Factors Predicting Whom to Screen for Coeliac Disease in Patients with Diarrhoea Predominant Irritable Bowel Syndrome in Developing Countries

Abstract

AIM: Screen all patients with irritable bowel syndromediarrhoea (IBS-D) for coeliac disease (CD) is no cost effective strategy in developing countries. So we planned this study to look for the clinical features and laboratory parameters useful to screen the patients of IBS-D for CD. Methods:We prospectively analyzed this retrospectively maintained data of 198 patients with chronic diarrhoea. IgA anti endomysial antibodies (EMA) and IgA were done in all patients and oesophagogastroduodenoscopy was done in patients with positive EMA (>40units/ml) and wherever indicated. Based on results of EMA, duodenal biopsy with or without HLADQ2or 8, we divided patients in to two groups (CD group and IBS-D group).We then analyzed clinical features and laboratory parameters by univariate and multivariate analysis, to look for the features more suggestive of CD.Results: Of 198 patients, 98 were diagnosed to have CD and of remaining 100 patients 78 patients had IBS-D. Multivariate analysis revealed duration of symptoms more than 6 months , iron deficiency anaemia(IDA), hemoglobin(Hb) less than 10gm/dl, presence of bone pains and transaminasemia (alanine aminotransferase more than 40mu/ml) to be statistically significant and suggestive of CD. Conclusion:Patient with chronic diarrhoea, who has any one or more of the following features like duration of symptoms more than 6 months, IDA, Hb less than 10gm/dl, bone pains and transaminasemia, should be screened for CD. .Individuals with IBS-D report abdominal pain, bloating, and diarrhoea, symptoms similar to those in CD. IBS-D is a diagnosis of exclusion and current professional society guidelines recommend performing a limited battery of tests to exclude common organic diseases masquerading as IBS [2]. Studies suggest that the prevalence of CD is increased in individuals with IBS; however, evidence is conflicting, and current guidelines do not always recommend screening for CD in these individuals. Prevalence of biopsy-proved CD in cases meeting diagnostic criteria for IBS was more than 4-fold that in controls without IBS [3].With data showing that patients with IBS-D may benefit from gluten free diet (GFD), GFD is used with increasing frequency in IBS-D patients [4][5][6]. Although there is little harm beyond cost to a patient on a balanced GFD,CD may be overlooked and complications ignored. So should panels of serologic studies for CD be more widely used in IBS-D patients? The widespread use of panels would not be cost-effective as first-line testing; although it may slightly improve overall sensitivity, it reduces specificity, leading to unnecessary endoscopy [7].We planned this study to look for the clinical features and laboratory parameters which can determine who should be screened for CD and referred for small bowel biopsy in patients presenting with diarrhoea and help to differentiate between CD and non CD aetiology like IBS-D. Materials and MethodsWe retrospectively analyzed prospectively maintained data of 198 consecutive patients attending the Gastroenterology clin...