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The Canadian Medical Association Journal (2/19/02;166;4) published the
following, “Irritable bowel syndrome:  Could it be celiac disease?”, as
excerpted below.  This was an analysis of a Lancet article (2001;358:1504-9)
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 below:
“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 as 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
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 who
were recruited from family practices in the hospital catchment area;  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
fashion 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
6 of only endomysial antibodies
14 of 66 were subsequently found to have histologic evidence of celiac
disease;  11 of the 14 were positive for endomysial antibodies
9 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 nad 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 disese among
patients referred for investigation of irritable bowel syndrome.  Perhaps
other gastroenterol(o)gists would be wise to do the same".

I verified the 5% 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.”  All of us on the list serv 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 my symptom of left side tenderness below my rib cage and a
sigmoidoscopy which revealed no abnormalities except a hemorroid.  Then, I
was diagnosed again last summer with lactose intolerance and IBS before I
discovered (with the help of my husband's medical library research and food
dairy taken since May 2001 plus corroboration by an allergist, not a
Gastroenterologist) in October that it may be celiac disease as my
malabsorption symptoms grew worse.
Regards, Laura




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