Refer to gastroenterologist

You discuss the results with Davina’s parents. You explain that the antibody tests should that she has antibody’s against gluten, which is a protein found in wheat, so is present in bread, pasta, biscuit. This finding, combined with her poor weight gain, is suggestive of coeliac disease, which is an allergic condition of the small intestine. In this condition, the lining of the intestine becomes inflamed because of the gluten in the diet. The consequence of this is that the intestine does not absorb nutrients properly.

The parents are not sure about this information.

Given this, she will need expert management by a specialist on the gut – a gastroenterologist. He will explain what will need to happen next.

Davina’s parents are happy with this, but tell you they will not allow their daughter to have further tests unless it is really needed.

You have been invited to the gastroenterology clinic by the specialist to join the consultation with Davina and her parents. You explain the course of events that led to the referral. The consultant listens, and explains that it can be difficult to explain to parents the need for a biopsy, especially if they have had test before that were not helpful. A biopsy is invasive but important - if there is absolute certainty about the diagnosis, it is easier to be clear and directive about diet and follow up. Without a biopsy, you cannot be certain.

Davina’s parents are told about the need for a biopsy and how a specific diet must be followed. They understand this, but are confused that this was not made clear before. They ask if it would not just be better to really stick to the diet and thereby avoid the biopsy.

Two weeks later you see Davina again with her parents in the gastroenterology clinic with the specialist.

The procedure went well, although Davina’s parents report that she was frightened before she went to sleep.

The biopsy results are back now and show that she has villous atrophy in the duodenal and jejunal specimens that were taken. This confirms that she has coeliac disease.

Her parents had been expecting this and are pleased that this is now clear. However they are annoyed by the delay and point out that the hospital could have got to this point earlier. Meanwhile, she has not been growing for this time and effectively lost 2 months of growth.

The gastroenterologist agrees, and then takes them back to the dietician. Some iron and vitamin supplements are also prescribed.