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• W2215281621 abstract "Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal (GI) disorder, characterized by abdominal pain or discomfort and altered bowel habit.1Longstreth G.F. Thompson W.G. Chey W.D. et al.Functional bowel disorders.Gastroenterology. 2006; 130: 1480-1491Abstract Full Text Full Text PDF PubMed Scopus (3911) Google Scholar Many patients with IBS also report troublesome bloating or visible abdominal distension. The condition affects between 5% and 20% of the population,2Lovell R.M. Ford A.C. Global prevalence of, and risk factors for, irritable bowel syndrome: a meta-analysis.Clin Gastroenterol Hepatol. 2012; 10: 712-721Abstract Full Text Full Text PDF PubMed Scopus (1308) Google Scholar depending on the criteria used to define its presence, and is more common in women and younger individuals.2Lovell R.M. Ford A.C. Global prevalence of, and risk factors for, irritable bowel syndrome: a meta-analysis.Clin Gastroenterol Hepatol. 2012; 10: 712-721Abstract Full Text Full Text PDF PubMed Scopus (1308) Google Scholar, 3Lovell R.M. Ford A.C. Effect of gender on prevalence of irritable bowel syndrome in the community: systematic review and meta-analysis.Am J Gastroenterol. 2012; 107: 991-1000Crossref PubMed Scopus (261) Google Scholar Although IBS is not a diagnosis of exclusion,4Ford A.C. Moayyedi P. Lacy B.E. et al.American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation.Am J Gastroenterol. 2014; 109: S2-S26Crossref PubMed Scopus (441) Google Scholar with physicians advised to minimize invasive investigations, the symptoms of IBS are not specific,5Ford A.C. Bercik P. Morgan D.G. et al.Validation of the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care.Gastroenterology. 2013; 145: 1262-1270Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar and may occur in several other organic GI conditions.6Sanders D.S. Carter M.J. Hurlstone D.P. et al.Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care.Lancet. 2001; 358: 1504-1508Abstract Full Text Full Text PDF PubMed Scopus (375) Google Scholar, 7Aziz I. Mumtaz S. Bholah H. et al.High prevalence of idiopathic bile acid diarrhea among patients with diarrhea-predominant irritable bowel syndrome based on Rome III criteria.Clin Gastroenterol Hepatol. 2015; 13: 1650-1655.e2Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 8Abboud R. Pardi D.S. Tremaine W.J. et al.Symptomatic overlap between microscopic colitis and irritable bowel syndrome: a prospective study.Inflamm Bowel Dis. 2013; 19: 550-553Crossref PubMed Scopus (39) Google Scholar Celiac disease is a chronic immune-mediated enteropathy characterized by T-cell sensitization to gluten in genetically predisposed individuals. The prevalence of a positive serologic test for celiac disease in US and European communities is estimated to be between 0.8% and 1.0%.9Katz K.D. Rashtak S. Lahr B.D. et al.Screening for celiac disease in a North American population: sequential serology and gastrointestinal symptoms.Am J Gastroenterol. 2011; 106: 1333-1339Crossref PubMed Scopus (117) Google Scholar, 10Mustalahti K. Catassi C. Reunanen A. et al.The prevalence of celiac disease in Europe: results of a centralized, international mass screening project.Ann Med. 2010; 42: 587-595Crossref PubMed Scopus (591) Google Scholar Patients with celiac disease can present with GI symptoms such as abdominal pain, bloating, and diarrhea. These symptoms may be overlooked, leading to mislabeling as IBS, and a delay until the diagnosis of celiac disease is established.11Canavan C. Card T. West J. The incidence of other gastroenterological disease following diagnosis of irritable bowel syndrome in the UK: a cohort study.PLoS One. 2014; 9: e106478Crossref PubMed Scopus (37) Google Scholar It is important to distinguish between IBS and celiac disease because the treatments are quite different. Patients with celiac disease are advised to adhere to a lifelong gluten-free diet, whereas patients with IBS usually are treated symptomatically, often using pharmacologic or psychological therapies aimed at providing relief of the predominant symptom reported.4Ford A.C. Moayyedi P. Lacy B.E. et al.American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation.Am J Gastroenterol. 2014; 109: S2-S26Crossref PubMed Scopus (441) Google Scholar, 12Palsson O.S. Whitehead W.E. Psychological treatments in functional gastrointestinal disorders: a primer for the gastroenterologist.Clin Gastroenterol Hepatol. 2013; 11: 208-216Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar Some studies have shown that patients who report symptoms compatible with IBS are more likely to have a positive celiac serology, and biopsy-proven celiac disease, than controls without such symptoms.6Sanders D.S. Carter M.J. Hurlstone D.P. et al.Association of adult coeliac disease with irritable bowel syndrome: a case-control study in patients fulfilling ROME II criteria referred to secondary care.Lancet. 2001; 358: 1504-1508Abstract Full Text Full Text PDF PubMed Scopus (375) Google Scholar, 13Sanders D.S. Patel D. Stephenson T.J. et al.A primary care cross-sectional study of undiagnosed coeliac disease.Eur J Gastroenterol Hepatol. 2003; 15: 407-413Crossref PubMed Scopus (227) Google Scholar A previous meta-analysis of observational studies showed a pooled prevalence of biopsy-proven celiac disease in suspected IBS of 4.1% (95% confidence interval, 1.9%–7.0%), and a 4-fold increase in the odds of biopsy-proven celiac disease compared with people without IBS-type symptoms.14Ford A.C. Chey W.D. Talley N.J. et al.Yield of diagnostic tests for celiac disease in subjects with symptoms suggestive of irritable bowel syndrome: systematic review and meta-analysis.Arch Intern Med. 2009; 169: 651-658Crossref PubMed Scopus (204) Google Scholar An economic analysis, conducted from a US perspective, suggested that testing patients with suspected IBS became cost effective when the prevalence of celiac disease exceeded 8%,15Spiegel B.M.R. DeRosa V.P. Gralnek I.M. et al.Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis.Gastroenterology. 2004; 126: 1721-1732Abstract Full Text Full Text PDF PubMed Scopus (140) Google Scholar close to the upper limit of the estimated prevalence of biopsy-proven celiac disease in individuals meeting criteria for IBS in the meta-analysis. Partly as a result of these findings, current guidelines for the management of celiac disease advise physicians to screen patients who present with IBS-type symptoms routinely via serologic testing.16Rubio-Tapia A. Hill I.D. Kelly C.P. et al.ACG clinical guidelines: diagnosis and management of celiac disease.Am J Gastroenterol. 2013; 108: 656-676Crossref PubMed Scopus (1164) Google Scholar, 17Ludvigsson J.F. Bai J.C. Biagi F. et al.Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology.Gut. 2014; 63: 1210-1228Crossref PubMed Scopus (724) Google Scholar In this issue of Clinical Gastroenterology and Hepatology, Choung et al,18Choung R.S. Rubio-Tapia A. Lahr B.D. et al.Evidence against routine testing of patients with functional gastrointestinal disorders for celiac disease: a population-based study.Clin Gastroenterol Hepatol. 2015; 13: 1937-1943PubMed Google Scholar reported data from Olmsted County, Minnesota, that at first appear to question the utility of this approach. The investigators conducted a cross-sectional questionnaire survey of 7217 residents in the community, collecting data on symptoms compatible with functional GI disorders, including IBS. These symptom data were linked to prevalence surveys of undiagnosed celiac disease conducted among more than 47,000 individuals within the same region, using immunoglobulin A tissue transglutaminase, followed by confirmatory endomysial antibody testing in those with a positive tissue transglutaminase. There were 3196 subjects whose data were available from both studies, of whom 434 (13.6%) had IBS according to the questionnaire used. In total, 31 (1%) individuals were seropositive for celiac disease, but only 1 (3%) individual met the criteria for IBS, compared with 433 (14%) of those with negative celiac serology. This suggests that the yield of testing people reporting symptoms compatible with IBS is low. However, of note is that subjects were no more likely to report other GI symptoms believed to be typical presenting features of celiac disease than those without. These included abdominal pain (19% in those testing seropositive vs 25% in those who were seronegative), diarrhea (3% vs 9%), bloating (5% vs 23%), or abdominal distension (0% vs 14%), and seropositive individuals also were less likely to report any GI symptom (45% vs 55%). The strength of this study, conducted among the general population in the United States, is also one of its inherent weaknesses. Prevalence studies of this type, which examine the epidemiology of functional GI symptoms, work on the premise that the prevalence of true organic disease in individuals reporting GI symptoms in the community is low, so it is perhaps no great surprise that only 1 person with IBS-type symptoms tested seropositive. In addition, current guidelines do not recommend screening people with symptoms compatible with IBS in the general population for celiac disease, regardless of whether they have consulted a physician. The studies on which these guidelines based their recommendations were, for the most part, conducted among patients presenting with GI symptoms. An issue that remains unclear is the temporal relationship between symptoms and the dates that serologic samples were obtained. It is well known that GI symptoms in the community fluctuate,19Ford A.C. Forman D. Bailey A.G. et al.Fluctuation of gastrointestinal symptoms in the community: a 10-year longitudinal follow-up study.Aliment Pharmacol Ther. 2008; 28: 1013-1020Crossref PubMed Scopus (47) Google Scholar however, the time point at which people were reporting symptoms compatible with IBS and the time point at which they returned a positive serologic test is unclear. In addition, individuals with celiac disease diagnosed around the time the serum samples were drawn were excluded from the analysis. It would be useful to know how many individuals’ data were excluded on this basis because, if these subjects were reporting symptoms compatible with IBS at the point the diagnosis of celiac disease was secured, the results of the study could change. Finally, the mean age of included individuals at the time of the survey was 61 years. Celiac disease has a bimodal age distribution and, in the United States, IBS is more common in younger individuals.20Hungin A.P.S. Whorwell P.J. Tack J. et al.The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40 000 subjects.Aliment Pharmacol Ther. 2003; 17: 643-650Crossref PubMed Scopus (624) Google Scholar A previous large study conducted in a US referral population showed a similarly low prevalence of biopsy-proven celiac disease of 0.4% in 492 patients with nonconstipated IBS,21Cash B.D. Rubenstein J.H. Young P.E. et al.The prevalence of celiac disease among patients with nonconstipated irritable bowel syndrome is similar to controls.Am J Gastroenterol. 2011; 141: 1187-1193Scopus (98) Google Scholar questioning the value of opportunistic screening even in patients presenting with suspected IBS in the United States. The well-designed and rigorous study conducted by Choung et al18Choung R.S. Rubio-Tapia A. Lahr B.D. et al.Evidence against routine testing of patients with functional gastrointestinal disorders for celiac disease: a population-based study.Clin Gastroenterol Hepatol. 2015; 13: 1937-1943PubMed Google Scholar showed a low yield of testing individuals reporting symptoms compatible with IBS in the community for celiac disease, leading them to conclude, justifiably, that testing in this setting is unlikely to have a significantly increased yield over population-based screening. However, it should not lead to a change in recommendations for practice in either primary or secondary care in other countries. Evidence Against Routine Testing of Patients With Functional Gastrointestinal Disorders for Celiac Disease: A Population-based StudyClinical Gastroenterology and HepatologyVol. 13Issue 11PreviewCeliac disease has been linked to irritable bowel syndrome (IBS)–like symptoms in outpatient clinics. Guidelines recommend that all patients with IBS-like symptoms undergo serologic testing for celiac disease, but there is controversy over whether celiac disease is more prevalent in populations with IBS-like symptoms. We aimed to determine whether positive results from serologic tests for celiac disease are associated with IBS and other functional gastrointestinal disorders (FGIDs) in a large U.S. Full-Text PDF" @default.
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• W2215281621 title "Is it Time to Rethink Screening of Individuals With Symptoms of Irritable Bowel Syndrome for Celiac Disease?" @default.
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