Practice 10-Minute Consultation

Reviewing a patient with coeliac disease

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.d8152 (Published 17 January 2012) Cite this as: BMJ 2012;344:d8152
  1. James W Berrill, specialist registrar in gastroenterology1,
  2. Haroon Ahmed, specialty academic trainee in general practice2,
  3. Sohail Butt, general practitioner3,
  4. Gillian Swift, consultant gastroenterologist1
  1. 1University Hospital Llandough, Cardiff CF64 2XX, UK
  2. 2Foundry Town Clinic, Aberdare, UK
  3. 3Studholme Medical Centre, Ashford, UK
  1. Correspondence to: J W Berrill jamesberrill1{at}doctors.org.uk
  • Accepted 15 November 2011

A 44 year old woman diagnosed with coeliac disease 10 years ago presents to her general practitioner with symptoms of bloating and diarrhoea that have developed over the past two months.

What you should cover

Coeliac disease is a common gastrointestinal disease, with international population studies reporting a prevalence of 0.5-1%. Inflammation of the small bowel mucosa occurs as a result of an immunological response to dietary gluten. The mainstay of treatment is a gluten-free diet.

The most appropriate method of follow-up for patients with coeliac disease is still debated. Evidence suggests that regular follow-up improves compliance with a gluten-free diet. Survey data have shown that patients would prefer a model allowing regular follow-up with a dietitian, with specialist medical expertise available if needed. However, limited resources and the ability of patients to self manage means that many patients consult their general practitioner only when they have concerns. This consultation presents an opportunity to review their management.

In patients with a relapse of symptoms:

  • Reconsider the diagnosis: is this definitely coeliac disease? Review the levels of antibodies to tissue transglutaminase and the histological findings.

  • Ascertain whether symptoms improved after starting a gluten-free diet; most patients report improvement of symptoms in the first few weeks. Of those whose symptoms do not improve with the diet, only a very small minority have true refractory coeliac disease, with about 90% having an alternative underlying cause identified.

  • Discuss the patient’s diet. The commonest cause of persistent or recurring symptoms is ingestion of gluten. Ongoing …

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