Examination

• Measure weight and height
  • Unintended weight loss may indicate continued presence of gluten in the diet
• Review symptoms
  • Any of the following may indicate continued presence of gluten in the diet
    • Gastrointestinal symptoms
    • Weight loss
    • Fatigue
    • Severe or persistent mouth ulcers
• Assess adherence to the gluten free diet
  • If symptoms return/continue, is patient following a gluten free diet?
  • Consider the need for specialist dietetic and nutritional advice – see management

Consider the need for blood tests

• Coeliac screen (TTG); after diagnosis it can take as long as 12 months on a gluten free diet for TTG to become negative. Some coeliacs do not get many symptoms on eating gluten so a patient whose TTG had gone negative but then becomes positive might not be adherent to gluten free diet.
• Ferritin, folate, B12 levels. Iron, folate and B12 deficiencies are common in coeliacs who continue to eat gluten.
• TFT and HbA1c. There is a 10% lifetime risk of developing another autoimmune condition, such as hypothyroidism and diabetes.

Consider the need for specialist dietetic and nutritional advice.

If patient struggling to adhere to diet or has symptoms despite maintaining they are following a strict gluten free diet refer patient to community dietetic service:

Community Dietitian
Stewart Smith House
Royal Devon & Exeter Hospital
Barrack Road
Exeter
Devon
EX2 5DW
Tel: 01392 402576

Referral Criteria

If concerns at annual review

• Refer to a specialist dietitian to investigate continued exposure to gluten. There are many sources of gluten that a patient may have overlooked, such as self-basting poultry or soy sauce.
• Investigate potential complications or coexisting conditions that may be causing persistent symptoms, such as irritable bowel syndrome, lactose intolerance, bacterial overgrowth, microscopic colitis or inflammatory colitis.
• Consider need for specialist referral. Patients 17 years or younger can be referred to Paediatrics. Patients 18 years or older should be referred to adult gastroenterology.

Referral Instructions

Refer to Specialist

Patients 17 years or younger

e-Referral Service Selection

• Specialty: Children's & Adolescent Services
• Clinic Type: Gastroenterology
• Service: DRSS-Eastern-Paediatrics- Devon ICB-15N

Patients 18 years or older

e-Referral Service Selection

• Specialty: GI & Liver (Medicine and Surgery)
• Clinic Type: Lower GI (medical) excl IBD
• Service: DRSS-Eastern-GI & Liver (Medicine & Surgery)-Devon ICB-15N

Refer to a Specialist Dietitian

This service is not available on e-Referral, please paper refer to:

Community Dietitian
Stewart Smith House
Royal Devon & Exeter Hospital
Barrack Road
Exeter
Devon
EX2 5DW
Tel: 01392 402576

Referral Forms

DRSS Referral Form

Evidence

NICE guidance

Pathway Group

Developed by Susie Costelloe, Paediatric Dietitian and James Hart, Consultant Paediatrician. This guideline has been signed off on behalf of NHS Devon.

Publication date: April 2018