Elsevier

The Lancet

Volume 358, Issue 9292, 3 November 2001, Pages 1504-1508
The Lancet

Articles
Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care

https://doi.org/10.1016/S0140-6736(01)06581-3Get rights and content

Summary

Background

Irritable bowel syndrome has a high prevalence. Consensus diagnostic criteria (ROME II) based on symptoms have been established to aid diagnosis. Although coeliac disease can be misdiagnosed as irritable bowel syndrome, no prospective study has been published in which patients with this disorder are investigated for coeliac disease. We aimed to assess the association of coeliac disease with irritable bowel syndrome in patients fulfilling ROME II criteria.

Methods

We undertook a case-control study at a university hospital. 300 consecutive new patients who fulfilled Rome II criteria for irritable bowel syndrome, and 300 healthy controls (age and sex matched) were investigated for coeliac disease by analysis of serum IgA antigliadin, IgG antigliadin, and endomysial antibodies (EMA). Patients and controls with positive antibody results were offered duodenal biopsy to confirm the possibility of coeliac disease.

Findings

66 patients with irritable bowel syndrome had positive antibody results, of whom 14 had coeliac disease (11 EMA positive, three EMA negative). Nine patients with positive antibody results were lost to follow-up or refused biopsy (only one EMA-positive patient refused biopsy), and 43 had normal duodenal mucosa. Two controls, both of whom were EMA positive, had coeliac disease. Compared with matched controls, irritable bowel syndrome was significantly associated with coeliac disease (p=0·004, odds ratio=7·0 [95% CI 1·7–28·0]).

Interpretation

Patients with irritable bowel syndrome referred to secondary care should be investigated routinely for coeliac disease. With only EMA, three of 14 cases would have been missed.

Introduction

Epidemiological surveys have suggested that irritable bowel syndrome (IBS) affects 2·4–15·5% of western populations.1, 2, 3, 4 The challenge for the clinician is to exclude organic abnormality on the basis of history, clinical examination, and absence of sinister features such as weight loss, rectal bleeding, nocturnal diarrhoea, or anaemia. In 1978, Manning and colleagues5 described specific symptoms to aid diagnostic confidence. These key symptoms have been incorporated into other scoring systems. A multinational working party developed ROME I6 and more recently ROME II7 diagnostic criteria for functional gastrointestinal disorders (panel). The validity of diagnostic criteria based on symptoms has been substantiated by studies of patients with irritable bowel syndrome,5, 8, 9 long-term follow-up of such patients,10 and factor analysis in healthy volunteers.2, 11

Patients who are referred from primary care for assessment by a specialist are not representative of people with irritable bowel syndrome within the population because the family practitioner will frequently have selected the most refractory cases.1, 4 This cohort of patients might require further investigations if only to provide reassurance and confirm the diagnosis with a negative series of tests for coeliac disease. But which investigations are appropriate? And how far should the specialist pursue the exclusion of organic disease? Studies designed to answer these questions have shown that the diagnostic yield from preliminary haematological and biochemical profiles is low.12, 13 However, morbidity of a missed diagnosis is substantial, and thus a pragmatic approach has been recommended.14 All patients referred for a specialist opinion are generally screened with an initial haematological and biochemical profile. Thereafter, for patients older than 45 years, a combination of lower gastrointestinal tests is usually done. Imaging might be colonoscopy or sigmoidoscopy with barium enema, depending on the availability of these investigations.14 Other diagnostic tests, such as stool culture and microscopy, laxative screen, lactosehydrogen breath test, and small-bowel radiological examination are usually undertaken only for specific symptom subtypes.14

Coeliac disease can be misdiagnosed as irritable bowel syndrome.15 The prevalence of adult coeliac disease in western European populations is thought to be about one per 100–300 people.16, 17 This proportion has been based on epidemiological studies in which cohorts of healthy volunteers were screened.

Patients with adult coeliac disease typically complain of gastrointestinal symptoms suggestive of malabsorption. This manner of presentation is now described as the classic (typical) form.16, 17, 18 The increasing recognition of this disorder is attributed to new serological assays, and to the realisation that patients do not always have gastrointestinal symptoms (silent or atypical form)19, 20 but can present with insidious symptoms: iron deficiency anaemia, osteoporosis,16, 17, 18 cryptogenic hypertransaminasaemia,21 ataxia, or peripheral neuropathy.22

In 1997, the American Gastroenterological Association published guidelines for investigation of patients with irritable bowel syndrome. No recommendations were made to investigate coeliac disease in patients with this syndrome.14 More recently, British Society of Gastroenterology guidelines15 have suggested use of only EMA (endomysial antibodies) as part of the baseline serological assessment of these patients. ROME II criteria were initially devised to allow stratification of patients for more accurate comparisons in studies of irritable bowel syndrome, but both societies recognise these criteria as the gold standard in aiding clinicians to diagnose irritable bowel syndrome—even though patients can have abdominal pain with altered bowel habit that does not exactly fit these criteria but can follow a similar clinical course to the syndrome.15 Some gastroenterologists might investigate patients with irritable bowel syndrome routinely for coeliac disease, but no previous controlled studies have assessed this approach. We aimed to assess the association of coeliac disease with irritable bowel syndrome in patients fulfilling ROME II criteria.

Section snippets

Participants

We undertook this study at a university hospital in south Yorkshire, UK, that serves a population of about 250 000 people. Data were collected from January, 1999, to October, 2000. Patients were excluded if they did not fulfil ROME II criteria or had sinister symptoms such as weight loss, rectal bleeding, nocturnal diarrhoea, or anaemia. Patients had been referred from family practitioners without previous investigation. Referral letters suggested altered bowel habit or a clinical diagnosis of

Results

We saw 686 new patients in gastroenterology clinics. 300 patients fulfilled ROME II criteria (panel) for irritable bowel syndrome: 214 women and 86 men with a median age of 56 years (range 18–87). 212 (71%) fulfilled all three criteria; the other 88 (29%) described only two. All 300 had supportive symptoms, with a median score of 5 of a possible 9 symptoms (2–9). Symptom duration ranged from 3 months to 11 years (median 9 months). Patients with irritable bowel syndrome were subdivided according

Discussion

Our results show a significantly increased incidence of coeliac disease in European patients with irritable bowel syndrome who fulfil ROME II diagnostic criteria. We have not clarified whether all primary-care patients with irritable bowel syndrome should be investigated for coeliac disease. However, we would suggest that those patients with irritable bowel syndrome with refractory symptoms or coeliac-associated disorders merit antibody testing. We now recognise typical, atypical, latent, and

References (35)

  • S Sulkanen et al.

    Tissue transglutaminase autoantibody enzyme linked immunosorbent assay in detecting celiac disease

    Gastroenterology

    (1998)
  • E Taub et al.

    Irritable bowel syndrome defined by factor analysis: gender and race comparisons

    Dig Dis Sci

    (1995)
  • WG Thompson et al.

    Irritable bowel syndrome in general practice: prevalence, characteristics, and referral

    Gut

    (2000)
  • AP Manning et al.

    Towards positive diagnosis of the irritable bowel

    BMJ

    (1978)
  • DA Drossman et al.

    Identification of sub-groups of functional gastrointestinal disorders

    Gastroenterol Int

    (1990)
  • WG Thompson et al.

    Functional bowel disorders and functional abdominal pain

    Gut

    (1999)
  • WG Thompson

    Gender differences in irritable bowel symptoms

    Eur J Gastroenterol Hepatol

    (1997)
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