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Gender and Mental Health are Factors in Irritable Bowel Disease-related Symptoms in Celiac Disease 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.

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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) welcomes your comments below (registration is NOT required).

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8 Responses:

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said this on
07 May 2008 4:41:08 AM PDT
Many of us have found that other foods are producing IBS. There is no mention of whether the study looked at whether the folks who continued to have IBS symptoms were assessed to find out if perhaps casien or soy might be a factor in the continued discomfort. There is also the assumption among most medical professionals that things that are put onto the skin, such as shampoos and lotions etc. are safe no matter what is in them. How many of the study group were still using gluten containing personal care products?
Also many of us suffer needlessly because our medications are a gluten source. Many trust pharms and their doctors to know if something is safe and as a result have long standing contamination from items such as supplements, over the counter meds, prescrition meds, wheat germ oils, alcohol and vinager and other items that are thought to be safe that in the reality are not.
For folks that have neuro impact in the celiac spectrum of disease adherence to a gluten free diet is often not enough to stop the autoimmune process that is inflaming the brain and blood. They need to avoid the items that many of us are taught are 'safe by processing'. Many who continue to have issues will achieve resolution by ferreting out the other items we are forming antibodies to and becoming zero tolerance strict with the gluten-free diet. Something doctors don't seem to think many of us can do.
IBS is not a diagnosis, it is a symptom. Unfortunately in our pharmadriven society there is too much of a rush to label and not enough time spent looking for the cause of the symptom.
It is unfortunate that many doctors and researchers seem to ignore that the impact of your body fighting a substance that it considers poison can result in neuro impact. The depression and anxiety are too often a symptom and not a cause. The rush to medicate folks for depression rather than find the physical trigger for it keeps many of us suffering for years.

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said this on
12 May 2008 12:51:49 AM PDT
People with Celiac may have other food intolerance, and food allergies. They can cause GI problems, if ingested. Doctors usually ignore this fact, and push mind altering drugs on people who don't need them. I have been allergic to corn all of my life, as well as other foods and sulfites. If I accidentally eat any of them, because they are not properly labeled in food products, I get sick. Mind control drugs would not help. Avoidance of the problem food is the only thing that does help. This is not rocket science, but is ignored by doctors.

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said this on
12 May 2008 9:59:49 AM PDT
Interesting, but no one has proven that the link mentioned in the article is a causative one. It seems almost useless to include 'anxiety' and 'depression' as mental health disorders when they are also common characteristics of people who are sick and have not been diagnosed or helped yet. Has anyone conducted a study yet to find out how often 'anxiety' and 'depression' are present in people with undiagnosed illnesses? Would be hard to construct - but a good contribution to science.

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said this on
12 May 2008 6:47:33 PM PDT
Gluten and/ or lactose intolerance in infants would cause extreme pain and untreated would lead to helpless or dissociative reactions which would lead to parents responding less lovingly and more fearfully. Allergies treated with dulling antihistamines would also lead to maladaptive cognitive functioning and, without sharpness and persistence, it is VERY DIFFICULT to get a doctor to look into intestinal symptoms, fogginess, etc. I shudder to think how many 'mental problems' started out as reactions to abuse and gluten abuses us without visible bruises. Think of the 'shame' of gaseousness and how a child might feel in school. Combine IBS symptoms with periods and having to sit still for 8 hours. I could go on and on. Pain starts the cycle.

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said this on
13 May 2008 8:13:38 AM PDT
After my daughter went on a gluten-free diet she improved immensely; however within six months she was having stomach problems again. Her pediatrician said it was IBS. We followed the recommendations for this condition, but it was soon apparent this was not helping. Thank God for a Naturopath Doctor who identified other food allergies that were upsetting her intestines (soy, milk, eggs). When these were eliminated, she was a happy gal again.

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said this on
14 May 2008 8:43:07 PM PDT
There is legitimacy to the issues raised in this article. I propose inhaled dermatitis or irritable bowel triggered by handling gluten items - I own a restaurant and exposure to large amounts of gluten has sent me home with a stomach ache and skin rash.

g harrison
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said this on
23 May 2008 7:57:33 AM PDT
I was almost convinced that I was a hypochondriac until I discovered it was gluten that was causing the multitude of symptoms that had afflicted me for over 25 years. When doctors don't have an answer, they make you feel as though you are inventing the problem. May be they don't listen to females or take them seriously and attribute their continued symptoms of IBS as female traits or manifestations of mental illness instead of recognizing their own biases have led to the demographics of the statistics in the first place. What drug company funded this study?

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said this on
26 Sep 2010 8:05:34 AM PDT
Women always lose out. That's why I try not to listen to my male doctors. I'm sick but I'll continue to search for the real answer. I wish men realized we are not inventing these symptoms. Women simply suffer more than men. Thanks for the encouraging article.

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I'm in the Houston area so I'm assuming there are plenty of specialists around, though finding one that accepts my insurance might be hard. This might sound dumb, but do I search for a celiac specialist?? I'm so new to this and want to feel confident in what is/isn't wrong with my daughter. I'm with you on trusting the specialist to know the current research.

Hi VB Thats sounds like a good plan. Would it help to know that a frustrating experience in seeking diagnosis isn't unusual With your IGG result I'm sure a part of you is still wondering if they are right to exclude celiac. I know just how you feel as I too had a negative biopsy, but by then a gluten challenge had already established how severely it affected me. So I was convinced I would be found to be celiac and in a funny way disappointed not to get the 'official' stamp of approval. Testing isnt perfect, you've already learned of the incomplete celiac tests offered by some organisations and the biopsy itself can only see so much. If you react positively to the gluten free diet it may mean you're celiac but not yet showing damage in a place they've checked, or it may be that you're non celiac gluten sensitive, which is a label that for a different but perhaps related condition which has only recently been recognised and for which research is still very much underway. We may not be able to say which but the good news is all of your symptoms: were also mine and they all resolved with the gluten free diet. So don't despair, you may still have found your answer, it just may be a bit wordier than celiac! Keep a journal when you're on the diet, it may help you track down your own answers. Best of luck!

Run to the nearest celiac disease specialty center if you can. Especially with conflicting doc opinions. Where do you live? Honestly, I test positive to only the DGP and the newest research on its specificity is a mixed bag. My recent scope did not show "active" celiac disease but only a slight increase in IELs. I am waiting for my post biopsy appointment with the Celiac specialist next month. But I've been through a couple of GI'S locally and honestly I feel it was definitely worth going to a specialist. Especially when you have some positive blood work but a normal biopsy the doctors really go back and Forth on diagnosis and never really know for certain. Unfortunately given the above I just said I probably still do not know for certain. Sigh. But I trust the specialist to be at the top of his game on the research and at least I can feel confident and comfortable in what his opinion may be next month.

That's a great list with such great info! Do you eat at Shucks?

I just got a call from the Kaiser GI department. The doctor who performed the endoscopy was supposed to call me with the results and instead the receptionist did. She said "Dr. X says your biopsy was normal and you do not have celiac disease." Word for word, that's it! So not only did I not get to talk to her the day of my procedure, but not at all! They are printing copy of the biopsy pathology report for me and I'll get it tomorrow. I want to see if it says how many samples they took. At this point, I still feel like crap, still have symptoms and I'm going to try a gluten-free diet to see how I improve, get blood tests again eventually.