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Rapid Responses: Rapid Responses published:
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obesity associated with untreated coeliac disease
- Margaret Elizabeth Lupton (2 April 2005)
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Atypical Coeliac Disease: importance of dermatologic clue in the diagnosis
- Vijay P. Zawar, Dr. Dr. Anil Gugle and Dr. Vijay Malpathak, Associate Professors in the Departments of Dermatology and Surgery, NDMVPS Medical College, Nashik, India. (2 April 2005)
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Overt or masked allergy to wheat is very common and contributes to numerous illnesses
- Ellen C G Grant (4 April 2005)
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Coeliac testing in primary care for IBS
- James E East, Neil P. Galletly, Devinder S. Bansi, Andrew V. Thillainayagam (4 April 2005)
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Dermatitis Herpetiformis as a clue for Celiac disease
- Mohamed S. Noshi (5 April 2005)
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Coeliac disease: what goes around comes around
- William Dickey (21 April 2005)
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Coeliac disease presentation for children in Britain originating from the northern part of the Indian subcontinent
- BADRI N GARLAPATI (22 April 2005)
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Margaret Elizabeth Lupton, GP Preston PR1 9PS
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I was very interested to read the Lesson of the Week on Atypical Presentations of Coeliac Disease (April 2nd 2005) and I feel it is important to alert doctors to the possibility of coeliac disease even in obese patients, but this presentation of coeliac disease has long been recognised. The authors questioned why untreated coeliacs gain excess weight - one obvious explanation is that an untreated coeliac tolerates fats better than carbohydrates, a fact observed by Herter in 1903. An untreated coeliac may therefore manipulate their diet to include an excessive quantity of fat, in order to reduce their symptoms. As for the subsequent effect of treating with a gluten free diet on the patient's weight, this all depends on the type of food the patient consumes when they change to gluten free. A gluten free diet is not in itself a high calorie diet, but if an obese coeliac on a gluten free diet eats excessively they will remain overweight just as any non-coeliac would. Witholding treatment with a gluten free diet is not an acceptable method of weight control and will not promote healthy eating. Competing interests: I have 2 children who are coeliacs - is this a competing interest? |
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Vijay P. Zawar, Consultant Dermatologist &Lecturer NDMVPS Medical College, Nashik, India, Dr. Dr. Anil Gugle and Dr. Vijay Malpathak, Associate Professors in the Departments of Dermatology and Surgery, NDMVPS Medical College, Nashik, India.
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Dear Sir, We read with great interest article by RM Furse and AS Mee. It is certainly enlightening on atypical cases of coeliac disease. The diagnosis could be missed if the consultant adheres strictly to the clinical and investigational parameters. We, at the other end of the type of set-up, have experienced that even though the clinical suspicion about the coeliac disease is strong enough, we are frequently unable to work the patient up for gliadin antibodies, endomysial antibodies, and tissue transglutaminase activity, inability to perfom endoscopic biopsies in those who are unaffording (or the needed gastro-intestinal expertise is lacking) chiefly due to the limitations in the resources for most our patients. Some of them, despite of taking to the task of detailed investigations, the tests may be inconclusive or may be negative.At times, the gastro-intestinal complains may be subtle or absent. In such situation, we noted that a careful watch on the cutaneous presentations might serve as a diagnostic clue to a probable diagnosis. Various cutaneous features noted are intensely itchy,grouped vesiculo -bullous eruptions on the erythematous base on the extensor aspects of the extremities and the trunk(known as Dermatitis Herpetiformis)in the most classical form. Less typically,just the itchy papules or the excoriations at the specified sites may be present, especially in the early lesions. These lesions are commonly unresponsive to steroids and antihistaminics. This should alert the physician about a potential possibility of Coeliac Disease in the given patient. A cutaneous biopsy and if feasible, direct immunofluorescence microscopy confirms the diagnosis. So even if the results of other laboratory tests are inconclusive, a gluten-restricted diet should be begun in such circumstances. We have found that it often helps to halt the clinical progression,provided the patient is adequately educated. Another way of strengthening the suspicion when the dermatitis is not very classical is to subject the patient to a gluten challenge with due education of the patient that this might exacerbate the "rashes". Yet another way of confirming may be a theraeutic trial with Dapsone, which dramatically clears off the dermatitis. At some of the instances, especially during the early gluten-free diet therapy, dapsone may indeed be required as a therapeutic agent. Thus, the importance of cutaneous clues to Coeliac Disease could not be under-emphasized though it is often under-recognised in the practice of internal medicine. Competing interests: None declared |
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Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, UK
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Since the dawn of civilisation cereals were regarded as peasant food while the rich ate meat and fish, according to the wall paintings in Mesopotamia. This empowered the brain function of the ruling classes for millennia. The problem is refined wheat contributes fewer key nutrients than is usually required for its metabolism and also blocks the absorption of zinc, iron and magnesium. Wheat ingestion can also cause bleeding from the small bowel. Mineral deficiencies or imbalances increase adverse reactions to food causing urinary losses of zinc and magnesium which further increasing adverse reactions to food. Wheat was the commonest masked food allergen in the migraine clinic patients tested in my food withdrawal and re-introduction study.2 If food allergens are avoided weight is lost in those overweight and gained in those underweight. Who decided that pasta was a healthy option? I am concerned that potato chips are being denigrated but cereals, bread and pasta are being promoted as part of healthy school meals.3-6 It is not enough for health officials to promote low fat, low salt and low sugar meals. High wheat diets can cause nutritional deficiencies of minerals, vitamins and essential fatty acids and therefore contribute to numerous illnesses. 1 Furse RM, Mee AS. Atypical presentation of coeliac disease BMJ 2005; 330: 773-774. 2 Grant ECG. Food allergies and migraine. Lancet 1979; 1: 966-969. 3 Grant ECG. Jamie Oliver’s school dinners and food allergy http://bmj.com/cgi/eletters/330/7492/678#100949, 19 Mar 2005 4 Grant ECG. Jamie Oliver’s school dinners and masked food allergy http://bmj.com/cgi/eletters/330/7492/678#101161, 21 Mar 2005 5 Grant ECG. Re: Jamie Oliver's school dinners and food allergy http://bmj.com/cgi/eletters/330/7492/678#101821, 29 Mar 2005 6 Grant ECG. Wheat bran can worsen IBS http://bmj.com/cgi/eletters/330/7492/632#100815, 18 Mar 2005 Competing interests: None declared |
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James E East, SpR Gastroenterology Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, Neil P. Galletly, Devinder S. Bansi, Andrew V. Thillainayagam
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Dear Editor, Furse and Mee make an important point regarding vigilance for coeliac disease when patients present with atypical symptoms.(1) Two of their four patients diagnosed with coeliac disease had IBS-type symptoms, with bloating and irregular bowel habit, and neither had “Red flag” signs. However in the BMJ only two weeks earlier Cayley suggests that for patients presenting with symptoms consistent with irritable bowel syndrome only a full blood count is mandatory for laboratory investigation of these patients, and does not mention endomysial antibody testing for coeliac disease.(2) If these two patients had been managed in this way, the diagnosis may have been missed in both cases. Coeliac disease has a prevalence of 1 in 200 in the United Kingdom, but is under-diagnosed as the symptoms are often non-specific, leading to a “coeliac iceberg” in the community.(3) In a large case-control study, patients fulfilling the ROME II criteria for irritable bowel syndrome had an odds ratio for coeliac disease seven times that of a control population.(4) Using widely available, cheap, sensitive and specific serological testing for coeliac disease in these patients is cost effective and avoids the significant morbidity associated with untreated coeliac disease.(5) We suggest therefore that endomysial or tissue transglutaminase antibody testing should comprise part of the laboratory work up of patients presenting with irritable bowel syndrome symptoms in primary care, especially where diarrhoea is a feature, to avoid missing this common diagnosis. 1. Furse RM, Mee AS. Atypical presentation of coeliac disease. BMJ 2005;330:773-4 2. Cayley WE Jr. Irritable bowel syndrome. BMJ 2005;330:632 3. Feighery C. Coeliac disease. BMJ 1999;319:236-9 4. Saunders DS, Carter MJ, Hurlstone DP et al. Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care. Lancet 2001;358:1504-08 5. Speigel BM, DeRosa VP, Grainek IM, Wang V, Dulai GS. Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost -effective analysis. Gastroenterology 2004;126:1721-32. Competing interests: None declared |
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Mohamed S. Noshi, Consultant ,Internal Medicine USA Florida USA 33062
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One of the clues for a subtle presentation of celiac disease is a severely pruritic rash on dorsal aspects of elbows and knees called dermatitis herpetiformis. Mohamed Noshi, MD, FACP
Competing interests: None declared |
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William Dickey, Gastroenterologist Altnagelvin Hospital, Londonderry, BT47 6SB
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Obesity in the untreated coeliac patient is not a new observation, but there remains a lack of awareness of the range of clinical presentations of coeliac disease among clinicians. The paper by Furse and Mee should therefore serve as a useful reminder to all. In a prospective survey of 50 patients published in this journal in 1998 [1], we found that 7% of men and 29% of women had a body mass index (BMI) under 20, while 67% of men and 20% of women had a BMI of 25 of over. Three patients (6%) had a BMI of 30 or greater. Coeliac disease is an autoimmune, multisystem disorder, capable of significant clinical effects on many organ systems or on none. Thus perceived, the failure of many patients to fit the "classical" picture of malabsorption should not surprise. 1. Dickey W, Bodkin S. Prospective study of body mass index in patients with coeliac disease. BMJ 1998 317: 1290. Competing interests: Associate, Medical Advisory Council, Coeliac UK |
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BADRI N GARLAPATI, HOUSE OFFICER WARWICK,CV34 5BW
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Coeliac disease can present with short stature, iron resistant anaemia, rickets and personality problems. Such a mode of presentation is characteristic for children in Britain originating from the northern part of the Indian sub-continent. Presentation may be with symptoms compatible with a diagnosis of irritable bowel syndrome or recurrent mouth ulcers. Competing interests: None declared |
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