MEDSCAPE: THE IMPORTANCE OF BEING VIGILANT

Two recent items on Medscape underscore the value of sustained vigilance when it comes to identifying cases of celiac disease—even in people who have previously tested negative for the condition. And one of the articles can be viewed as also illustrating how symptoms that might be assumed to be reactions to "hidden" gluten by a gluten-free person with celiac disease might actually be due to another medical condition such as ulcerative colitis, with no "hidden" gluten involved.

A gluten-free diet can help protect people with celiac disease against cancer, according to an Italian paper, published in BioMedCentral Gastroenterology (September 2007) and available on Medscape, that encourages doctors of adults diagnosed with celiac disease to be on the lookout for tumors. So the nearly two million Americans estimated to have undiagnosed celiac disease may well be at an increasing risk for malignancies—especially gastro-intestinal cancer.

The study includes the following statements, verbatim:

Coeliac patients have an increased risk of developing cancer in relation to the age of diagnosis of CD. This risk results higher for malignancies of the gastro-intestinal sites. An accurate screening for tumors should be performed in patients diagnosed with CD in adulthood and in advancing age.

This paper confirms that the gluten-free diet is likely to protect from the development of malignancies in CD patients, since higher is the age at diagnosis of CD, higher is the risk of developing a malignancy, Therefore, the importance of a prompt diagnosis of CD is emphasized. Our data require to be confirmed by larger population based studies, but some implications for an accurate screening for cancers in people with CD are added.

Another recent Medscape item is a case study about a 65-year-old woman who tested negative for celiac disease and received a diagnosis of diverticulosis, then several years later tested positive for celiac disease and showed improvement on a gluten-free diet, then suffered diarrhea that eventually led to an additional diagnosis of ulcerative colitis.

The case study—written by William Dickey, entitled "A Case of Sequential Development of Celiac Disease and Ulcerative Colitis," and published in Nature Clinical Practice: Gastroenterology & Hepatology (Volume 4, Number 8)—offers the following conclusions:

Patients can develop, or present with, celiac disease at any stage in life. Previous negative test results do not preclude the diagnosis of celiac disease at a later date. The possibility of additional pathology should be considered, particularly in older patients whose symptoms fail to respond, or who later relapse, despite the exclusion of gluten from their diet. Diarrhea and anemia, in particular, should prompt colonoscopy. In patients with celiac disease there is an increased prevalence of not only microscopic colitis, but also ulcerative colitis and Crohn's disease.

The article advises that "Colonoscopy should, therefore, be part of the initial work-up in patients who are 40 years of age or older who present with iron-deficiency anemia or diarrhea, even if initial tests indicate celiac disease."