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CHAPTER12 Gastrointestinalmedicine
Anal and perianalproblems
Haemorrhoids (‘piles’) Common in all age groups from mid- teens
onwards. Represent distention of the submucosal plexus of veins in the
anus. 3 main groups situated at 3, 7, and 11 o’clock positions (relative to the
patient viewed in lithotomy position). Risk factors: constipation; FH; varicose veins; pregnancy; i anal tone (cause not understood); pelvic tumour;
portal hypertension. Classication:
• 1st degree Piles remain within the anal canal
• 2nd degree Prolapse out of anal verge but spontaneously reduce
• 3rd degree Prolapse out of anus and require digital reduction
• 4th degree Permanently prolapsed
Presentation Discomfort or discharge ± fresh red rectal bleeding (blood on
toilet paper, coating stool, or dripping into pan after defecation); feeling of
incomplete emptying of the rectum; mucus discharge; pruritus ani. Rectal
examination:prolapsing piles are obvious, 1st- degree piles are not visible
or palpable.
Management If piles are not obvious on examination, arrange proctoscopy
± sigmoidoscopy for all patients >40y. Treatment:soften stool (bran, ispaghula husk) and recommend topical analgesia (e.g. lidocaine 5% ointment or
OTC preparation). If not responding to treatment, uncertainty over diagnosis, or severe symptoms (e.g. soiling of underwear), refer for surgical
assessment. Complications:
• Strangulation Circulation to the pile is obstructed by the anal sphincter.
Results in intense pain + anal sphincter spasm. Treat with analgesia. If
severe pain or symptoms are not settling, admit
• Thrombosis Pain/ anal sphincter spasm— analgesia, ice packs and bed
rest— consider referral for surgery to prevent recurrence
Perianal haematoma (thrombosed external pile) Due to a rup-
tured supercial perianal vein causing a subcutaneous haematoma. Presents
with sudden onset of severe perianal pain. Atender, 2– 4mm ‘dark blueberry’ under the skin adjacent to the anus is visible. Give analgesia. Settles
spontaneously over 71wk. If <1d old can be evacuated via a small incision
under LA.
Rectal prolapse Occurs in 2 age groups— the very young, and those
>60y. Presents with mass coming down through the anus ± anal discharge.
In adults there are 2 types:
• Mucosal Adults with 3rd- degree piles— bowel musculature remains in
position but redundant mucosa prolapses from the anal canal
• Complete Descent of the upper rectum into the lower anal canal.
Usually due to weak pelvic oor from childbirth. Bowel wall is inverted
and passed out through the anus. May be associated uterine prolapse
Refer for surgery. Asupporting ring may be used if unt for surgery.
Anal ssure Anal mucosa is torn— usually on the posterior aspect of the
anal canal. May occur at any age. Presents with pain on defecation ± constipation ± fresh rectal bleeding (‘blood on toilet paper’). The ssure is often
visible as is a ‘sentinel pile’ (bunched up mucosa at the base of the tear).
Rectal examination is very tender due to muscle spasm.
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ANAL AND PERIANALPROBLEMS
Management Soften stool (e.g. ispaghula husk); try analgesic suppositories/
cream (e.g. cinchocaine/ hydrocortisone). If unsuccessful add glyceryl trinitrate 0.4% ointment bd which relieves pain and spasm but may cause
headache; 2% topical diltiazem cream bd is a 3rd- line option (unlicensed). If
interventions fail refer for surgical review.
Perianal abscess Usually caused by infection arising in a perianal gland.
Tends to lie between the internal and external sphincters and points towards the skin at the anal margin. May aect patients of any age and presents with gradual onset of perianal pain which becomes throbbing and
severe; defecation and sitting are painful— characteristically patients sit with
one buttock raised o the chair. Examination:abscess in the skin next to the
anus. Refer as an acute surgical emergency for drainage.
Perianal stula Abnormal connection between the lumen of the anus
(or rectum) and skin. Usually develops from a perianal abscess. Fistulae are
either ‘high’ (open into the bowel above the deep external anal sphincter)
or ‘low’ (open into the bowel below this point). High stulae are rare and
usually due to UC, Crohn’s disease, or tumour— they are more complex
to repair. Presents with persistent perianal discharge and/ or recurrent abscess. The external opening is usually visible lateral to the anus; the internal
opening may be palpable on rectal examination. Refer for surgical repair.
Pilonidal sinus Obstruction of a hair follicle in the natal cleft. The in-
growing hair triggers a foreign body reaction l pain, swelling, abscess, and/
or stula formation ± foul smelling discharge. Refer for surgery.
Pruritus ani Itching around the anus. Occurs if the anus is moist or
soiled, e.g. poor personal hygiene; anal leakage or faecal incontinence; ssures; nylon/ tight underwear. Other causes:dermatological conditions (e.g.
contact dermatitis, lichen sclerosus); threadworm infection; anxiety; other
causes of generalized pruritus (E p. 566). Treat cause if possible; avoid
spicy food; moist wipe post- defecation.
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Threadworm Common in the UK— especially in children.
Enterobius vermicularis causes anal itch as it leaves the bowel
to lay eggs on the perineum. Often seen as silvery thread- like
worms at the anus of children. Treatment:mebendazole (available OTC). Treat household contacts as well as the index case.
Anal ulcers Rare. Consider Crohn’s disease, syphilis, tumour— refer
Anal cancer Usually squamous cell cancer (>50%). Risk factors:anal sex;
syphilis; anal warts (HPV). Presents with bleeding, pain, anal mass or ulcer,
pruritus, stricture, change in bowel habit. Amass may be palpable on rectal
examination. Check for inguinal LNs.
Management Refer for urgent surgical review and conrmation of diagnosis. Treatment is usually with a combination of radiotherapy ± chemotherapy. Abdominoperineal resection is reserved for salvage therapy after
chemo or radiotherapy failure.
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CHAPTER12 Gastrointestinalmedicine
Patients withostomies
0 Specialist stoma nurses are an extremely useful source of advice and
help. If in doubt about the correct stoma appliances and accessories to
supply, or a patient has a problem with a stoma, wherever possible liaise
with your local specialist stoma nurse.
The rst iatrogenic stoma was constructed in France in 1776 for an
obstructing rectal cancer. Stomas (from the Greek meaning ‘mouth’) may
be temporary or permanent (Table 12.10).
Stoma retraction Can lead to leakage and severe skin problems. Most
common reason for re- operation. Refer for specialist advice.
Prolapse Seen most frequently with loop colostomy. If persists and dis-
rupts pouching, refer for consideration of revision.
Peristomal hernia Common complication. Symptomatic cases require
referral for repair.
Stenosis Narrowing of the stoma may result in diculty or pain passing
stool and/ or obstruction. If problematic refer for revision.
Skin complication Skin irritation can be due to:
• Leakage onto the skin
• Allergic reactions to the adhesive material in a skin barrier
• Fungal infection
• Inadequate hygiene
Prevention ofskincomplications
• Advise patients to clean, rinse, and pat the skin dry between pouch
changes
• Avoid using an oily soap, which can leave a lm that interferes with
proper adhesion of the skin barrier
• Ensure the pouch system ts
• Treat any infection with oral antibiotics and/ or oral/ topical antifungals
• Apply skin barrier cream
• If the skin is uneven (e.g. due to scarring), ll irregularities with stoma
paste to give a better t
• Consider the use of convex discs or stoma belts (refer to specialist
stoma nurse for advice)
Diet
• Avoid foods that cause intestinal upset or diarrhoea
• For descending/ sigmoid colostomy, avoid foods that cause constipation.
If constipation does occur, i uid intake and/ or dietary bre
• Certain foods, e.g. beans, cucumbers, and carbonated drinks, can cause
gas, along with certain habits such as talking or swallowing air while
eating, using a straw, breathing through the mouth, and chewing gum
• Adaily portion of applesauce, cranberry juice, yogurt, or buttermilk
can help control odour. If odour is strong and persistent, consider use
of charcoal lters or pouch deodorizers (seek advice from a specialist
stoma nurse)
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PATIENTS WITHOSTOMIES
Table12.10 The 3 main types ofstoma
Colostomy Ileostomy Urostomy
Age:most >50y Peak age range:10– 50y Age:most >50y
Output:depends on site:
• Transverse
colostomy— soft stool
• Descending/ sigmoid
colostomy— formed stool
Reasons for colostomy:
Carcinoma
Diverticular disease
Trauma
Radiation enteritis
Bowel ischaemia
Hirschsprung’s disease
Congenital abnormalities
Obstruction
Crohn’s disease
Faecal incontinence
Output:soft/ uid stool Output:urine— continent
Reasons for ileostomy:
Ulcerative colitis
Crohn’s disease
Familial polyposis coli
Obstruction
Radiation enteritis
Trauma
Bowel ischaemia
Meconium ileus
Carcinoma
procedures using bowel
to fashion a bladder which
is then drained with a
catheter through the stoma
are becoming common
Reasons for urostomy:
Carcinoma
Urinary incontinence
Fistulas
Spinal column disorders
Drugs Enteric- coated and modied- release preparations are unsuitable
for people with bowel stomas— particularly for patients with ileostomy.
Psycho- social problems Self- help groups provide information and tips
on lifestyle and stoma care; specialist stoma nurses can provide support
and counselling.
Activities Advise patients to avoid rough contact sports and heavy lifting
as these might l herniation around the stoma. Patients with stomas may
swim. Water will not enter a stoma due to peristalsis so stomas do not
need to be covered when bathing. Abody belt (available on FP10) to hold
the stoma bag in place against the body may stop rustling/ leakage for those
doing aerobic exercise— seek advice from a specialist stoma nurse.
Travel Advise patients to pack sucient supplies of their stoma products
and carry supplies with them in case baggage is misplaced. Avoid storing
supplies in a very hot environment as heat may damage pouches.
Patient advice and support
British Colostomy Association F 0800 328 4257 M www.
colostomyassociation.org.uk
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CHAPTER12 Gastrointestinalmedicine
Chronic diarrhoea andmalabsorption
Chronic diarrhoea Diarrhoea persisting >4wk. Patients’ perceptions
of diarrhoea vary widely. Clarify what is meant. Chronic diarrhoea aects
~4– 5% of adults in the UK. There are many causes (Table 12.11) and all
patients require investigation. Careful history is vital.
Symptoms suggestive oforganicdisease
• History of <3mo duration
• Mainly nocturnal or continuous (as opposed to intermittent) diarrhoea
• Signicant weight d
• Liquid stools with blood and/ or mucus
Symptoms suggestive ofmalabsorption
• Pale and/ or oensive stools
• Steatorrhoea— excess fat in faeces. The stool is pale- coloured, foul
smelling, and oats (‘dicult to ush’)
Examination and investigation Full examination. Look for signs of systemic
disease and examine abdomen/ pelvis thoroughly. Check:
• Blood FBC, ESR, Ca2+, LFTs, haematinics, TFTs, coeliac serology, CA125
in women (refer for USS of abdomen/ pelvis if i)
• Stool M,C&S ± faecal calprotectin (useful in primary care for
distinguishing between IBS and inammatory bowel disease if <40y)
Management
• If obvious identiable cause (e.g. GI infection, constipation, drug side
eect) treat and review. Refer to gastroenterology if treatment fails
• If symptoms suggestive of functional bowel disease and <45y with
normal investigations, irritable bowel syndrome is likely. Reassure, oer
advice, and review as necessary. Refer to gastroenterology if atypical
symptoms appear or the patient is unhappy with the diagnosis
• Otherwise refer to gastroenterology for assessment. Speed of referral
depends on age and severity of symptoms
• Refer urgently (to be seen in <2wk)
To a team specializing incolorectal cancerif
• Any age + anal, rectal, or abdominal mass*
• Any age + rectal bleeding + unexplained abdominal pain, change in
bowel habit, weight loss, or iron deciency anaemia
• Aged ≥40y + unexplained weight loss + abdominal pain, or
• Aged ≥50y + unexplained rectal bleeding, or
• Aged ≥60y + iron- deciency anaemia or persistent change in bowel
habit or faecal occult blood +ve
* Apelvic mass outside the bowel warrants urgent referral to a urologist
or gynaecologist.
For direct access CT (or USS ifCT not available) if ≥60y + weight loss
AND ≥1 of:
• Diarrhoea
• Back pain
• Abdominal pain
N
• Nausea/ vomiting
• Constipation
• New- onset diabetes
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CHRONIC DIARRHOEA ANDMALABSORPTION
Table12.11 Causes ofchronic diarrhoea
Colon
Colonic cancer
Ulcerative colitis
Crohn’s disease
Constipation with
overow diarrhoea
Endocrine
DM (autonomic
neuropathy)
Hyperthyroidism
Hypoparathyroidism
Addison’s disease
Hormone- secreting
tumours (e.g. carcinoid)
Small bowel
Crohn’s disease
Coeliac disease
Other enteropathies (e.g.
Whipple’s disease)
Bile acid malabsorption
Ischaemia
Enzyme deciencies (e.g.
lactase deciency)
Radiation damage
Bacterial overgrowth
Lymphoma
Infection (e.g. giardiasis,
Cryptosporidium)
Irritable bowel syndrome
Pancreas
Pancreatic cancer
Chronic pancreatitis
CF
Other
Ovarian cancer
Bowel resection
Bile salt malabsorption
Intestinal stula
Drugs
Alcohol
Autonomic neuropathy
‘Factitious’ diarrhoea
Malabsorption Presents with chronic diarrhoea, weight d, steator-
rhoea, vitamin/ iron deciencies, and/ or oedema due to protein deciency.
Refer to gastroenterology for investigation/ treatment of the cause.
Usualcauses
• Coeliac disease— E p. 382
• Crohn’s disease— E p. 384
• Chronic pancreatitis— E p. 402
Rarercauses
• Cystic brosis (CF)
• Pancreatic cancer— E p. 404
• Whipple’s disease
• Biliary insuciency
• Bacterial overgrowth
• Chronic infection (e.g. giardiasis,
tropical sprue)
• Following gastric surgery
Whipple’s disease A cause of malabsorption which usually occurs
in >50y. Other features: arthralgia, pigmentation, weight d, lymphadenopathy, ± cerebellar or cardiac signs. Cause: Tropheryma whipplei.
Refer for gastroenterology assessment. Jejunal biopsy is characteristic.
Treatment:long- term broad spectrum antibiotics.
Malabsorption inchildren E p. 866
Factitious diarrhoea Responsible for 4% of referrals to gastroenter-
ology departments and 20% of tertiary referrals. Due to laxative abuse or
adding of water or urine to stool samples. Dicult to spot— have a high
index of suspicion especially in patients with history of eating disorder or
somatization.
Further information
British Society of Gastroenterology (2018) Guidelines for the investigation of chronic diarrhoea. M https:// gut.bmj.com/ content/ 67/ 8/ 1380
NICE (2009) Diarrhoea and vomiting in children under 5. M www.nice.
org.uk/ Guidance/ CG84
NICE (2015, updated 2017)Suspected cancer:recognition and referral.
Mwww.nice.org.uk/ guidance/ ng12
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CHAPTER12 Gastrointestinalmedicine
Faecalincontinence
Aects 72% of all ages, causing great personal disability. It is a common
reason for carers to request placement in a nursing home.
Causes
• Age and frailty
• Constipation (overow incontinence)
• Colonic resection/ anal surgery
• Rectal prolapse/ haemorrhoids
• Loose stools or diarrhoea from any
cause, e.g. inammatory bowel disease
• After radiotherapy
History Aimed at establishing the underlying causes of the incontinence
(may be >1) and other factors that might be contributing to it. Ask about:
• Onset and nature of symptoms. 0 Always consider faecal incontinence
when patients present with anal soreness and/ or itching
• Bowel habit including timing and frequency of incontinence
• Diculties with toileting and help available
• Other medical conditions
• Medication
Examination General and rectal examination (to detect abnormalities
of anal tone, local anal pathology, e.g. rectal prolapse, and constipation
causing overow incontinence). Further examination depends on age group
and history, e.g. cognitive assessment if suspected cognitive decit; neurological examination if d anal tone.
• Systemic sclerosis
• Neurological disorders
• Congenital disorders (e.g.anal
atresia, Hirschsprung’s
disease)
• Emotional problems
(e.g.encopresis in children)
• Diet
• Social circumstances
• Persistent change in bowel habit to looser stools may be a sign of GI
malignancy— E p. 362.
Primary caremanagement
Treatment ofcause
• Clear any constipation/ faecal loading (E p. 350)— use rectal
preparations initially to clear faecal load. If unsuccessful/ rectal
preparations are inappropriate, then switch to oral laxatives. Take steps
to prevent recurrence, e.g. add bre to diet, i uid intake, consider
regular laxatives
• Treat other reversible causes, e.g. infective diarrhoea, UC
• Consider alternatives to any contributing medications, e.g. tranquillizers
General measures where cause cannot betreated
• Advise uid intake of at least 1.5L/ d
• Encourage bowel emptying after a meal— advise patients to assume a
seated/ squatting position and not to strain
• Ensure that toilet facilities are private, accessible, and safe— refer for OT
assessment if needed
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FAECALINCONTINENCE
• Manipulate diet to promote optimal stool consistency and predictable
bowel emptying. Afood/ uid diary may be helpful. Only change one
food at a time. Consider referral to a dietician
• If stool must be in the rectum at a set time (e.g. when a carer is there),
manipulate bowel action with PR/ PO laxatives and/ or loperamide
• If loose stools, consider treatment with loperamide, co- phenotrope
or codeine phosphate, prn or continuously. When using loperamide,
introduce at a very low dose (consider syrup for doses <2mg) and
idose until desired stool consistency is reached. Dose and/ or frequency
can be adjusted i or d in response to stool consistency and lifestyle.
0Do not use if hard stools, undiagnosed diarrhoea, or are- up of UC
• Review regularly. If no improvement with simple strategies, consider
referral for specialist care
Patients with faecal incontinence from enteral feeding Discuss with the
patient’s dietician. Modifying type/ timing of feeds may help.
Patients withspinal injury or disease Bowel function is a reex action which
we learn to override as children. If the lesion is above the level of this reex
pathway (T12 for bowel function) then automatic emptying will still occur
when the bladder or bowel is full, although there is no control. If the lesion
is below this level there is no emptying reex. Bowel care programmes reect this. Useful leaets are available from the Spinal Injuries Association
(F0800 980 0501 M www.spinal.co.uk).
Referral Consider if symptoms are not controlled:
• To continence adviser— for advice on skin care/ hygiene, and supplies
of incontinence pads. Pelvic oor muscle training, bowel retraining,
biofeedback, electrical stimulation, and/ or rectal irrigation may be useful.
Devices, e.g. anal plugs or faecal collectors, can help in some situations
• To surgeon— for sphincter repair if signicant sphincter defect;
for consideration of implanted sacral nerve stimulation device; for
appendicostomy/ continent colonic conduit for anterograde irrigation in
patients with colonic motility disorders; for stoma formation (last resort)
• To old age psychiatry— if cognitive decit and incontinence
• To paediatrics— if encopresis due to chronic constipation— or child
psychiatry if encopresis due to emotional distress
Encopresis inchildren E p. 893
Further information
NICE (2007) Faecal incontinence. M www.nice.org.uk/ guidance/ cg49
Patient information
Bladder and Bowel Community Provides information and support as well
as ‘Just can’t wait’ or JCW cards. This card allows patients with bowel problems access to sta toilet facilities in many high street stores on production
of their access card. F 0800 031 5412 M www.bladderandbowel.org
RADAR keys The National Key Scheme (NKS)oers independent access
to disabled people to around 7000 locked public toilets around the UK.
Keys are available to purchase from M www.disabilityrightsuk.org. If the
patient has an ongoing disability, purchase can be made VAT free.
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CHAPTER12 Gastrointestinalmedicine
Coeliacdisease
Coeliac disease is a common disorder (UK prevalence 0.5– 1%, : 83:1)
although only a minority have recognized disease. Gluten sensitivity results
in inammation of the bowel and malabsorption. Peak incidence in adults is
in the 5th decade; in children at ~4y. Associated with HLA- DQ2 or DQ8;
rst- degree relatives have a 1:10 chance of being aected. See Table 12.12.
Investigation
• Serological testing IgA anti- tissue transglutaminase antibodies (TTG) or
anti- endomysial antibodies (EMA). Test ifN:persistent/ unexplained GI
symptoms, faltering growth, prolonged fatigue, unexpected weight d,
severe/ persistent mouth ulcers, unexplained iron, vitamin B12 or folate
deciency, type 1 DM or autoimmune thyroid disease (at diagnosis),
irritable bowel syndrome, rst- degree relative with coeliac disease,
0test only if eaten >1 meal/ d containing gluten for ≥6wk
• Other tests Also consider FBC, ESR/ CRP, vitamin B12, folate, ferritin,
LFTs, Ca2+, TFTs, and stool sample for M,C&S (if diarrhoea)
• IgA deciency is i >6× in people with coeliac disease. If IgA de-
cient, IgA TTG/ EMA may give false −ve result. If clinical suspicion and IgA
TTG/ EMA is −ve, check serum IgA. If decient, request IgG TTG/ EMA.
Initial management Refer for specialist review if:
• +ve serology— duodenal biopsy showing villous atrophy is diagnostic
• Strong clinical suspicion of coeliac disease but −ve serology
• Unwilling to reintroduce gluten to diet to enable serological testing
Gluten- free diet Cornerstone of management of coeliac disease.
Should be followed lifelong. Avoid proteins derived from wheat, rye or
barley. Avoidance of oats is controversial. Refer to a dietician for specialist advice. Coeliac UK provides a directory of approved products as well
as recipes for those on gluten- free diets.
Prescriptions for gluten- free foods Prescribe adequate gluten- free foods
(Table 12.13), marking prescriptions ‘ACBS’. Add decient nutrients (e.g.
iron, folic acid, Ca2+) until established on a gluten- free diet.
Failure torespond todiet Most commonly due to continued gluten ingestion
(intentional or inadvertent). Re- refer to dietician. If symptoms recur after a
period of remission, re- refer for specialist review.
Pneumococcal vaccination Pneumococcal infection is more common
2° to hyposplenism— advise vaccination.
Follow- up Every 12mo by GP. Routine checks include:symptoms, weight,
diet, and consider blood tests (Hb, vitamin B12, folate, iron, albumin, Ca2+,
TTG or EMA antibodies), co- morbidities, and need for specialist follow- up.
Long- term complications Almost eliminated by strict diet:
• Osteoporosis— consider DEXA scan at diagnosis, after 3y on a gluten-
free diet (if abnormal baseline DEXA), at the menopause for , aged
55y for , or if fragility fracture
• Malignancy— lymphoma or carcinoma of the small intestine. Rare— if
suspected, refer urgently for specialist review
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COELIACDISEASE
Table12.12 Presentation ofcoeliac disease
Symptoms and signs Associated conditions
Chronic/ intermittent
diarrhoea (50%)
Failure to thrive/ faltering
growth in children
Recurrent abdominal pain/
cramping/ bloating
Other persistent
unexplained GI symptoms,
e.g. nausea/ vomiting
Sudden or unexpected
weight d
Unexplained anaemia (iron
deciency or other)
Genetic predisposition
First- degree relative
(parent, sibling, child)
Down’s/ Turner syndrome
GI
Dental enamel defects
Mouth ulcers
Irritable bowel syndrome
Microscopic colitis
Persistent/ unexplained
constipation
Unexplained, persistent i
in liver enzymes (usually
normalize in <6mo on
gluten- free diet)
Autoimmune liver disease
Musculoskeletal
d bone mineral density
Low trauma fracture
Metabolic bone disease
(e.g. rickets, osteomalacia)
Sjögren’s syndrome
Sarcoidosis
Endocrine
Type 1 DM
Autoimmune thyroid
disease
Addison’s disease
Amenorrhoea
Other
Unexplained alopecia
Dermatitis herpetiformis
Depression or bipolar
disorder
Polyneuropathy
Epilepsy
Autoimmune myocarditis
Chronic TTP
Lymphoma
Recurrent miscarriage
Unexplained subfertility
Table12.13 Guide tothe amount ofgluten- free products toprescribe
monthly forpatients withcoeliac disease
Child age Units/ mo age Units/ mo age Units/ mo
1– 3y 10 19– 59y 18 19– 74y 14
4– 6y 11 60– 74y 16 75+y 12
7– 10y 13 75+y 14 Breastfeeding Add 4 units
11– 14y 15 3rd trimester
15– 18y 18 High activity level ( or )— add 4 units
400g of bread or rolls or baguette=1 unit 250g of pasta=1 unit
500g of bread or our=2 units 2 pizza bases=1 unit
200g of sweet or savour y biscuits, crackers, or crispbread=1 unit
pregnancy
Add 1 unit
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Further information
British Society of Gastroenterology (2014) Diagnosis and management of
adult coeliac disease. M www.bsg.org.uk/ clinical- guidelines/ small- bowelnutrition/ guidelines- on- the- diagnosis- and- management- of- adult- coeliacdisease.html
NICE (2015) Coeliac disease:recognition, assessment and management.
M www.nice.org.uk/ guidance/ ng20
Patient advice and support
Coeliac UK F 0333 332 2033 M www.coeliac.org.uk
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