Post by kickingfrog on Jan 30, 2011 16:22:11 GMT
Guidelines re CD in children:
bspghan.org.uk/document/coeliac/BSPGHANcoeliacguidelinesFINAL.pdf
*******************
Posted by Charlotte, Oxford on 5/3/2009
GF board
bspghan.org.uk/document/coeliac/BSPGHANcoeliacguidelinesFINAL.pdf
"...This guideline is based on the NASPGHAN Celiac Guideline of 2005..."
WHO TO TEST
The prevalence of coeliac disease is estimated to be 1:100 in the UK. Universal population
screening is not currently advised. However there should be low threshold for investigating both
symptomatic children and those with associated conditions.
A. Symptomatic children (GI Tract and non-GI Tract symptoms)
� Persistent diarrhoea
� Faltering growth, idiopathic short stature
� Abdominal pain, vomiting, constipation, abdominal distension
� Dermatitis herpetiformis
� Dental enamel defects
� Osteoporosis / pathological fractures
� Delayed menarche
� Unexplained anaemia or Iron deficient anaemia unresponsive to treatment
� Recurrent aphthous stomatitis
� Unexplained raised transaminases
� Lassitude / weakness
� Irritable bowel syndrome
Also consider: JCA, epilepsy, with associated intracranial calcification, unexplained neurological
problems (palsies, neuropathies, migraine)
B. Asymptomatic but with associated condition (estimated lifetime prevalence)
� Type I diabetes (≥ 8%)
� Selective IgA deficiency (1.7 - 7.7%)
� Down�s (5-12%), Williams� (8.2%) and Turner�s (4.1 - 8.1%) Syndrome
� Autoimmune thyroiditis (~15%)
� Relatives of coeliac patient:
o 1st degree relative (~10%)
o HLA matched sibling (~30 - 40%)
o Monozygotic twin (~70%)
2. BLOOD ANTIBODY TESTING TO SCREEN FOR COELIAC DISEASE
Total IgA and IgA anti-tTG are screening tests. All positive results will
require biopsy confirmation.
� In IgA deficiency: IgG anti-EmA or IgG anti-tTG may help to decide on need for biopsy. However
neither IgG anti-tTG nor IgG anti-EmA are as sensitive or specific as IgA antibodies and biopsy
may still be clinically indicated if these tests are negative. Remember, false positive tests can
occur in other bowel diseases (esp. Crohn�s).
� Other blood tests to consider: FBC, U and Es, creatinine, LFTs, Total Protein, glucose,
Coagulation (PT), IgA, IgG, IgM, ferritin, folate, B12, thyroid function tests.
� If serology negative but clinical suspicion persists, perform endoscopy and duodenal biopsies
(e.g. chronic diarrhoea, faltering growth, IgA deficiency, positive family history) � to identify
seronegative coeliac disease and other mucosal disorders.
� In asymptomatic children with associated condition and negative serology, consider HLA typing.
If HLA DQ2 / DQ8 positive: continue surveillance (optimum frequency for repeat blood testing
unclear) and perform endoscopy if symptomatic.
If HLA DQ2/DQ8 negative: development of CD highly unlikely (see refs below). Discontinue
regular antibody screening but clinical review if suggestive symptoms develop.
3. CONFIRMATION OF THE DIAGNOSIS
Requires biopsy in all cases.
Therapeutic trials of Gluten Free Diet (GFD) are NOT indicated if coeliac
disease is suspected.
Children should not be started on a GFD on the basis of an antibody test.
� At endoscopy, take 4 biopsies from D2 or lower (as patchy changes may be present)
� Ensure adequate gluten intake prior to testing with advice from dietician if necessary. Typically,
10-15g gluten per day is required for adequate intake in most children (eg. 2-3g gluten are
contained in one medium bread slice, one Weetabix� or Shredded Wheat�, two rusks or
digestives and 4 tablespoons of cooked pasta).
3 months gluten challenge prior to testing is advised if asymptomatic with option to expedite blood
testing if patient develops symptoms. Biopsy when serology positive or significant symptoms
have developed.
./�
Histology
The Marsh grading system is now accepted as the Standard method of analysis:
� Villous atrophy (Marsh type 3) characteristic
� Infiltrative changes with crypt hyperplasia (Marsh type 2) compatible;
o diagnosis strengthened by positive serology
o if serology negative, reconsider CD after exclusion of other disorders
� Infiltrative changes only (Marsh type 1) are non-specific for CD but
o diagnosis strengthened by positive serology
� If diagnosis uncertain: negative serology and mild infiltrative changes, options are
o consider HLA type (DQ2 and DQ8)
o consider repeat biopsy after further challenge with increased gluten intake
o consider repeat serology and biopsy after trial of GFD
� Document basis for diagnosis in case notes (appx 2)
� Document response to GFD in case notes at follow up
See also AMERICAN GUIDELINES (NASPGHAN) referred to above for more detail, and monitoring/ follow-up:
www.naspghan.org/user-assets/Documents/pdf/PositionPapers/celiac_guideline_2004_jpgn.pdf
*************************
bspghan.org.uk/document/coeliac/BSPGHANcoeliacguidelinesFINAL.pdf
*******************
Posted by Charlotte, Oxford on 5/3/2009
GF board
bspghan.org.uk/document/coeliac/BSPGHANcoeliacguidelinesFINAL.pdf
"...This guideline is based on the NASPGHAN Celiac Guideline of 2005..."
WHO TO TEST
The prevalence of coeliac disease is estimated to be 1:100 in the UK. Universal population
screening is not currently advised. However there should be low threshold for investigating both
symptomatic children and those with associated conditions.
A. Symptomatic children (GI Tract and non-GI Tract symptoms)
� Persistent diarrhoea
� Faltering growth, idiopathic short stature
� Abdominal pain, vomiting, constipation, abdominal distension
� Dermatitis herpetiformis
� Dental enamel defects
� Osteoporosis / pathological fractures
� Delayed menarche
� Unexplained anaemia or Iron deficient anaemia unresponsive to treatment
� Recurrent aphthous stomatitis
� Unexplained raised transaminases
� Lassitude / weakness
� Irritable bowel syndrome
Also consider: JCA, epilepsy, with associated intracranial calcification, unexplained neurological
problems (palsies, neuropathies, migraine)
B. Asymptomatic but with associated condition (estimated lifetime prevalence)
� Type I diabetes (≥ 8%)
� Selective IgA deficiency (1.7 - 7.7%)
� Down�s (5-12%), Williams� (8.2%) and Turner�s (4.1 - 8.1%) Syndrome
� Autoimmune thyroiditis (~15%)
� Relatives of coeliac patient:
o 1st degree relative (~10%)
o HLA matched sibling (~30 - 40%)
o Monozygotic twin (~70%)
2. BLOOD ANTIBODY TESTING TO SCREEN FOR COELIAC DISEASE
Total IgA and IgA anti-tTG are screening tests. All positive results will
require biopsy confirmation.
� In IgA deficiency: IgG anti-EmA or IgG anti-tTG may help to decide on need for biopsy. However
neither IgG anti-tTG nor IgG anti-EmA are as sensitive or specific as IgA antibodies and biopsy
may still be clinically indicated if these tests are negative. Remember, false positive tests can
occur in other bowel diseases (esp. Crohn�s).
� Other blood tests to consider: FBC, U and Es, creatinine, LFTs, Total Protein, glucose,
Coagulation (PT), IgA, IgG, IgM, ferritin, folate, B12, thyroid function tests.
� If serology negative but clinical suspicion persists, perform endoscopy and duodenal biopsies
(e.g. chronic diarrhoea, faltering growth, IgA deficiency, positive family history) � to identify
seronegative coeliac disease and other mucosal disorders.
� In asymptomatic children with associated condition and negative serology, consider HLA typing.
If HLA DQ2 / DQ8 positive: continue surveillance (optimum frequency for repeat blood testing
unclear) and perform endoscopy if symptomatic.
If HLA DQ2/DQ8 negative: development of CD highly unlikely (see refs below). Discontinue
regular antibody screening but clinical review if suggestive symptoms develop.
3. CONFIRMATION OF THE DIAGNOSIS
Requires biopsy in all cases.
Therapeutic trials of Gluten Free Diet (GFD) are NOT indicated if coeliac
disease is suspected.
Children should not be started on a GFD on the basis of an antibody test.
� At endoscopy, take 4 biopsies from D2 or lower (as patchy changes may be present)
� Ensure adequate gluten intake prior to testing with advice from dietician if necessary. Typically,
10-15g gluten per day is required for adequate intake in most children (eg. 2-3g gluten are
contained in one medium bread slice, one Weetabix� or Shredded Wheat�, two rusks or
digestives and 4 tablespoons of cooked pasta).
3 months gluten challenge prior to testing is advised if asymptomatic with option to expedite blood
testing if patient develops symptoms. Biopsy when serology positive or significant symptoms
have developed.
./�
Histology
The Marsh grading system is now accepted as the Standard method of analysis:
� Villous atrophy (Marsh type 3) characteristic
� Infiltrative changes with crypt hyperplasia (Marsh type 2) compatible;
o diagnosis strengthened by positive serology
o if serology negative, reconsider CD after exclusion of other disorders
� Infiltrative changes only (Marsh type 1) are non-specific for CD but
o diagnosis strengthened by positive serology
� If diagnosis uncertain: negative serology and mild infiltrative changes, options are
o consider HLA type (DQ2 and DQ8)
o consider repeat biopsy after further challenge with increased gluten intake
o consider repeat serology and biopsy after trial of GFD
� Document basis for diagnosis in case notes (appx 2)
� Document response to GFD in case notes at follow up
See also AMERICAN GUIDELINES (NASPGHAN) referred to above for more detail, and monitoring/ follow-up:
www.naspghan.org/user-assets/Documents/pdf/PositionPapers/celiac_guideline_2004_jpgn.pdf
*************************