You’re at work in your clinic, and this pale and thin-looking boy wanders in with a half-eaten loaf of bread in his hand. He pulls down his trousers and does the single worst smelling poo all over the floor. It’s pale and very oily, and just as he’s finished his legs give way and he falls over, landing right in it. Unfortunately he lands on his front, right on top of his bread, making his tummy hurt.

• caucasian
• failure to grow
• foul smelling faeces
• steatorrhoea
• muscle wasting
• abdominal pain

As he attempts to get back up, he continues to slip and slide, gliding around the room like an ice rink. After a little while he gets tired, and you’re worried because you start to see some blood on your new poo-ice-rink floor, and you think he may have broken his arm in the process of trying to stand up.

• gliadin protein sensitivity
• fatigue
• anaemia
• osteoporosis/osteopenia 

To try and cheer him up a little, you hand him some toys from Star Wars, and after deb8-ing for a little while he chooses a plastic R2-D(Q)2. While he’s playing you notice a nasty rash over his legs, and so you ask him what his name is in order to call his parents. He says his name is Marsh and his parents can’t come to help him because his mother is pregnant.

• HLA-B8
• HLA-DQ2
• Dermatitis herpetiformis
• Marsh classification
• pregnancy complications

Finally you ask why he’s come in today, and he says he thinks his spleen is too small, and he’s broken his toy dIgA (digger).

• Hyposplenism
• IgA deficiency

Hopefully this particularly ridiculous scenario will help link some of the features and associations of coeliac disease in your mind. Feel free to change what you will, and the details are summarised below.

The Background

Coeliac disease is a condition in which the small intestine undergoes villous atrophy as the result of a T cell mediated autoimmune sensitivity response to gliadin and other gluten proteins found in wheat. These proteins set off an inflammatory cascade that causes the villi of the intestine to be burned away, reducing the ability of the intestine to absorb the necessary nutrients, and the characteristic features of foul-smelling diarrhoea and failure to gain weight result.

Symptoms

• Those related to the villous atrophy
  • pale, loose, fatty stools that smell foul
  • abdominal pain and cramping
    • sometimes with distension, though to be due to fermentation in the gut
• Those related to the malabsorption
  • weight loss
  • fatigue
  • anaemia
    • iron deficiency
    • B12 deficiency
    • Folate deficiency
  • Calcium and vitamin D deficiency
    • osteoporosis
    • osteopenia
  • Rarely – coagulopathy
    • vitamin K deficiency

Here’s a story to help remember some of the details of intussusception. Remember to try and really picture this event, in your garden. If you can use children that you’ve seen or know, it will help make the story stick better. If you can make it even more ridiculous than I have, then go for it – the weirder the better!

Two boys and a girl are playing in the garden at a family barbecue. The boys are 6 months and 18 months old, and the girl is 12 months old.

• Typically affects children between 6 and 18 months
• Boys are twice as affected as girls

They’re all dancing, and doing a special dance where they have to jump as high as they can, and bring their knees up to their chest. As they’re doing this, they all turn completely white and start rolling around on the floor complaining of pain in their abdomen.

• Child complains of abdominal pain
• Often characteristically draws knees up to chest
• Pale
• Characteristic ‘Dance’s Sign’ (retraction of right iliac fossa)

One of the boys then does a poo. Unfortunately all he’s been eating is jelly, so he blasts jelly all over the other two. They both vomit, but since they’ve just been eating sausages from the barbecue, there’s now jelly and sausages all over the garden.

• Vomiting
• Blood-stained faeces (like jelly)
• Sausage like mass palpable in the lower right quadrant