GPAtlas🧭 When to suspect
Coeliac disease is a lifelong autoimmune enteropathy triggered by dietary gluten (the storage protein of wheat, barley and rye) in genetically susceptible people. The immune response causes villous atrophy of the small bowel and consequent malabsorption. It affects roughly 1 in 100 of the UK population, yet around two-thirds remain undiagnosed, largely because the presentation is so variable.
The clinical challenge is that coeliac disease is a true “clinical chameleon”. Far fewer patients now present with classic steatorrhoea and weight loss; many present with unexplained iron-deficiency anaemia, an IBS-type picture, persistent fatigue, or are picked up while screening for an associated condition. It can present at any age once gluten has been introduced into the diet.
The key skill in primary care is twofold: maintain a low threshold for serological testing in the right groups, and remember that any test is only valid while the patient is still eating gluten.
| Offer serological testing | Consider serological testing |
|---|---|
|
• Persistent unexplained abdominal or GI symptoms • Faltering growth (children) • Prolonged fatigue or unexpected weight loss • Severe or persistent mouth ulcers • Unexplained iron, vitamin B12 or folate deficiency |
• Metabolic bone disorder (reduced bone density or osteomalacia) • Unexplained neurological symptoms – peripheral neuropathy or ataxia • Unexplained subfertility or recurrent miscarriage • Persistently raised liver enzymes of unknown cause • Dental enamel defects |
|
• Type 1 diabetes, at diagnosis • Autoimmune thyroid disease, at diagnosis • Irritable bowel syndrome (in adults) • First-degree relatives of people with coeliac disease |
• Down’s syndrome • Turner syndrome • Have a low threshold to re-test any of these groups if new or persistent symptoms develop |
Source: NICE NG20 · British Society of Gastroenterology
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