Screening for coeliac disease in patients fulfilling the Rome II criteria for irritable bowel syndrome in a secondary care hospital in The Netherlands: a prospective observational study

Irritable bowel syndrome is the most commonly diagnosed gastrointestinal condition and affects a large proportion of the population in the West.1 Several guidelines suggest that in typical patients with no alarm symptoms or signs, apart from routine laboratory tests, no additional tests are necessary.2 Coeliac disease, however, may present with symptoms suggestive of irritable bowel disease.3 Several studies suggested that screening for coeliac disease in patients with symptoms suggestive of irritable bowel disease might be cost‐effective.4,5,6,7 We, therefore, started to routinely screen patients with typical irritable bowel disease symptoms for coeliac disease using antiendomysial antibodies. All patients referred to three doctors at the outpatient gastroenterology department of our hospital between November 2002 and November 2005 for suggestive irritable bowel disease and fulfilling the Rome II criteria were included if routine laboratory tests and an endoscopy of the lower gastrointestinal tract were performed. Furthermore, all patients received standard care including an interview and physical examination. Apart from these tests, the treating physician could order any other diagnostic test as considered necessary. In addition, serological screening for coeliac disease was carried out in all patients. Total IgA was measured to exclude IgA deficiency. Thereafter, IgA antiendomysial antibodies were measured using indirect fluorescent antibody test anti‐EmA (monkey endomysial) IgA Assay (Scimedx Corporation, Denville, New Jersey, USA) according to the instructions of the manufacturer. A titre of 1:10 U/l or more was considered positive. A total of 163 patients (108 women, 55 men, median age 35 years, range 16–75 years) fulfilled the inclusion criteria and have been included in this analysis. 154 (94%) patients were diagnosed finally with irritable bowel disease, 4 with Crohn's disease, 2 with hyperthyroidism, 1 with endometriosis, 1 with lactase deficiency and 1 with idiopathic bile salt malabsorption. Fifteen patients were not screened with antiendomysial antibodies. In four of these patients, the treating physician ordered duodenal biopsy specimens because of predominant diarrhoeal symptoms. Histological examination of the biopsy specimens showed normal mucosa in all of them. Therefore, in 148 evaluated patients antiendomysial antibodies were measured. IgA deficiency was not observed. Moreover, in none of the 148 patients (0%, 95% confidence interval 0 to 2, 4%) endomysial antibodies were positive. In 32 patients, the treating physician ordered duodenal biopsy specimens as well. In two of them, histological examination of the biopsy specimens showed an increased number of intraepithelial lymphocytes but a normal villous morphology, in the other 30 patients, duodenal biopsy specimens showed normal mucosa. To our knowledge, only two similar studies have been performed in the Western world.4,7 Our study is in contrast with a study performed in the UK that observed 11 cases of positive antiendomysial antibodies in 300 patients (3.6%).4 Furthermore, a study performed in the US found a prevalence of 4% (2/50 patients) when screening of patients with symptoms suggestive of irritable bowel syndrome was performed with antitissue transglutaminase antibodies, although none of these patients had positive antiendomysial antibodies.7 Most probably, our study is negative because of a low prevalence of coeliac disease in our examined population. In a recent Dutch survey, the overall prevalence of unrecognised coeliac disease in The Netherlands is 1:286.8 This is lower than the prevalence of 1:100 observed in the UK and of 1:133 observed in the US.9,10 In summary, this study shows that in patients referred to a secondary care hospital in The Netherlands because of suggestive irritable bowel syndrome, the prevalence of coeliac disease is low and that screening for coeliac disease in this population is ineffective. Footnotes Competing interests: None. References - 1.Hungin A P, Whorwell P J, Tack J.et al The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40 000 subjects. Aliment Pharmacol Ther 200317643–650. [DOI] [PubMed] [Google Scholar] - 2.Drossman D A, Camilleri M, Mayer E A.et al AGA technical review on irritable bowel syndrome. Gastroenterology 20021232108–2131. [DOI] [PubMed] [Google Scholar] - 3.O'Leary C, Wieneke P, Buckley S.et al Celiac disease and irritable bowel‐type symptoms. Am J Gastroenterol 2002971463–1467. [DOI] [PubMed] [Google Scholar] - 4.Sanders D S, Carter M J, Hurlstone D P.et al Association of adult celiac disease with irritable bowel syndrome: a case–control study in patients fulfilling ROME II criteria referred to secondary care. Lancet 20013581504–1508. [DOI] [PubMed] [Google Scholar] - 5.Spiegel B M, DeRosa V P, Gralnek I M.et al Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost‐effectiveness analysis. Gastroenterology 20041261721–1732. [DOI] [PubMed] [Google Scholar] - 6.Mein S M, Ladabaum U. Serological testing for coeliac disease in patients with symptoms of irritable bowel syndrome: a cost‐effectiveness analysis. Aliment Pharmacol Ther 2004191199–1210. [DOI] [PubMed] [Google Scholar] - 7.Locke G R, 3rd, Murray J A, Zinsmeister A R.et al Celiac disease serology in irritable bowel syndrome and dyspepsia: a population‐based case–control study. Mayo Clin Proc 200479476–482. [DOI] [PubMed] [Google Scholar] - 8.Schweizer J J, von Blomberg B M E, Bueno‐de Mesquita H B.et al Coeliac disease in the Netherlands. Scand J Gastroenterol 200439359–364. [DOI] [PubMed] [Google Scholar] - 9.McLoughlin R, Sebastian S S, Qasim A.et al Coeliac disease in Europe. Aliment Pharmacol Ther 20031845–48. [DOI] [PubMed] [Google Scholar] - 10.Accomando S, Cataldo F. The global village of celiac disease. Dig Dis Sci 200436492–498. [DOI] [PubMed] [Google Scholar]