisins,apricotsanddates

Insummary,thegluten-freedietistheonlytreatmentforcoeliacdisease.Eliminatingglutencompletelyfromyourdietforlifeshouldhelptoimproveanydamagethathasoccurredtotheliningoftheintestines.Thiswillimprovesymptomsandyourabilitytoabsorbnutrientsfromfood.


© 2015 ICGP

1. CheckBMI

2. Askresymptoms

3. CheckeitherantiTTGorantiDGPforcomplianceifappropriate

4. Askregardinganyredflags

a. Persistentsymptomsb. Bloodprc. Weightloss

5. Checkbonehealth-dotheyneedaDXAscan?Iscalciumintakeadequate?Adviserealcohol,smokingandexercise

6. CheckHb,ferritin,B12,folateifindicated

7. ConsiderimmunisationagainstPCV13,PPV,Hib,MenACWY,MenBandinfluenza

8. Adviserecoeliacsocietymembershipandtaxreimbursementonglutenfreefoods

Annual Follow Up Appointment

• Well – review in a year• Symptomatic/dietary questions/compliance issues – refer to a dietician• Persistent symptoms despite dietician review – consider alternative

diagnosis and refer to gastroenterology• Red flag symptoms – refer to gastroenterology

Appendix 2

diagnosis and management of adult coeliac disease

Documents