Refer for endoscopy for biopsy

You discuss the results with Davina’s parents. You explain that the antibody tests show 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.

You explain that, once the diagnosis is made, she will need to go on a diet without gluten. Then her gut will stop being inflamed and start absorbing properly again. The new diet will need to continue lifelong.

First, however, a biopsy is needed to establish for certain whether Davina has coeliac. It would not be appropriate to make a lifelong change to her diet without being completely sure of the cause.

Davina’s parents ask about how the biopsy is done and learn that an anaesthetic is needed. They do not think that it is appropriate at this stage and request a second opinion.

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. 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.