Excerpts on the Association of Irritable Bowel Syndrome and Celiac Disease by Laura Yick

Celiac.com 09/30/2002 - The Canadian Medical Association Journal (Hoey, 2002;166:479-80) published the following, Irritable Bowel Syndrome: Could it be Celiac Disease?, as excerpted below. This was an analysis of a Lancet article (Sander et al, 2001;358:1504-8) called, Association of Adult Coeliac Disease with Irritable Bowel Syndrome: A Case-Control Study in Patients Fulfilling Rome II Criteria Referred to Secondary Care.

Here are the CMAJ excerpts:
Irritable Bowel Syndrome is found in 10% to 20% of people with the use of standard diagnostic tools such as the Rome II criteria. Rome II criteria is specified below: At least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 out of 3 features:

• Relieved with defecation
• Onset associated with a change in frequency of stool
• Onset associated with a change in form (appearance) of stool

Celiac.com Sponsor (A12):
Symptoms that cumulatively support the diagnosis of irritable bowel syndrome:

• Abnormal stool frequency (more than 3 bowel movements per day or fewer than 3 bowel movements per week)
• Abnormal stool form (lumpy/hard or loose/watery stool)
• Abnormal stool passage (straining, urgency or feeling of incomplete evacuation)
• Passage of mucus
• Bloating or feeling of abdominal distention

Question: What proportion of patients who meet the Rome II criteria for irritable bowel syndrome have celiac disease?

Case subjects: The article cites that 300 people (214 women, 86 men ranging in age from 18 to 87, (mean 56 years)) met the Rome II criteria out of 686 new patients who were referred by a family physician to a university hospital gastroenterology clinic. Control subjects were healthy people without irritable bowel syndrome. Also, most control subjects were companions of the patients who were matched to case subjects by age (within 1 year) and sex, as well as questioned in the same manner as case subjects.

All case and control subjects underwent a wide range of baseline investigations, including full blood count, measurement of erythrocyte sedimentations rate, blood urea nitrogen and serum electrolyte levels, and thyroid function tests. In addition, they were investigated for celiac disease by analysis of serum levels of IgG antigliadin, IgA antigliadin and endomysial antibodies. Most of the case subjects, particularly those older than 45, underwent colonoscopy or sigmoidoscopy and barium enema. Case and control subjects with positive antibody test results were offered duodenal biopsy to confirm the possibility of celiac disease.

Of the 66 case subjects who had positive antibody test results,
49 had elevated levels of only IgG antigliadin
4 of only IgA antigliadin and
6 of only endomysial antibodies
Fourteen of the 66 were subsequently found to have histologic evidence of celiac disease; 11 of the 14 were positive for endomysial antibodies. Nine of the of 66 case subjects were lost to follow-up or refused duodenal biopsy; 1 of them was positive for endomysial antibodies.

Of the 44 control subjects who had positive antibody test results,
41 had elevated levels of only IgG antigliadin
1 of only IgA antigliadin and
2 of IgG antigliadin and endomysial antibodies
Only the last 2 subjects elected to undergo duodenal biopsy, and both were found to have histologic evidence of celiac disease.

Commentary: The authors found that a high proportion of patients (about 5%) who were referred to a university hospital gastroenterology clinic and who met the Rome II criteria did have celiac disease. In addition, the clinic specialists uncovered other organic abnormalities in almost 20% of the referred patients.

The study had several weaknesses. For instance, although most of the case subjects underwent extensive investigations of the lower gastrointestinal tract, the control subjects did not. Thus, some of the case subjects who were lost to follow-up or refused investigation and many of the age-matched control subjects might have been found to have irritable bowel disease, celiac disease or other gastrointestinal abnormalities.

The authors conclude from their findings that patients who meet the Rome II criteria for irritable bowel syndrome and who are referred to a secondary care centre should be investigated routinely for celiac disease.

In an editorial accompanying the Lancet article, a gastroenterologist cautioned that more studies are needed. He noted an earlier study in which 121 consecutive patients were referred for investigation of irritable bowel syndrome. Using Rome I criteria and similarly extensive investigation, the researchers detected no cases of celiac disease.

Because of the findings from the Lancet study, the editorialist has decided to further lower his threshold for screening for celiac disease among patients referred for investigation of irritable bowel syndrome. Perhaps other gastroenterologists would be wise to do the same.

I verified the five percent as cited in the CMAJ as 14 out of the 300 patients who met the Rome II criteria also had celiac disease. The CMAJ also cites the following, Studies in Europe have shown that up to 1% of the adult population may have celiac disease. We can make our own conclusions from this study in Lancet and we might agree that 1% may be understated but further studies have to be performed to corroborate a higher percentage of undiagnosed celiacs; I hope this definitely encourages closer scrutiny of IBS patients like myself who was diagnosed with IBS in 1997 with only a symptom of left side tenderness below my rib cage and a sigmoidoscopy which revealed no abnormalities except a hemorrhoid. Then, in the summer of 2001, I was diagnosed with lactose intolerance and IBS once more before discovering from medical research and my food dairy taken since May 2001, along with corroboration by an allergist in October 2001, that it may be celiac disease, as my malabsorption symptoms grew worse.