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 200.1^–4

The diagnosing of coeliac disease is often delayed,3^–7 perhaps owing to a failure to recognise the protean manifestations of this disease in both primary and secondary care.5^–9 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.5^–10 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 …