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