Coeliac Disease

Coeliac Disease

Follow-Up Questions/Answers

Please present your findings.

• This patient had a completely normal abdominal examination.

• Critically, there was no tenderness on deep palpation of his abdomen.
• Important negatives include:
o lack of clinical signs of anaemia
o no lymphadenopathy
o no signs of cachexia.
• Incidentally, there were some ocular signs in a right-sided ptosis and down-sloping
palpebral fissures.
• These are not related to any abdominal pathology.

Was his abdominal examination definitely normal?

o Yes, I think his abdominal examination was entirely normal.

With that in mind, what is the likely diagnosis?

• The diagnosis here could be broad, given the limited history provided.
• Ideally, we would go on to take a full history from the patient.
• Enquire more about the:
o abdominal tenderness
o its character
o possibly its relation to food
o how often this abdominal tenderness occurs
o the time span.
• More detail would also be useful in relation to the weight loss; specifically
details about the period of weight loss and how much weight has been lost.

Let's say over the past few months, this man has lost several kilograms in weight. He has
had pain predominantly after eating and is associated with diarrhoea. He is also feeling
very tired, has no other medical history and is not on any medications.

How would that narrow down the differential diagnosis?

 Coeliac Disease

• It does narrow down the differentials a lot; however, there are still a few to be
concerned about.
• At the top of the list would be conditions such as:
o inflammatory bowel disease
o coeliac disease.
• Other autoimmune causes could still be a cause for this, such as:
o thyroid related disorders.
• I would also be concerned about infective causes of his symptoms as well.

Let's say that from taking a full history, you suspect coeliac disease as your main
differential diagnosis.

How should the patient be investigated?

• Basic blood tests.

• A full blood count, looking for signs of anaemia, taking this into consideration
along with full haematinics looking for the cause of that anaemia
• Cell count, looking for any signs of infection, and compare this to an ESR
• Baseline renal function and liver function.
• More specifically, thinking about coeliac disease:
o an anti-tissue transglutaminase (TTG) antibody test
o screen for other autoimmune problems, such as thyroid related disorders by
doing a thyroid stimulating hormone (TSH) test.

Let's say that everything seems to be in keeping with coeliac disease, but the TTG level is
borderline. How should you proceed?

• Investigate whether the patient is on a diet containing gluten or not, as this can make
the TTG negative or borderline normal.
• However, if the patient was on a gluten diet and coeliac disease is still
suspected, an OGD may be required.
• Specifically, the Endoscopist should take a biopsy from the D2 region.
• Looking for subtotal or total villous atrophy.

If you a diagnosis of coeliac disease is confirmed, how should the patient be

managed?
• Give the patient more education around their diagnosis. The primary management of
this condition is around the avoidance of gluten (wheat, rye and barley-containing
products).
• The patient may need to see a dietician to have further advice about this, but
most patients after having advice do well by avoiding those substances.
Coeliac Disease

Coeliac Disease

Key Words and Phrases

This is a case which has a normal abdominal examination.

Having the confidence to rely on your clinical acumen and to say to the examiner that there
are no abnormal findings is difficult to do.

It is important that you do not make up any findings when examining any patient for
PACES as the examiners will mark you negatively.

In this case, you could see that the differential diagnosis would be extremely broad with a
rather vague history of abdominal pain and weight loss with a normal examination.

If you are faced with this in the exam, the examiner will guide you towards a particular
diagnosis, as you could see in this case where they focused the questioning around coeliac
disease.
In summary, if you get a normal examination in your PACES exam, have the confidence to say
that there were no abnormal findings, and be led by the examiner as to which path to take for
the differential diagnosis.