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• W4243860414 abstract "David Sanders and colleagues (Nov 3, p 1504)1Sanders DS Carter MJ Hurlstone DP 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: 1504-1508Summary Full Text Full Text PDF PubMed Scopus (371) Google Scholar report that 14 of 300 secondary-care patients fulfilling the ROME II criteria for irritable bowel syndrome (IBS) had coeliac disease. Their data provoke many questions to be considered before their conclusions can be accepted.The ROME II criteria were never meant to be used in the absence of clinical judgment. Used wisely, they can help guide physicians to a positive diagnosis. They cannot replace the complex amalgam of skill, learning, care, and intuition that should characterise clinical practice. The criteria are accompanied by exhortation to take a careful history, do a physical examination, and specifically to look for alarm symptoms that could suggest structural disease.2Thompson WG Longstreth GF Drossman DA Heaton KW Irvine EJ Muller-Lissner SA Functional bowel disorders and D functional abdominal pain.in: Drossman DA Coraniari E Talley NJ Thompson WG Whitehead WE The functional gastrointestinal disorders. 2nd edn. Degnon, Washington2000Google Scholar Sanders and colleagues mention sinister symptoms as exclusion criteria, but can we be sure they were absent in patients who were diagnosed as having coeliac disease? When asked about the ROME criteria were patients also specifically asked about continuous diarrhoea, weight loss, nutritional defects, family history, and so on? Did they have characteristics that might help doctors identify IBS patients at risk for coeliac disease?Duodenal histology characteristic of coeliac disease does not necessarily negate a diagnosis of IBS. Did the IBS symptoms vanish on a gluten-free diet? In their table 1, Sanders and colleagues show data suggesting that 26% of ROME-II-positive patients have disorders other than IBS, but is that true? 6% were lost to follow-up, 5% had diverticular disease—surely not a cause of ROME II symptoms3Thompson WG Patel DG Clinical picture of diverticular disease of the colon.Clin Gastroenterol. 1986; 16: 903-916Google Scholar—and many of the remaining disorders, such as infective enteritis, alcoholic diarrhoea, radiation enteritis, and IBS should have been clinically suspected by a careful doctor. How old were the patients with rectal carcinoma or colon polyps? Would they not have been picked up routinely on colon examination that the researchers say is normally done in patients older than 45 years and is recommended by ROME? Do the researchers think the polyps caused the IBS symptoms?Sanders and colleagues are correct to raise our sensitivity to coeliac disease, and their advocacy for early diagnosis is convincing. However, in addition to omission of clinical clues, there are two important issues that they do not discuss. IBS is the most common disorder seen in gastrointestinal clinics worldwide. What would be the cost of implementing their suggestion that a panel of immunological tests be part of an IBS work-up? Do they think that ROME III should add a negative result with such tests as a criterion for IBS?Perhaps the most important issue is the implication that recommendations for automatic testing could return us to the bad old days when IBS was deemed a diagnosis of exclusion. This attitude is damaging. No test or set of diagnostic criteria is infallible. Every patient deserves careful consideration of their complaints, and neither rote application of ROME II nor immunological tests for coeliac disease will serve. If they did, gastroenterologists could be replaced by computers and save a great deal of money—more than enough for the immunological tests. David Sanders and colleagues (Nov 3, p 1504)1Sanders DS Carter MJ Hurlstone DP 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: 1504-1508Summary Full Text Full Text PDF PubMed Scopus (371) Google Scholar report that 14 of 300 secondary-care patients fulfilling the ROME II criteria for irritable bowel syndrome (IBS) had coeliac disease. Their data provoke many questions to be considered before their conclusions can be accepted. The ROME II criteria were never meant to be used in the absence of clinical judgment. Used wisely, they can help guide physicians to a positive diagnosis. They cannot replace the complex amalgam of skill, learning, care, and intuition that should characterise clinical practice. The criteria are accompanied by exhortation to take a careful history, do a physical examination, and specifically to look for alarm symptoms that could suggest structural disease.2Thompson WG Longstreth GF Drossman DA Heaton KW Irvine EJ Muller-Lissner SA Functional bowel disorders and D functional abdominal pain.in: Drossman DA Coraniari E Talley NJ Thompson WG Whitehead WE The functional gastrointestinal disorders. 2nd edn. Degnon, Washington2000Google Scholar Sanders and colleagues mention sinister symptoms as exclusion criteria, but can we be sure they were absent in patients who were diagnosed as having coeliac disease? When asked about the ROME criteria were patients also specifically asked about continuous diarrhoea, weight loss, nutritional defects, family history, and so on? Did they have characteristics that might help doctors identify IBS patients at risk for coeliac disease? Duodenal histology characteristic of coeliac disease does not necessarily negate a diagnosis of IBS. Did the IBS symptoms vanish on a gluten-free diet? In their table 1, Sanders and colleagues show data suggesting that 26% of ROME-II-positive patients have disorders other than IBS, but is that true? 6% were lost to follow-up, 5% had diverticular disease—surely not a cause of ROME II symptoms3Thompson WG Patel DG Clinical picture of diverticular disease of the colon.Clin Gastroenterol. 1986; 16: 903-916Google Scholar—and many of the remaining disorders, such as infective enteritis, alcoholic diarrhoea, radiation enteritis, and IBS should have been clinically suspected by a careful doctor. How old were the patients with rectal carcinoma or colon polyps? Would they not have been picked up routinely on colon examination that the researchers say is normally done in patients older than 45 years and is recommended by ROME? Do the researchers think the polyps caused the IBS symptoms? Sanders and colleagues are correct to raise our sensitivity to coeliac disease, and their advocacy for early diagnosis is convincing. However, in addition to omission of clinical clues, there are two important issues that they do not discuss. IBS is the most common disorder seen in gastrointestinal clinics worldwide. What would be the cost of implementing their suggestion that a panel of immunological tests be part of an IBS work-up? Do they think that ROME III should add a negative result with such tests as a criterion for IBS? Perhaps the most important issue is the implication that recommendations for automatic testing could return us to the bad old days when IBS was deemed a diagnosis of exclusion. This attitude is damaging. No test or set of diagnostic criteria is infallible. Every patient deserves careful consideration of their complaints, and neither rote application of ROME II nor immunological tests for coeliac disease will serve. If they did, gastroenterologists could be replaced by computers and save a great deal of money—more than enough for the immunological tests." @default.
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• W4243860414 title "Irritable bowel syndrome and coeliac disease" @default.
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