451 Review of diagnosis and management of coeliac disease in a district general hospital in the North West (Audit)

Abstract

<h3>Background</h3> The guidance for Coeliac Disease (CD) has evolved over the last few years. The ESPGHAN guidelines from January 2020 state that HLA typing is not mandatory. Asymptomatic and symptomatic children will require the same diagnostic approach where biopsy is not required as long as high serological markers are confirmed. This change will significantly help in improving diagnosis of undiagnosed cases and in diabetic children with a positive screen. <h3>Objectives</h3> To review the management of patients and compare it with the latest ESPGHAN/BSPGHAN guidelines. To review time to confirmed diagnosis from the start of the symptoms. To look at the provision of Gluten-free products at schools and Primary Care services. <h3>Methods</h3> Retrospective data collected from the Coeliac database from January 2018 till November 2020 in a District General Hospital with provision for a dedicated Coeliac Clinic supported by a Specialist Dietician. We reviewed the presenting symptoms, methods of confirmation of CD, time duration from onset of symptoms till diagnosis, provision of gluten-free meals at schools, and availability of gluten-free products on prescription. <h3>Results</h3> 35 patients were diagnosed with CD, 31 were symptomatic and 4 were asymptomatic. 27/31 of the symptomatic patients had high-level tTG (&gt;10 times the upper limit), 20 had positive EMA and HLA DQ2/DQ8 for a confirmed diagnosis. The two negative EMA were referred for biopsy. Five had HLA typing, no EMA but had had high tTG on two separate occasions which confirms the diagnosis. Four symptomatic patients with low tTG&lt;10x, had biopsy confirmation. 4 asymptomatic patients had high tTG and +ve EMA. Of 28 patients referred from primary care, Seven were screened and referred with symptom duration of 4–12 months. Another 7 were diagnosed through screening due to positive family history or type1 Diabetes Mellitus. Fourteen cases had no specific duration of symptoms recorded. The remaining seven were diagnosed by hospital paediatricians due to different presentations. Most parents stated that they were providing a packed lunch box even if the school provided some gluten-free meals as the menu choice lacked variety. Patients with Type 1 diabetes found a packed lunch easier for carbohydrate counting. Parents felt tailor-made menu recommendation from the dietician to the school would be beneficial for families and the school. <h3>Conclusions</h3> We thus identified that 88.5% of patients had met the criteria for the diagnosis of CD as per 2015 guidelines, but if 2020 guidelines were applied all the patients would have met the criteria. <b>Recommendations:</b> Identifying the duration of time needed for the child to be screened will help to raise awareness within primary care practice. This will be audited in the future. There is a large knowledge gap in schools about CD and the importance of convenient access to gluten-free meals in enhancing compliance with gluten-free food in children. Offering tailor-made presentations to the local schools will address this issue. A further review to identify if a similar knowledge gap exists in schools regionally is planned.