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Broadening the Differential Diagnosis from a Different Perspective
The American Journal of Medicine (2007) 120, e13
LETTER Broadening the Differential Diagnosis from a Different Perspective To the Editor: Although not included in the disease associations mentioned by the author,1 celiac disease may be associated with inflammatory bowel disease (IBD) to a degree that is perhaps greater than can be ascribed to pure chance.2 In the event of such an association, there is the potential for coexisting celiac disease to be overlooked or for one of the presenting symptoms, such as diarrhea, to be misattributed to celiac disease or IBD. Misattribution also can occur when the presenting symptom is abdominal pain, given the fact that this is a symptom common to both celiac disease and Crohn’s disease,3,4 and, for the same reason, in the event of a presentation characterized by hematinic deficiencies.1,5-7 Supporting evidence for the association of celiac disease and IBD comes from a study that compared the prevalence of IBD in a cohort of 455 patients with celiac disease with the prevalence of IBD in the US population. This yielded an age- and sex-adjusted prevalence ratio of 8.49 (95% confidence interval, 3.53-20.42) for Crohn’s disease and 3.56 (95% confidence interval, 1.48-8.56) for ulcerative colitis.2 Among first-degree relatives of patients with celiac disease, there also seems to be an increased risk of IBD; the relative risk of ulcerative colitis, in particular, is 5 times higher in these patients than for the general population.8 The association also has prognostic implications, as shown in a study in which the coexistence of celiac disease and IBD conferred a higher mortality risk (attributable to
0002-9343/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
small bowel cancer and non-Hodgkin lymphoma, respectively) in those with the association than in those without the association.9 Oscar M. Jolobe, MRCP(UK) (retired geriatrician) Manchester Medical Society Manchester, United Kingdom
doi:10.1016/j.amjmed.2006.09.026
References 1. Rajendra A, Perepletchikov A, Kopelman RI. Broadening the differential diagnosis. Am J Med. 2006;119:410-412. 2. Yang A, Chen Y, Scherl E, et al. Inflammatory bowel disease in patients with celiac disease. Inflamm Bowel Dis. 2005;11:528-532. 3. Cooke T, Peeney ALP, Hawkins CF. Symptoms, signs, and diagnostic features of idiopathic steatorrhoea. Q J Med. 1953;XXII:59-77. 4. Glickman RM. Inflammatory bowel disease: ulcerative colitis and Crohn’s disease. In: Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison’s Principles of Internal Medicine, 14th Edition, Chapter 286. New York, St Louis, San Francisco: McGraw-Hill; 1998;1633-1645. 5. Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology. 2004;126:643-653. 6. Chowers Y, Sela B-A, Holland R, et al. Increased levels of homocysteine in patients with Crohn’s disease are related to folate levels. Am J Gastroenterol. 2000;96:3498-3502. 7. Dickey W. Low serum B12 is common in celiac disease and is not due to autoimmune gastritis. Eur J Gastroenterol Hepatol. 2002;14:425427. 8. Shah A, Mayberry JF, Williams G, et al. Epidemiological survey of celiac disease and inflammatory bowel disease in first degree relatives of coeliac patients. Q J Med. 1953;74(275):283-288. 9. Peters U, Askling J, Gridley G, et al. Causes of death in patients with celiac disease in a population-based Swedish Cohort. Arch Intern Med. 2003;163:1566-1572.
LETTER Broadening the Differential Diagnosis from a Different Perspective To the Editor: Although not included in the disease associations mentioned by the author,1 celiac disease may be associated with inflammatory bowel disease (IBD) to a degree that is perhaps greater than can be ascribed to pure chance.2 In the event of such an association, there is the potential for coexisting celiac disease to be overlooked or for one of the presenting symptoms, such as diarrhea, to be misattributed to celiac disease or IBD. Misattribution also can occur when the presenting symptom is abdominal pain, given the fact that this is a symptom common to both celiac disease and Crohn’s disease,3,4 and, for the same reason, in the event of a presentation characterized by hematinic deficiencies.1,5-7 Supporting evidence for the association of celiac disease and IBD comes from a study that compared the prevalence of IBD in a cohort of 455 patients with celiac disease with the prevalence of IBD in the US population. This yielded an age- and sex-adjusted prevalence ratio of 8.49 (95% confidence interval, 3.53-20.42) for Crohn’s disease and 3.56 (95% confidence interval, 1.48-8.56) for ulcerative colitis.2 Among first-degree relatives of patients with celiac disease, there also seems to be an increased risk of IBD; the relative risk of ulcerative colitis, in particular, is 5 times higher in these patients than for the general population.8 The association also has prognostic implications, as shown in a study in which the coexistence of celiac disease and IBD conferred a higher mortality risk (attributable to
0002-9343/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
small bowel cancer and non-Hodgkin lymphoma, respectively) in those with the association than in those without the association.9 Oscar M. Jolobe, MRCP(UK) (retired geriatrician) Manchester Medical Society Manchester, United Kingdom
doi:10.1016/j.amjmed.2006.09.026
References 1. Rajendra A, Perepletchikov A, Kopelman RI. Broadening the differential diagnosis. Am J Med. 2006;119:410-412. 2. Yang A, Chen Y, Scherl E, et al. Inflammatory bowel disease in patients with celiac disease. Inflamm Bowel Dis. 2005;11:528-532. 3. Cooke T, Peeney ALP, Hawkins CF. Symptoms, signs, and diagnostic features of idiopathic steatorrhoea. Q J Med. 1953;XXII:59-77. 4. Glickman RM. Inflammatory bowel disease: ulcerative colitis and Crohn’s disease. In: Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison’s Principles of Internal Medicine, 14th Edition, Chapter 286. New York, St Louis, San Francisco: McGraw-Hill; 1998;1633-1645. 5. Pennazio M, Santucci R, Rondonotti E, et al. Outcome of patients with obscure gastrointestinal bleeding after capsule endoscopy: report of 100 consecutive cases. Gastroenterology. 2004;126:643-653. 6. Chowers Y, Sela B-A, Holland R, et al. Increased levels of homocysteine in patients with Crohn’s disease are related to folate levels. Am J Gastroenterol. 2000;96:3498-3502. 7. Dickey W. Low serum B12 is common in celiac disease and is not due to autoimmune gastritis. Eur J Gastroenterol Hepatol. 2002;14:425427. 8. Shah A, Mayberry JF, Williams G, et al. Epidemiological survey of celiac disease and inflammatory bowel disease in first degree relatives of coeliac patients. Q J Med. 1953;74(275):283-288. 9. Peters U, Askling J, Gridley G, et al. Causes of death in patients with celiac disease in a population-based Swedish Cohort. Arch Intern Med. 2003;163:1566-1572.