The video version of this podcast can be found here: ·      https://youtu.be/474v7gUrz38This channel may make reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". The content on this channel reflects my professional interpretation/summary of the guidance and I am in no way affiliated with, employed by or funded/sponsored by NICE. My name is Fernando Florido (also known as Juan Fernando Florido Santana), a GP in the UK. In this episode, I will go through the new NICE guideline on coeliac disease: assessment and management, NG20, focusing on what is relevant in Primary Care only.  I am not giving medical advice; this video is intended for health care professionals, it is only my summary and my interpretation of the guidelines and you must use your clinical judgement.   Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through   There is a podcast version of this and other videos that you can access here: Primary Care guidelines podcast:  ·      Redcircle: https://redcircle.com/shows/primary-care-guidelines·      Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK·      Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148 There is a YouTube version of this and other videos that you can access here: The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The link to the NICE guideline on coeliac disease can be found here:·      https://www.nice.org.uk/guidance/ng20/chapter/recommendationsDisclaimer:The Video Content on this channel is for educational purposes and not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read or seen on this YouTube channel. The statements made throughout this video are not to be used or relied on to diagnose, treat, cure or prevent health conditions. In addition, transmission of this Content is not intended to create, and receipt by you does not constitute, a physician-patient relationship with Dr Fernando Florido, his employees, agents, independent contractors, or anyone acting on behalf of Dr Fernando Florido. TranscriptIf you are listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome, I am Fernando, a GP in the UK. Today, we will go through the new NICE guideline on coeliac disease: assessment and management, or NG20, focusing on what is relevant in Primary Care only.  Right, let’s jump into it.And before we start on the guideline itself, what is coeliac disease exactly?Coeliac disease is a genetic, immune-mediated enteropathy triggered by gluten in some people. It primarily affects the small intestine, leading to villous atrophy, crypt hyperplasia, and malabsorption.Why does it happen? Well, the pathophysiology is as follows:Gluten (specifically gliadin) is found in wheat, barley, and rye. An enzyme called tissue transglutaminase (tTG) modifies gluten peptides. In genetically predisposed people, these modified peptides are presented to T-cells, triggering an inappropriate immune response. This leads to inflammation and damage to the small intestinal mucosa, particularly in the proximal small bowel.We should suspect coeliac disease and offer serological testing if there is:persistent unexplained abdominal or gastrointestinal symptomsfatigue or weight lossmouth ulcersunexplained iron, vitamin B12 or folate deficiencyfirst‑degree relatives affected.conditions such as type 1 diabetes, autoimmune thyroid disease, and irritable bowel syndrome (in adults) and we should also consider testing in a number of other conditions, for example:·      reduced bone mineral density, ·      unexplained neurological symptoms (like peripheral neuropathy or ataxia)·      persistently raised liver enzymes and·      Down's and Turner syndromesHowever, before arranging any investigations we will need to explain that any test is accurate only if a gluten‑containing diet is eaten during the entire diagnostic process. This also means that they should not start a gluten‑free diet until diagnosis is confirmed by a specialist, even if the results of a serological test are positive.Additionally, people following a normal diet should be advised to eat some gluten in more than 1 meal every day for at least 6 weeks before testing.If they have already restricted their gluten intake and they are unable to re‑introduce it, we will refer them to gastroenterology explaining that it may be difficult to confirm their diagnosis even by intestinal biopsy.People who have tested negative for coeliac disease should be retested if new suggestive symptoms arise or persist, particularly if they have type 1 diabetes or a family history.What serological testing should we do for coeliac disease?NICE recommends that the first choice of test should be IgA tissue transglutaminase antibodies (tTG) together with total immunoglobulin A (IgA) to exclude deficiency. But why is this?Let’s remember that everyone has the tissue transglutaminase enzyme (tTG). However, in people with coeliac disease, the immune system produces autoantibodies against this enzyme — particularly IgA autoantibodies.This autoantibody response is:Highly specific to coeliac diseaseTriggered by gluten exposure in genetically susceptible people andCorrelate with intestinal damage (i.e. the higher the autoantibodies, the more likely there is villous atrophy)This is why serum IgA tissue transglutaminase antibodies are the first-line screening test — it’s convenient, non-invasive, and has high sensitivity and specificity, especially in untreated people.Additionally in adults the lab should test for IgA endomysial antibodies (EMA) if IgA tissue transglutaminase antibodies are weakly positive and consider additional tests if IgA levels are low. Then the Lab should clearly communicate the interpretation of the results as well as the recommended action.We should then refer anybody with positive serological test results to a gastrointestinal specialist for further assessment, which for adults will most likely include endoscopic intestinal biopsy. We should also refer those with negative serological test results if coeliac disease is still clinically suspected.People diagnosed with coeliac disease should have an annual review in order to:measure weight and heightreview symptoms and dietand consider the need for specialist dietetic advice.For those who have persistent symptoms despite gluten exclusion we should:review the certainty of the original diagnosisrefer them to a specialist dietitian to investigate continued exposure to glutenand investigate potential complications or coexisting conditions such as irritable bowel syndrome, lactose intolerance, bacterial overgrowth, or colitis.If no other cause is found we would call it refractory coeliac disease and we will need to refer them and consider prednisolone while waiting for specialist advice. We should give people with coeliac disease sources of information on the disease, including, for example:·      Specialist groups and dietitians how to manage social situations, like eating out and travelling avoiding cross contamination at home andimmunisation against pneumococcus, all of thisBeing aware that people with coeliac disease may experience anxiety and depression. In terms of dietary management, they should seek advice before taking over‑the‑counter vitamin or mineral supplements, explaining that they may need to take specific supplements such as calcium or vitamin D if their dietary intake is insufficient.We can also explain that:they can choose to include gluten‑free oats in their diet at any stage andcontinuing them will depend on their response.So that is it, a review of the NICE guideline on coeliac disease.We have come to the end of this episode. Remember that this is not medical advice but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.Thank you for listening and goodbye.

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