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    No Link Found Between Celiac Disease and Irritable Bowel Syndrome


    Scott Adams

    Mayo Clin Proc 2004;79:476-482.


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    Celiac.com 05/25/2004 - The results of a study conducted by Dr. G. Richard Locke III and colleagues at the Mayo Clinic College of Medicine in Rochester, Minnesota do not show an association between irritable bowel syndrome (IBS) and celiac disease. The case-control study was based on the respondents of a bowel disease questionnaire that was sent to random Olmsted County residents who were 20 to 50 years old. The researchers evaluated 150 subjects, 72 of whom reported having symptoms of IBS and dyspepsia, and 78 controls with no gastrointestinal symptoms. In the group with symptoms they found that 50 had IBS, 24 had dyspepsia and 15 had both conditions. Serological screening of both groups for celiac disease showed no significant difference between them—two controls, two IBS subjects and two people with dyspepsia tested positive for celiac disease. The researchers conclude that celiac disease alone cannot explain the presence or IBS or dyspepsia in the subjects.

    The results of this study are interesting, but probably not large enough to be statistically significant. The total number of people with celiac disease in each group was astounding:
    2 out of 50 with IBS (4%)
    2 out of 24 with dyspepsia (6%)
    2 of the 78 controls (2.6%)

    These findings do not necessarily contradict previous IBS/celiac disease studies that looked at hospital outpatients who are more likely to have more severe and prolonged symptoms than a group that selects itself from the general public by responding to a questionnaire. Additionally most of the earlier studies that concluded that there was a connection between celiac disease and IBS were conducted before more recent epidemiological studies that have shown just how high the incidence of celiac disease in the general population is--now estimated between 0.8% and 1.3%--this study suggests 2 -3%. These recent epidemiological studies have also shown that a large percentage of celiacs have little or no symptoms, perhaps due to the length of time or the severity of the disease.

    A 1 in 20 diagnosis of celiac disease in patients with IBS/dyspepsia is consistent with other studies, and is still high and suggests that testing for celiac disease should be done routinely on these patients. No studies have ever suggested that all or even most IBS patients have celiac disease, just that the incidence is higher than that of the normal population.

    I propose that if this study had been done on exactly the same people several years from now, the 2 people in the control group who were found to have celiac disease may well develop symptoms that would put them in either the IBS or dyspepsia group, which would create a statistically significant result that would contradict this studys result. Last, perhaps the results of this study really support a more broad conclusion: Everyone ought to be screened for celiac disease, not just those with symptoms.

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  • About Me

    In 1994 I was diagnosed with celiac disease, which led me to create Celiac.com in 1995. I created this site for a single purpose: To help as many people as possible with celiac disease get diagnosed so they can begin to live happy, healthy gluten-free lives. Celiac.com was the first site on the Internet dedicated solely to celiac disease. In 1998 I founded The Gluten-Free Mall, Your Special Diet Superstore!, and I am the co-author of the book Cereal Killers, and founder and publisher of Journal of Gluten Sensitivity.

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  • Related Articles

    Scott Adams
    Lancet Nov 2001 Volume 358, Number 9292 1504-08 03
    Celiac.com 11/14/2001 - A recent study published in The Lancet by Dr. David S Sanders et al. of the Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK, explored the number of people who were diagnosed with irritable bowel syndrome but actually had celiac disease.
    The case-control study was done at a university hospital in which 300 consecutive new irritable bowel syndrome patients who met the Rome II criteria for their diagnosis were compared against 300 healthy age and sex-matched controls. Both groups were investigated for celiac disease by analysis of their serum IgA antigliadin, IgG antigliadin, and endomysial antibodies (EMA). Patients and controls with positive antibody results were offered duodenal biopsy to confirm the possibility of celiac disease.
    An amazing 66 patients with irritable bowel syndrome tested positive for the antibodies, and 14 of them or 4.6% had active celiac disease as compared with 2 or 0.66% of the non-IBS matched controls. In other words there is a sevenfold increase over the normal population in the number of people with IBS who have celiac disease. All of the patients with celiac disease in the IBS group were therefore misdiagnosed. The study did not indicate how many of the other 52 patients who had positive antibody results would eventually develop celiac disease, but this would be an interesting follow-up study. Celiac.com believes that the 4.6% with celiac disease will grow higher over time.
    Conclusion: All patients with irritable bowel syndrome should be screened celiac disease.

    Scott Adams
    Celiac.com 09/30/2002 - The Canadian Medical Association Journal (Hoey, 2002;166:479-80) published the following, Irritable Bowel Syndrome: Could it be Celiac Disease?, as excerpted below. This was an analysis of a Lancet article (Sander et al, 2001;358:1504-8) called, Association of Adult Coeliac Disease with Irritable Bowel Syndrome: A Case-Control Study in Patients Fulfilling Rome II Criteria Referred to Secondary Care.
    Here are the CMAJ excerpts:
    Irritable Bowel Syndrome is found in 10% to 20% of people with the use of standard diagnostic tools such as the Rome II criteria. Rome II criteria is specified below: At least 12 weeks, which need not be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 out of 3 features:
    Relieved with defecation Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool Symptoms that cumulatively support the diagnosis of irritable bowel syndrome:
    Abnormal stool frequency (more than 3 bowel movements per day or fewer than 3 bowel movements per week) Abnormal stool form (lumpy/hard or loose/watery stool) Abnormal stool passage (straining, urgency or feeling of incomplete evacuation) Passage of mucus Bloating or feeling of abdominal distention Question: What proportion of patients who meet the Rome II criteria for irritable bowel syndrome have celiac disease?
    Case subjects: The article cites that 300 people (214 women, 86 men ranging in age from 18 to 87, (mean 56 years)) met the Rome II criteria out of 686 new patients who were referred by a family physician to a university hospital gastroenterology clinic. Control subjects were healthy people without irritable bowel syndrome. Also, most control subjects were companions of the patients who were matched to case subjects by age (within 1 year) and sex, as well as questioned in the same manner as case subjects.
    All case and control subjects underwent a wide range of baseline investigations, including full blood count, measurement of erythrocyte sedimentations rate, blood urea nitrogen and serum electrolyte levels, and thyroid function tests. In addition, they were investigated for celiac disease by analysis of serum levels of IgG antigliadin, IgA antigliadin and endomysial antibodies. Most of the case subjects, particularly those older than 45, underwent colonoscopy or sigmoidoscopy and barium enema. Case and control subjects with positive antibody test results were offered duodenal biopsy to confirm the possibility of celiac disease.
    Of the 66 case subjects who had positive antibody test results,
    49 had elevated levels of only IgG antigliadin
    4 of only IgA antigliadin and
    6 of only endomysial antibodies
    Fourteen of the 66 were subsequently found to have histologic evidence of celiac disease; 11 of the 14 were positive for endomysial antibodies. Nine of the of 66 case subjects were lost to follow-up or refused duodenal biopsy; 1 of them was positive for endomysial antibodies.
    Of the 44 control subjects who had positive antibody test results,
    41 had elevated levels of only IgG antigliadin
    1 of only IgA antigliadin and
    2 of IgG antigliadin and endomysial antibodies
    Only the last 2 subjects elected to undergo duodenal biopsy, and both were found to have histologic evidence of celiac disease.
    Commentary: The authors found that a high proportion of patients (about 5%) who were referred to a university hospital gastroenterology clinic and who met the Rome II criteria did have celiac disease. In addition, the clinic specialists uncovered other organic abnormalities in almost 20% of the referred patients.
    The study had several weaknesses. For instance, although most of the case subjects underwent extensive investigations of the lower gastrointestinal tract, the control subjects did not. Thus, some of the case subjects who were lost to follow-up or refused investigation and many of the age-matched control subjects might have been found to have irritable bowel disease, celiac disease or other gastrointestinal abnormalities.
    The authors conclude from their findings that patients who meet the Rome II criteria for irritable bowel syndrome and who are referred to a secondary care centre should be investigated routinely for celiac disease.
    In an editorial accompanying the Lancet article, a gastroenterologist cautioned that more studies are needed. He noted an earlier study in which 121 consecutive patients were referred for investigation of irritable bowel syndrome. Using Rome I criteria and similarly extensive investigation, the researchers detected no cases of celiac disease.
    Because of the findings from the Lancet study, the editorialist has decided to further lower his threshold for screening for celiac disease among patients referred for investigation of irritable bowel syndrome. Perhaps other gastroenterologists would be wise to do the same.
    I verified the five percent as cited in the CMAJ as 14 out of the 300 patients who met the Rome II criteria also had celiac disease. The CMAJ also cites the following, Studies in Europe have shown that up to 1% of the adult population may have celiac disease. We can make our own conclusions from this study in Lancet and we might agree that 1% may be understated but further studies have to be performed to corroborate a higher percentage of undiagnosed celiacs; I hope this definitely encourages closer scrutiny of IBS patients like myself who was diagnosed with IBS in 1997 with only a symptom of left side tenderness below my rib cage and a sigmoidoscopy which revealed no abnormalities except a hemorrhoid. Then, in the summer of 2001, I was diagnosed with lactose intolerance and IBS once more before discovering from medical research and my food dairy taken since May 2001, along with corroboration by an allergist in October 2001, that it may be celiac disease, as my malabsorption symptoms grew worse.
     

    Scott Adams
    Aliment Pharmacol Ther 19(11):1199-1210, 2004.
    Celiac.com 06/08/2004 - Researchers at the University of California, San Francisco have determined that everyone with Irritable Bowel Syndrome (IBS) should also be screened for celiac disease. The researchers used decision analysis to estimate the number of celiac disease cases detected, quality-adjusted life-years gained, and costs resulting from screening suspected IBS patients for tissue transglutaminase antibody and antibody panel. Positive tests were followed up with an endoscopic biopsy. A gluten-free diet was initiated to improve the quality of life in those with celiac disease.
    The results of this study indicate that 3% of the 1,000 patients with suspected IBS have celiac disease. Based on these results the researchers analyzed the costs of several celiac disease screening methods used a decision analysis formula to determine whether or not the screening is cost effective. The researchers conclude that celiac disease screening in patients with suspected irritable bowel syndrome is likely to be cost-effective even at a relatively low celiac disease prevalence.
    Perhaps the researchers should have taken their analysis one step further and concluded that it would make good economic sense to screen the entire population of the USA (as well as that of other countries) for celiac disease, rather than just those with IBS, given the fact that it affects approximately 1% of the population--which is the only conclusion that I could reach after my review of their good work. -Scott Adams

    Jefferson Adams
    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 lifethat is on par with non-celiacs. Still a small percentage of celiacsseem to suffer from persistent gastrological discomfort in the form ofirritable bowel or irritable-bowel-like symptoms. Very few studies havebeen done on persistent gastrological problems in adults with celiacdisease. Those that have been done rely upon univariate statisticalanalysis in clinical samples at the secondary or tertiary care leveland fail to assess the potential influence of non-celiac diseasespecific factors, which are considered to be a risk factor of irritablebowel syndrome (IBS), such as mental disorders, or gender.
    Ateam of researchers made up of doctors Winfried Hauser, Frauke Musial,Wolfgang Caspary, Jurgen Stein, and Andreas Stallmach set out todetermine rates of irritable bowel syndrome, irritable bowelsyndrome-related symptoms, and consecutive health care-seeking behaviorand their influence upon health-related quality of life (HRQL) and anyconceivable bio-psychosocial factors influencing adult patients withceliac disease. The research team made a medical and socio-demographicsurvey of 1000 adult celiac patients from the German Celiac Society bypost. The medical portion of the survey included bowel history. Theteam also had patients fill out a Short Form Health Survey (SFHS),along with the Hospital Anxiety and Depression Scale.
    516 ofthe questionnaires came back completed. Respondents were similar ingender ratio and median age from the whole membership directory of theGerman Celiac Society, a group of more than 18,000 people who reportedsuffering 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 totalof 446 patients indicated that they had biopsy-proven celiac disease. Of these 446patients, 18 were excluded because they indicated adherence to agluten-free diet for less than 1 year. Sixteen patients were tossed outbecause they reported a major non-adherence to the gluten-free diet. Thus,the study group was confined to 412 patients with self-reportedbiopsy-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% metmodified Rome I criteria for Irritable Bowel Syndrome. Of those 96patients, 76 patients, or nearly 80%, made an effort to get help, bothmedical and non-medical, as a result of the bowel symptoms (we’ll callthe patients who sought help "irritable bowel syndrome patients").
    Irritable bowel syndrome-like symptoms were shown to drive SFHS scores sharply downward. Mentalhealth disorders, being female, falling off the gluten-free dietall contributed to a greater likelihood of irritable bowel syndrome symptoms.
    Theresults of the study seem strengthen the bio-psychosocial model of irritable bowel syndrome, in which biological and psychological factorsare understood to affect the clinical manifestation of celiac disease.Under this model, irritable bowel syndrome-like symptoms in adults withceliac disease are understood through a combination of clinical andsocio-psychological mechanisms. This model leads doctors to anunderstanding of celiac disease and other gastro-intestinal ailmentsthat goes beyond simple biological or psychological factors alone, andlooks at factors like adverse life events, stress, and hypochondriasisamong others.
    Limited studies indicate that gender differencesin visceral perception, cardio-autonomic responses, gastrointestinalmotility, and brain activation patterns to visceral stimuli are afactor in irritable bowel syndrome. Gender differences in psychosocialfactors have not been fully studied.
    The results of this studyalso support the need for further investigation to determine exactly whatfactors contribute to the bio-psychosocial model of what is called’celiac irritable bowel syndrome.’
    Future psycho-physiologicalstudies in patients with celiac disease and irritable bowel syndromeshould look to determine if psychological discomfort can prolongmucosal inflammation, reduce visceral pain thresholds, or disturb gutmotility.
    In the event that the right psychotherapeutictreatment for irritable bowel syndrome-like symptoms and/or mentaldisorder serve to improve reduced HRQOL in adult patients with celiacdisease and irritable bowel syndrome-like symptoms, it might benecessary 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 bowelsyndrome-like symptoms in people with celiac disease, and that furtherstudy is needed to sort out all of the possibilities and determine ifthere might be better ways to treat celiac disease that will reduce oreliminate irritable bowel syndrome-like symptoms.
    Psychosomatic Medicine 69:370 –376 (2007)


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    Premium ingredients, bakeshop delicious recipes, and happy customers were our inspiration from the beginning— and are still the cornerstones of Bakery On Main today. We are a fiercely ethical company that believes in integrity and feels that happiness and wholesome, great tasting food should be harmonious. We strive for that in everything we bake in our dedicated gluten-free facility that is GFCO Certified and SQF Level 3 Certified. We use only natural, NON-GMO Project Verified ingredients and all of our products are certified Kosher Parve, dairy and casein free, and we have recently introduced certified Organic items as well! 
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    Source:
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