Royal Prince Alfred Hospital Royal Prince Alfred Hospital
Allergy Unit

Student research

An analysis of the clinical manifestations of coeliac disease

Josie Duncan
Master of Nutrition and Dietetics, The University of Sydney
Supervisors: Robert Loblay, Anne Swain, Kim Faulkner-Hogg
November 2002

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Background- Coeliac disease (CD) is well known to many clinicians as a diagnostic challenge, due to the diverse range of pre-diagnostic clinical manifestations. It is thought that this wide spectrum of signs and symptoms might be responsible for delays in diagnosis or misdiagnosis. The clinical presentation of CD has changed with traditional 'classic' symptoms of malabsorption being replaced by milder, atypical symptoms.

Objective- To document and analyze the clinical manifestations leading to the diagnosis of CD in a cohort of subjects previously studied at RPAH Allergy unit.

Methods- This retrospective cohort study examined the medical records of 105 adults previously diagnosed with CD. Data was collected in the following categories: pre-diagnosis signs; symptoms and precipitating events at initial diagnosis; length of time from onset of symptoms to CD diagnosis; associated disorders and family history; and GFD information sources and response to diet. Data was analysed using Excel and SQL Query Analyzer and the results were compared with the existing literature.

Results- Many subjects reported having gastrointestinal symptoms: bloating/wind (81.9%), diarrhoea (72.4%) and abdominal pain (61 %). However a large proportion also had atypical features such as headaches (66.7%), fatigue (61%) and aneamia (60 %). Eighty four percent of subjects experienced symptoms during childhood and in 71.5% of subjects it took more than 2 years to be diagnosed. A total of 84.5% of subjects were initially diagnosed with another condition to explain symptoms and 32% linked the onset of their symptoms to a precipitating event. Associated disorders were prevalent in 38.1% of subjects and 28.1% of subjects had relatives with CD. The main information source regarding the gluten free diet (GFD) was the Coeliac Society and for most subjects (86%) it took more than 12 months for symptoms to resolve on the GFD.

Conclusions- CD is now presenting more commonly with extra-intestinal symptoms. An increase in the awareness and recognition of atypical manifestations is necessary among physicians to reduce delayed or mistaken diagnosis, and to decrease long-term complications such as malignancies, osteoporosis and infertility.