Coeliac disease - A case study
Alison is a 32-year-old woman who has a history of bowel frequency with occasional bouts of constipation going back over 15 years. About 12 months ago, she was diagnosed by her doctor as having irritable bowel syndrome (IBS) for which she has occasionally tried mebeverine tablets with little beneficial effect. Today she comes to the pharmacy and asks for a medicine for diarrhoea. On questioning, Alison says she had a meal in an Italian restaurant yesterday evening after which she began to suffer what she felt to be the worst bout of diarrhoea and abdominal pains she had experienced for several years. She then admits that her bowels do seem to have been more troublesome than normal recently, and she is beginning to feel very miserable.
How would you advise Alison?
The history here is not straightforward. Although the symptoms Alison describes could be indicative of IBS, other possibilities should be considered. Alison should therefore be referred to her general practitioner.
About a week later Alison returns to your pharmacy with a prescription for erythromycin for her four-year-old son. At the same time she tells you that her GP has referred her to a gastroenterologist for tests for coeliac disease.
What is coeliac disease?
Coeliac disease is a condition where there is a permanent intolerance to gluten. This results in stunting and disorganisation of the intestinal villi, with lymphocytic infiltration of the epithelial surface and malabsorption of nutrients.
What is gluten?
Gluten has been defined as the viscoelastic mass which remains when a wheat flour dough is washed exhaustively in tap water. The term has now been extended to include all those proteins which are harmful to individuals with gluten sensitivity, ie, the storage proteins of wheat, rye, barley and, possibly, oats (the role of oats in this regard is now much in doubt). Within wheat gluten, it is the gliadin (a simple protein seperable from wheat gluten) fraction that is known to trigger disease in susceptible individuals.
How does gluten exert its harmful effects?
Several hypotheses have been developed as to the aetiology of coeliac disease. Initially, it was thought that incomplete brush border hydrolysis of gluten occurred as a result of a deficiency of mucosal peptidase or carbohydrase, leading to the formation of toxic products. However, inability to show low activity of such enzymes following treatment with a gluten-free diet rendered this idea untenable. There is now growing acceptance that the immune system is involved. Ingestion of gluten activates T-cells in the small intestine, which results in release of inflammatory mediators. This causes damage to the absorptive surface of the small bowel and malabsorption of nutrients.
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Citation: The Pharmaceutical Journal URI: 10978488
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