Clinical Review Lesson of the week

Antibody negative coeliac disease presenting in elderly people—an easily missed diagnosis

BMJ 2005; 330 doi: http://dx.doi.org/10.1136/bmj.330.7494.775 (Published 31 March 2005) Cite this as: BMJ 2005;330:775
  1. David S Sanders ([email protected]), consultant gastroenterologist1,
  2. David P Hurlstone, consultant gastroenterologist1,
  3. Mark E McAlindon, consultant gastroenterologist1,
  4. Marios Hadjivassiliou, consultant neurologist1,
  5. Simon S Cross, consultant histopathologist1,
  6. Graeme Wild, senior scientist in immunology1,
  7. Christopher J Atkins, general practitioner2
  1. 1Royal Hallamshire Hospital, Sheffield S10 2JF
  2. 2Greystones Medical Centre, Sheffield S11 7BJ
  1. Correspondence to: D S Sanders, Room P39, P Floor, Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield S10 2JF
  • Accepted 28 January 2005

Introduction

Epidemiological studies screening cohorts of healthy volunteers in the United States of America, the United Kingdom, and other European countries have determined that the prevalence of adult coeliac disease in the general population is in the magnitude of 1 per 100 to 200.14

The diagnosing of coeliac disease is often delayed,37 perhaps owing to a failure to recognise the protean manifestations of this disease in both primary and secondary care.59 Coeliac disease used to be perceived as involving gastrointestinal symptoms suggestive of malabsorption, but this manner of presentation is now described as the classic (typical) form.4 Patients with coeliac disease may have the silent or atypical form (no gastrointestinal symptoms), and the condition may present insidiously—for example, with iron deficiency anaemia, osteoporosis, cryptogenic hypertransaminasaemia, or neurological symptoms.510 The increasing recognition of coeliac disease is attributed to the use of new serological assays that have a high sensitivity and specificity.4 Antibody testing, however, is not the absolute method of diagnosis. We present a case of an elderly man presenting with coeliac disease in whom the condition would not have been recognised without a second duodenal biopsy.

Case report

In May 2003 a 79 year old man with longstanding dyspepsia presented to his general practitioner with worsening indigestion, tiredness, and rapid weight loss. Blood tests arranged by the doctor showed a macrocytic anaemia with low concentrations of vitamin B-12 and folate. The patient subsequently had a …

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