Association of Adult Celiac Disease with IBS
Abstract & Commentary
Synopsis: Irritable bowel syndrome patients (at least in the United Kingdom) should be routinely investigated for the presence of celiac disease .
Source: Sanders DS, et al. Lancet. 2001;358:1504-1508.
Irritable bowel syndrome (IBS) is extremely common in western populations. However, important medical organizations such as the American Gastroenterological Association do not recommend any routine medical assessment of IBS patients. Three hundred consecutive new gastrointestinal patients at a University Hospital in Sheffield, England who fulfilled Rome II criteria for IBS were matched with 300 healthy controls. Consensus diagnostic criteria (Rome II criteria) for IBS include abdominal discomfort or pain with 2 of the following 3 features: discomfort relieved with defecation, onset associated with a change in frequency of stool, and onset associated with a change in form (appearance) of stool. Supporting symptoms of IBS include: fewer than 3 bowel movements/week, more than 3 bowel movements/day, hard or lumpy stools, loose (mushy) or watery stools, straining with stools, urgent stools, feeling of incomplete rectal emptying, mucus in stools, and abdominal fullness or swelling or bloating.
All patients and controls in this study were evaluated for celiac disease using serum IgA antigliadin, IgG antigliadin, and endomysial antibodies (EMA). Positive antibody results were followed up with recommended duodenal biopsy. Sixty-six patients with IBS had positive antibody results, and 14 of these patients had celiac disease. Compared to matched controls, IBS was significantly associated with celiac disease (P = 0.004, odds ratio [OR] 7.0; 95% confidence interval [CI], 1.7-28.0). A variety of other medical problems were ultimately documented in many of the IBS patients including: 1 rectal cancer, 16 cases of diverticular disease, and 3 cases of inflammatory bowel disease (among other diagnoses).
Comment by Malcolm Robinson, MD, FACP, FACG
Gluten sensitive enteropathy (celiac disease) is relatively common in England and elsewhere in the United Kingdom. Although these precise numerical results would not apply here in the United States, it is likely that we too may miss some patients with occult celiac disease who present with nondescript symptoms suggesting IBS. Use of the antibody testing as described in this article might well be appropriate in some individuals, especially if there are other findings suggesting celiac disease such as iron-deficiency anemia, diabetes, cryptogenic hyperamylasemia, peripheral neuropathy, and/or osteoporosis. Celiac disease is commonly thought to involve steatorrhea and weight loss, but some patients actually are quite constipated and without weight loss. Onset of celiac disease can be quite insidious.
Dr. Robinson, Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine, University of Oklahoma College of Medicine Oklahoma City, OK, is Associate Editor of Internal Medicine Alert.