celiac disease in kids with irritable bowel syndrome

article in jama pediatrics looked at kids with functional GI disease and assessed the incidence of concomitant celiac disease (see irritable bowel dz in kids and celiac dz jama peds 2014 in dropbox, or doi:10.1001/jamapediatrics.2013.4984). background is that approx 1% of US population has celiac disease (often asymptomatic). adults with IBS have approx 4-fold increased prevalence of celiac disease. the present study is a 6-year prospective cohort study in Italy, where prior large epidemiologic studies have found celiac disease prevalence to be in the 0.5-1% range. 992 kids (43% male, median age 6.8y) referred by their primary care MD for recurrent abdominal pain, 782 of whom had diagnosis of IBS, functional dyspepsia, functional abdominal pain, or abdominal migraine by Rome III criteria. these kids were then assessed for celiac disease, with total IgA, IgA tissue transglutaminase antibody, and endomysial antibodies, then duodenal bx if positive.  results for these 992 children:

    --270 had IBS, of whom 12 tested positive for celiac disease = 4.4%
    --201 had functional dyspepsia, of whom 2 tested positive for celiac disease = 1%
    --311 had functional abdominal pain, of whom 1 tested positive for celiac disease = 0.3%
    --210 were excluded from this study because they had some "organic disorder", mostly GERD, gastritis, lactose intolerance
    --of note, there was no difference in wt, ht, iron levels, ferritin, albumin, hemoglobin, or ALT in those diagnosed with celiac disease vs those without the diagnosis 

so, recurrent abdominal pain is common (10-15% of school-aged children). one could argue, as the editorialists do, that those who meet criteria for IBS are at high enough risk (4% range) that they should be tested for celiac disease (at the 1% prevalence rate and given the sens and specificity of the serum tests, there would be a 68% false positive rate for celiac disease, suggesting that universal testing is not useful. at the 4.4% prevalence rate, 32% would be false positive). in fact NICE (natl institute for health and clinical excellence in the UK) does recommend celiac testing on all patients meeting criteria for IBS. there are some advantages to an earlier diagnosis (avoiding osteopenia, short stature, delayed puberty, infertility, intestinal lymphoma) in later life, so it seems reasonable to me to test kids and adults with IBS.

fyi, full set of Rome III diagnostic criteria for functional GI disorders -- see GI rome criteria for functional syndromes in dropbox, or URL: http://www.romecriteria.org/assets/pdf/19_RomeIII_apA_885-898.pdf .

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