Celiac.com 05/06/2008 - In the majority of people with celiac disease, strict adherence to a gluten-free diet can result in a quality of life that is on par with non-celiacs. Still a small percentage of celiacs seem to suffer from persistent gastrological discomfort in the form of irritable bowel or irritable-bowel-like symptoms. Very few studies have been done on persistent gastrological problems in adults with celiac disease. Those that have been done rely upon univariate statistical analysis in clinical samples at the secondary or tertiary care level and fail to assess the potential influence of non-celiac disease specific factors, which are considered to be a risk factor of irritable bowel syndrome (IBS), such as mental disorders, or gender.

A team of researchers made up of doctors Winfried Hauser, Frauke Musial, Wolfgang Caspary, Jurgen Stein, and Andreas Stallmach set out to determine rates of irritable bowel syndrome, irritable bowel syndrome-related symptoms, and consecutive health care-seeking behavior and their influence upon health-related quality of life (HRQL) and any conceivable bio-psychosocial factors influencing adult patients with celiac disease. The research team made a medical and socio-demographic survey of 1000 adult celiac patients from the German Celiac Society by post. The medical portion of the survey included bowel history. The team also had patients fill out a Short Form Health Survey (SFHS), along with the Hospital Anxiety and Depression Scale.

516 of the questionnaires came back completed. Respondents were similar in gender ratio and median age from the whole membership directory of the German Celiac Society, a group of more than 18,000 people who reported suffering from celiac disease at the age of 18. Of these, 213 (41.3%) had a diagnosis of celiac disease that was made by a duodenal biopsy, 37 (7.2%) by serological tests (celiac disease-specific antibodies), 34 (6.6%) using stool tests for trans-glutaminase antibodies, and 232 (45.0%) using intestinal biopsy and serological tests.

A total of 446 patients indicated that they had biopsy-proven celiac disease. Of these 446 patients, 18 were excluded because they indicated adherence to a gluten-free diet for less than 1 year. Sixteen patients were tossed out because they reported a major non-adherence to the gluten-free diet. Thus, the study group was confined to 412 patients with self-reported biopsy-proven celiac disease who were on a strict gluten-free diet for at least one year. The survey showed that out of these 412 patients that met the criteria, 96 patients, or just over 23% met modified Rome I criteria for Irritable Bowel Syndrome. Of those 96 patients, 76 patients, or nearly 80%, made an effort to get help, both medical and non-medical, as a result of the bowel symptoms (we’ll call the patients who sought help "irritable bowel syndrome patients").

Irritable bowel syndrome-like symptoms were shown to drive SFHS scores sharply downward. Mental health disorders, being female, falling off the gluten-free diet all contributed to a greater likelihood of irritable bowel syndrome symptoms.

The results of the study seem strengthen the bio-psychosocial model of irritable bowel syndrome, in which biological and psychological factors are understood to affect the clinical manifestation of celiac disease. Under this model, irritable bowel syndrome-like symptoms in adults with celiac disease are understood through a combination of clinical and socio-psychological mechanisms. This model leads doctors to an understanding of celiac disease and other gastro-intestinal ailments that goes beyond simple biological or psychological factors alone, and looks at factors like adverse life events, stress, and hypochondriasis among others.

Limited studies indicate that gender differences in visceral perception, cardio-autonomic responses, gastrointestinal motility, and brain activation patterns to visceral stimuli are a factor in irritable bowel syndrome. Gender differences in psychosocial factors have not been fully studied.

The results of this study also support the need for further investigation to determine exactly what factors contribute to the bio-psychosocial model of what is called ’celiac irritable bowel syndrome.’

Future psycho-physiological studies in patients with celiac disease and irritable bowel syndrome should look to determine if psychological discomfort can prolong mucosal inflammation, reduce visceral pain thresholds, or disturb gut motility.

In the event that the right psychotherapeutic treatment for irritable bowel syndrome-like symptoms and/or mental disorder serve to improve reduced HRQOL in adult patients with celiac disease and irritable bowel syndrome-like symptoms, it might be necessary to take a second look at interventional practices.

So, in a nutshell, this all means that things like mental health, gender, and other non-clinical factors might play a role in irritable bowel syndrome-like symptoms in people with celiac disease, and that further study is needed to sort out all of the possibilities and determine if there might be better ways to treat celiac disease that will reduce or eliminate irritable bowel syndrome-like symptoms.

Psychosomatic Medicine 69:370 –376 (2007)

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