1. Prevalence of Coeliac Disease in Adult Saudi Patients with
Symptoms of Irritable Bowel Syndrome; pilot study.
Shendy M. Shendy* and Nihal Al-Assaly** , Naema I. El-Ashry**.
*Tropical, Hepatology and gastroenterology department, **Clinical biochemistry dep,
Theodor Bilharz research Institute.
-Accepted for publication in Journal of Arab Society for Medical Research (JASMR), 29-
12- 2006
Abstract:
Few recent studies have found higher prevalence of coeliac disease among patients with diagnosis of
irritable bowel syndrome (IBS) than general population (3-11% vs. 0.2-0.6%). Similar studies showed
that coeliac disease is as common in Middle Eastern countries as in Europe; in both the general
population and at-risk groups. The aim of this work is to estimate the prevalence and the potential
clinical consequences of coeliac disease testing in adult Saudi patients with IBS. Materials and
methods: This is a prospective pilot study including 320 Arab patients with features compatible with IBS
as defined by Rome III criteria without any other co-morbidity. The age of patients ranged between18-70
years. All patients were subjected to good history taking, clinical examination, and some investigations if
needed such as stool, urine, CBC, liver enzymes, kidney function tests, ECG, electrolytes, H pylori
serology, upper and lower endoscopy when indicated. Those diagnosed as having persistent criteria of
IBS were tested for coeliac disease by IgA and IgG anti-gliadin antibodies, anti endomysial antibodies
(EMA) IgA and anti-TG2 (IgA and IgG). Upper endoscopy and duodenal biopsies were done and gluten
free diet was implemented for only those with positive serological test. The same tests were repeated after
period of about 6 months. Results: Anti-gliadin antibodies were found positive in 15/320(4.69%) patients
(14 with IgA and 13 IgG), EMA IgA in 13/320 (4.06%), anti-TG2 IgA in 12/320 (3.76%) and anti- TG2
IgG in 13/320 (4.06%). Abdominal pain, diarrhea, dyspepsia, postprandial distress, epigastric pain,
distension and chronic diarrhea were significantly higher and more common in combinations in those
with positive serology in comparison to serologically negative patients (P < 0.05). Haemoglobin level,
serum iron, albumin and calcium were found to be significantly lower in those with positive serology in
comparison to serologically negative patients (P < 0.05). All these parameters improved significantly
after gluten free died (GFD) for about 6 months (P< 0.05). Only 11 patients (74.44% of those with
positive serology and 3.49% of total patients) were diagnosed by biopsies as compatible with coeliac
disease of which, two patients have family history of coeliac disease in first degree relatives. After gluten
free died (GFD) for about 6 months, seroconversion to negative tests occurred in 6 patients for AGA-IgA,
4 for AGA- IgG, 3 for EMA IgA, 5 for Anti-TG2 IgA and 5 for Anti-TG2 IgG. Also, the grade of
histopathology showed complete healing in 4 patients and improvement to lower grades in 4 patients after
GFD. Worsening occurred in one case and still 7 cases showed the same grade of the disease.
Conclusion: It is concluded from this study that minimally symptomatic coeliac disease can easily be
mistaken for IBS. The presence of many persistent gastrointestinal symptoms in addition to the lower
serum levels of some nutritional parameters must alert the physicians to screen for coeliac disease. Any
serological test can be used for the screening but this must be confirmed by tissue diagnosis which is the
gold standard for diagnosis. Finally, screening for coeliac disease among patients with IBS must be
considered to offer better prognosis to these patients simply by gluten free diet.
Introduction:
Irritable bowel syndrome (IBS) is a highly prevalent, multi-symptomatic, gastrointestinal
motility disorder that has a wide clinical spectrum. This disease is associated with
gastrointestinal dysmotility and/or visceral hypersensitivity.

2. Although the recent trend has been to consider IBS a condition that can be diagnosed based
on symptom criteria, as opposed to regarding it as a 'diagnosis of exclusion' only to be made
after extensive testing, a limited screen for other diseases is recommended in patients with
symptoms suggestive of IBS.[2,3,4] The yield of haematology, chemistry and thyroid function
tests, sigmoidoscopy or colonoscopy, and microbiological stool studies in patients with
'suspected' IBS ('s'-IBS) is modest.[2] Recent studies suggest that the prevalence of coeliac
disease, a gluten-sensitive enteropathy characterized by intestinal villous blunting and
malabsorption,[5] is 3-11%[6,7,8] among patients diagnosed with IBS, compared with 0.02-
0.65%[6,7,8,9] in the general population. Coeliac disease may be present in patients with IBS-like
symptoms with diarrhoea or constipation predominance, or alternating bowel habit.[6,7]
While a classic presentation of coeliac disease consists of steatorrhea and weight loss, the
presentation can be more subtle, including symptoms characteristic of IBS (abdominal
discomfort, altered defecation, bloating, gas), and diagnosis can be delayed.[10,11] 24-37% of
coeliac disease patients were initially diagnosed with IBS.[10,11,12] Whereas IBS is a chronic
condition with no cure and with limited therapeutic options, adherence to a gluten-free diet may
improve quality of life and prevent long-term complications in coeliac disease.[5,12-19]
Recent studies showed that coeliac disease is as common in Middle Eastern countries as in
Europe; in both the general population and at-risk groups, e.g. patients with irritable bowel
syndrome or type 1 diabetes. Also, these studies showed that presentation with non-specific
symptoms or no symptoms is as common in the Middle East as in Europe. Frequent exposure to
wheat protein may lead to immune tolerance, leading to milder symptoms that may be
misdiagnosed as irritable bowel syndrome or unexplained gastrointestinal disorders (20).
Symptom overlap and comorbidity between IBS and other gastrointestinal motility disorders
(eg, chronic constipation, functional dyspepsia, gastroesophageal reflux disease), with
gastrointestinal disorders that are not related to motility (eg, celiac disease, lactose intolerance),
and with somatic conditions (eg, fibromyalgia, chronic fatigue syndrome), are frequent. The
clinical associations and pathophysiologic links between IBS and these disorders continue to be
explored (22).
Measurement of IgA antibody to human recombinant tissue transglutaminase (TTG) is
recommended for initial testing for CD. Although as accurate as TTG, measurement of IgA
antibody to endomysium (EMA) is observer dependent and therefore more subject to
interpretation error. Because of the inferior accuracy of the antigliadin antibody tests (AGA), the
use of AGA IgA and AGA IgG tests is no longer recommended for detecting CD. In individuals
with known selective IgA deficiency and symptoms suggestive of CD, testing with TTG IgG is
recommended. It is recommended that confirmation of the diagnosis of CD require an intestinal
biopsy in all cases. Because the histologic changes in CD may be patchy, it is recommended that
multiple biopsy specimens be obtained from the second or more distal part of the duodenum.
There is good evidence that villous atrophy (Marsh type 3) is a characteristic histopathological
feature of CD (34). The presence of infiltrative changes with crypt hyperplasia (Marsh type 2) on
intestinal biopsy is compatible with CD but with less clear evidence. The presence of infiltrative
changes alone (Marsh type 1) on intestinal biopsy is not specific for CD in children.
Concomitant positive serological tests for CD (TTG or EMA) increases the likelihood such an
individual has CD. In circumstances where the diagnosis is uncertain additional strategies can be
considered, including determination of the HLA type, repeat biopsy or a trial of treatment with a
gluten-free diet (GFD) and repeat serology and biopsy. The diagnosis of CD is considered
definitive when there is complete symptom resolution after treatment with a strict GFD in a
previously symptomatic individual with characteristic histologic changes on small intestinal

3. biopsy. A positive serological test that reverts to negative after treatment with a strict GFD in
such cases is further supportive evidence for the diagnosis of CD (33).
The detection of high titres of antigliadin antibody (AGA), antireticulin antibody (ARA) or
antiendomysium (EMA) antibody at the time of diagnosis, and the subsequent decrease in titres
after removal of dietary gluten, add specificity to the histologic findings of coeliac disease (31).
The identification of tissue transglutaminase (tTG 2) as the main antigen of EmAs (28 ) allows a
new diagnostic approach to CD. A large number of ELISA methods, mainly based on
commercially available guinea pig tTG, have been produced. Anti-tTG antibodies are highly
sensitive and specific for the diagnosis of CD (29,30 ). Enzyme-linked immunosorbent assay
(ELISA) tests for IgA anti-tTG antibodies are now widely available and are easier to perform,
less observer-dependent, and less costly than the immunofluorescence assay used to detect IgA
endomysial antibodies. The diagnostic accuracy of IgA anti-tTG immunoassays has been
improved further by the use of human tTG in place of the nonhuman tTG preparations used in
earlier immunoassay kits.
In one study of 288 patients with significant complaints and physical signs attributable to the
lower GIT in Eastern Province of the Kingdom of Saudi Arabia; 128 patients (44.5%),
sigmoidoscopy and rectal and/or colonic biopsies did not reveal any pathological abnormalities.
These patients were considered to have various disorders such as irritable bowel syndrome or
parasitic infestation. Eighty-one patients (28%) were found to have mild to moderate non-specific
colitis or proctitis. In another 49 patients (17%) the diagnosis of schistosomiasis
mansoni was made. Ulcerative colitis and colorectal carcinoma were detected in only 11 (4%)
and 4 (1.5%) patients respectively. In the remaining 15 patients (5%), other lower GIT diseases
were found (21). It has been suggested that patients with IBS should be tested for coeliac disease.
[2,6,7]
Our aims were to estimate the prevalence and the potential clinical consequences of coeliac
disease testing in adult Saudi patients with IBS.
Materials and methods:
This is a prospective pilot study evaluating adult patients attending GIT outpatient clinic in
Riyadh city in SA. Those patients with symptoms suggestive of IBS and those also diagnosed
after exclusion as IBS were included in the study. The study included 320 patients. All patients
were Arabs. They were 184 males and 136 females. Their age ranged from 18-67 years. They
were chronic patients attending the clinic for more than 6 months complaining of abdominal pain
with features compatible with IBS as defined by Rome III criteria.
Exclusion criteria:
1- Those with age below 18 years or above 70 years
2- Presence of red flag signs or alarm features as severe unrelenting diarrhoea, nocturnal
symptoms, unintentional weight loss, haematochezia, a family history of organic
gastrointestinal diseases such as IBD, celiac sprue or malignancy
3- Symptoms or signs of coeliac disease or those already on gluten free diet being
diagnosed already as coeliac disease.
4- Those with other medical illnesses or on chronic medications for organic disease.
5- Those who did not agree to continue follow up and giving consent to study.
6- Females during pregnancy or breast feeding
All patients were subjected to good history taking, clinical examination, and some
investigations if needed such as stool, urine, CBC, liver enzymes, kidney function tests, ECG,

4. electrolytes, H pylori serology, upper and lower endoscopy when indicated. Those with mixed or
atypical presentation were investigated properly for other diagnoses and then managed
accordingly. Those diagnosed as having persistent criteria of IBS were included in the study. As
serological tests and small bowel biopsy remain the cornerstones of diagnosis of coeliac disease
(23), these patients were subjected to:
1- Serum IgA and IgG anti-gliadin antibodies (AGA), Anti endomysial antibodies (EMA)
IgA (The test result is reported simply as positive or negative, since even low titers of
serum IgA endomysial antibodies are specific for CD) and Anti-TG2 (IgA and IgG).
2- Upper endoscopy for those with positive serology and histopathology of duodenal
biopsy.
3- Gluten free diet for those with positive serology.
4- All the above tests were repeated after period of 6-12 months.
During endoscopy of patients with any positive serological tests, 4 to 6 duodenal biopsies
were obtained. An experienced pathologist who was blinded to the patient’s history and antibody
assay results assessed the mucosal biopsy sections for pathologic features of CD. Diagnosis of
CD was made when there were an increased number of intraepithelial lymphocytes with
associated subtotal or total villous atrophy (32). Histological grading was done according the
conventional system which grades the mucosal findings as normal, slight partial villous atrophy,
marked partial villous atrophy, subtotal and total villous atrophy and Marsh system (34) which
classified the histological changes of CD as Type 0 or preinfiltrative stage (normal), Type 1 or
infiltrative lesion (increased intraepithelial lymphocytes), Type 2 or hyperplastic lesion (Type 1+
hyperplastic crypts), Type 3 or destructive lesion (Type 2 + variable degree of villous atrophy)
and Type 4 or hypoplastic lesion (total villous atrophy with crypt hypoplasia). Type 3 has been
modified to include Type 3a (partial villous atrophy), Type 3b (subtotal villous atrophy) and
Type 3c (total villous atrophy) (35).
Antigliadin antibody assay (36)
IgA and IgG AGA titres were determined by means of enzyme-linked immunosorbent assay (ELISA). Gliadin was prepared
from wheat gluten (product no. G-3375; Sigma Chemical Company, St. Louis, Mo.) in 70% ethanol (1 mg/mL). A 200-μL
aliquot of gliadin (5 μg/mL in carbonate buffer [0.015M sodium carbonate + 0.03M sodium bicarbonate adjusted to pH 9.6 in
water]) was added to each well of a microtitre ELISA plate (Falcon 3915; Becton Dickinson Labware, Lincoln Park, NJ) and
kept overnight at 4°C. Subsequently, 200 μL of PBS–BSA 1% Tween (phosphate-buffered saline [PBS; Gibco, Grand Island,
NY], bovine serum albumin [BSA; Sigma] and Tween 20 [Sigma]) were added to each well, and the plate was left at room
temperature for 11.2 hours. Each serum sample (100 μL) to be tested was added to the wells in quadruplicate at a 1:100 dilution
in PBS–BSA 1% Tween. Subsequently, 100 μL of either peroxidase conjugated goat antihuman IgA or IgG (Sigma) was added
at a concentration of 1:500 or 1:20 000, respectively, in PBS–BSA 1% Tween, each in duplicate wells. After a 1-hour incubation
at 37°C, 100 μL of OPD (ophenylmediamine dihydrochloride) substrate solution (10 mL of buffer [0.2M sodium hydrogen
phosphate + 0.1M citric acid] adjusted to pH 5.0), 4 μL of hydrogen peroxide and 4 mg of OPD (Sigma) were added to each well.
The plates were then incubated at room temperature, without exposure to light, for 30 minutes. Washing steps (× 3) with PBS-Tween
were incorporated after each of the above interaction stages to remove any nonimmobilized species. To stop the reaction,
25 μL of 4N sulfuric acid was added to each well. Optical density was read at 492 nm using an automated ELISA detector. The
optimal discriminative ability of IgA AGA and IgG AGA using this method was at an optical density of 0.25 and 0.30,
respectively. The celiac patient’s serum was used as a positive control with each batch, to confirm the reproducibility of the AGA
assays on different days. Furthermore, appropriate negative controls were routinely carried out, using the anti-human
immunoglobulin antibodies without serum. The background optical densities from these negative control wells were subtracted
from results with each patient’s serum.
Endomysial IgA antibody test:
(ImmuGlo™ Anti-Endomysial Antibody (EMA) Test System: indirect immunofluorescence): IMMCO Diagnostics, Inc. 60
Pineview Drive Buffalo, NY 14228-2120 USA. Patient serum (diluted 1 in 10 in 0.5 mol/L phosphate-buffered saline (PBS; pH
7.2) containing 0.2% bovine serum albumin (BSA)) is incubated at room temperature on tissue sections(5 mum cryostat primate
smooth muscle sections attached to glass microscope slides coated with poly-L-lysine (Sigma)) for 20 minutes to allow binding
of antibodies to the substrate. Any antibodies not bound are removed by rinsing. Bound antibodies of the IgA and IgG class are
detected by incubation of the substrate with fluorescein-labeled, anti-human immunoglobulin (Ig A) conjugate (Fluorescein
isothiocynate (FITC)-conjugated rabbit anti-human IgA (Dako, Denmark), diluted 1 in 50 with PBS). Reactions are observed
under a fluorescence microscope equipped with appropriate filters. The presence of EMA is demonstrated by an apple green
fluorescence of the endomysial lining of smooth muscle bundles. The titer (the reciprocal of the highest dilution giving a positive
reaction) of the antibody is then determined by testing serial dilutions (26, 27).
IgA Anti-tissue transglutaminase:

5. The anti-tTG IgA antibodies were determined in duplicate using an ELISA-based commercially available kit (Eu-tTG Eurospital,
Trieste, Italy) that uses recombinant human/E coli tTG antigen preparation as the coating antigen, and anti-human IgA peroxidase
Goat HRP conjugate as the secondary antibody; as indicated by the manufacturer. TMP was used as substrate. Sera with a
concentration > 5 arbitrary units (AU)/ml were considered positive.
IgG anti-tissue transglutaminase antibodies (IgG-ANTI-tTG) detection and estimation:
IgG-anti-tTG were detected using tTG coated 96 well plates (100 ng/well) from a commercially available IgA-anti-tTG detection
kit (Immunopharmacology Research, Catania, Italy) activated with CaCl2 (5 mM), as suggested by Sulkanen and colleagues and
Dieterich and colleagues. After four washes with phosphate buffered saline (PBS) 0.15 M, 0.1% human serum albumin (HSA),
and 0.05 % Tween 20, the wells were blocked by incubation with HSA (2% in PBS) for two hours at room temperature. After
three washes, sera diluted 1:250 in PBS were incubated at room temperature for two hours. The presence of IgG anti-tTG
autoantibodies were evaluated after incubation with horseradish-peroxidase conjugated antihuman IgG (1:6000 in PBS, 0.05%
HSA, one hour at room temperature) and substrate (1 mg/ml ortho-phenylendiamine (Sigma) in sodium citrate 1 M, citric acid
1 M, and 0.06% H202, 30 minutes at room temperature) as absorbance values of blocked reactions (0.3 M sulphuric acid) at
492 nm were measured on an ELISA reader. Sera were considered positive for IgG -anti-tTG when absorbance (ABS) of a sample
was twofold greater than that of the calculated cut off value ((positive control ABS+ negative control ABS)/2). Positive and
negative control values were, respectively, the absorbance of pool EMA-IgG positive and negative sera after background
subtraction. The antibody levels in patient diluted serum samples were estimated by comparison with the levels on a standard
curve (antibody concentration range, 0 to 100 U/ml), and samples yielding a result greater than 100 U/ml were reinvestigated by
the use of higher dilutions.
Patients can be considered as one of two groups - 'silent' celiac disease when the patients are symptom
free and serologically negative but bear the hallmarks of the disease on histological grounds, and 'latent'
celiac disease when serological tests are positive but there are no or minimal histological changes, such as
increased density of intraepithelial lymphocytes (IELs) (25).
Statistical analysis
Results were analysed using SPSS 12 for windows software.
Results:
This study included 320 patients; 184 males and 136 females. Age ranged from 18-56 years. The most
common clinical presentations in all patients, according sex and seropositivity were shown in table 1 and
2. The result of serology for coeliac disease is shown in table 3.
Table 1: clinical presentation in all patients.
Complaints Males
N=184
Females
N=136
Total
N=320
Complaints Males
N=184
Females
N=136
Total
N=320
Abdominal pain
Frequent or loose stool
Hard or infrequent stool
Altered stool habits
Other stool abnormalities*
78
35
21
26
32
98
16
46
20
27
176
51
67
46
95
Dyspepsia
Postprandial distress.
Epigastric pain
Abdominal distension
Eructation.
Chronic Anorexia
52
38
64
41
18
4
22
18
47
45
21
11
74
56
101
86
39
15
Other stool abnormalities*: straining during a bowel movement ,urgency (having to rush to have a
bowel movement) , feeling of incomplete bowel movement or anorectal obstruction, passing mucus
(white material) during bowel movement , abdominal fullness, bloating or swelling.
Table 2: clinical presentation in all patients according sero-positivity.
Complaints Serologically
negative
(n=305)
Serologically
positive
(n=15)
Complaints Serologically
negative
(n=305)
Serologically
positive
(n=15)
Abdominal pain
Frequent or loose stool
Hard or infrequent stool
Altered stool habits
Other stool abnormalities
164 (53.8%)
43(14.1%)
66(21.6%)
45(14.8%)
93(30.5%)+
12 (80.0%)*
8 (53.3%)*
1 (6.7%)
1 (6.7%)
2 (13.3%)
Dyspepsia
Postprandial distress.
Epigastric pain
Abdominal distension
Eructation.
Chronic Anorexia
64(21.0%)
55(18.0%)
91(29.8%)
87(28.5%)
34(14.1%)
11(3.6%)
10 (66.7%)*
11 (73.3%)*
10 (66.7%)*
9 (60.0%)*
5 (33.3%)*
4 (26.7%)*
Significantly higher in comparison to serologically negative (P < 0.05).
Table 3: clinical presentation in sero-positive patients before and after Gluten Free Diet (GFD):
Complaints
Serologically positive (n=15)
Complaints
Serologically positive (n=15)
Before GFD After GFD Before GFD After GFD
Abdominal pain
Frequent or loose stool
12 (80.0%)
8 (53.3%)
3(20.0%) *
2(13.3%) *
Dyspepsia
Postprandial distress.
10 (66.7%)
11 (73.3%)
4 (26.7%) *
2 (13.3%) *

6. Hard or infrequent stool
Altered stool habits
Other stool abnormalities
1 (6.7%)
1 (6.7%)
2 (13.3%)
2 (13.3%)
3 (20.0%)
4 (26.7%)
Epigastric pain
Abdominal distension
Eructation.
Chronic Anorexia
10 (66.7%)
9 (60.0%)
5 (33.3%)
4 (26.7%)
3 (30.0%) *
2 (13.3%) *
1 (6.7%)
1 (6.7%)
* Significant decrease in the number of patients after GFD in comparison to before GFD (P < 0.05).
Table 4: Haemoglobin, serum iron, and liver enzymes in serologically negative and serologically
positive patients before and after gluten free diet.
Factor Serologically negative patients Serologically Positive patients
At diagnosis At diagnosis After GFD
Hb (g/dl) 14.53 ± 03.45 13.21 ± 3.72* 14.25 ± 3.25+
S. iron (μg/dl) 72.63 ± 29.32 55.65 ±23.72* 65.34 ±20.76+
ALT (units/dl) 25.61 ± 11.34 27.23 ± 13.52 26.53 ± 13.84
AST (units/dl) 22.16 ± 10.35 26.35 ± 11.72 24.73 ± 11.51
Alk. Phosphatase (U/dl)
* Significant differences in comparison with serologically negative patients at diagnosis (P< 0.05).
+ Significant differences in comparison with serologically positive patients at diagnosis (P< 0.05).
Table 5: Blood levels of albumin, calcium, cholesterol and triglycerides in serologically negative and
serologically positive patients before and after gluten free diet.
Factor Serologically negative patients Serologically Positive patients
At diagnosis At diagnosis After GFD
S. albumin (g/dl) 4.30 ± 00.65 3.51 ± 00.71* 4.22 ± 0.51+
S calcium (mg/dl) 10.13 ± 1.20 8.35 ± 1.41* 9.02 ± 4.52+
Blood Cholesterol (mg/dl) 169.50 ±21.37 151.28±23.56 158.40±22.64
Triglycerides (mg/dl) 153.28 ± 32.62 146.53±28.35 150.24 ±23.52
* Significant differences in comparison with serologically negative patients at diagnosis (P< 0.05).
+ Significant differences in comparison with serologically positive patients at diagnosis (P< 0.05).
Table 6: the results of serology in all patients
Serological tests total Positivity Positivity (males) Positivity (female)
Anti-gliadin antibodies (IgA/G) 15/320 (4.69% 7 (2.19%) 8 (2.50%)
EMA IgA 13/320 (4.06%) 6 (1.88%) 7 (2.19%)
Anti-TG2 IgA 12/320 (3.76%) 5 (1.57%) 7(2.19%)
Anti- TG2 IgG 13/320 (4.06%) 6 (1.88%) 7 (2.19%)
Table 7: IgA and IgG anti-gliadin antibody titres in those with positive tests (15 patients):
IgA anti-gliadin titre IgG anti-gliadin titre
Optical
density
Number of patients Optical
density
Number of patients
At the diagnosis After GFD At the diagnosis After GFD
>0.875
0.75-0.875
0.625–0.75
0.5–0.625
0.375–0.5
0.25–0.375
0.125–0.25
0.0–0.125 (-)*
52133001
01122125
>1.0
0.9-1.0
0.8–0.9
0.7–0.8
0.6–0.7
0.5–0.6
0.4–0.5
0.3–0.4
0.1-0.3
0.0-0.1 (-)*
3221121102
0011013117
Titre is expressed as optical density. GFD: gluten free diet. 14 patients were positive for IgA, and 13 were positive
for IgG. Those who were negative for any of them are positive for the other. * = negative values

7. Table 8: Serology and histopathology in all positive cases (Before/After GFD):
AGA EMA
IgA
Anti-TG2 Histopathology (Marsh
classification)**
IgA IgG IgA IgG At diagnosis After GFD*
12
3 +
456789
10
11+
12
13
14
15
Total
positivity
+/+
+/-
+/+
+/-
+/-
+/+
+/+
+/-
+/-
-/-
+/+
+/+
+/+
+/+
+/-
14/8
+/+
+/+
+/+
+/+
-/-
+/+
+/+
+/-
+/-
+/-
+/+
+/+
-/-
+/+
+/-
13/9
+/+
+/+
+/+
+/-
+/-
+/+
+/+
+/-
+/+
-/-
+/+
+/+
-/-
+/+
+/+
13/10
+/-
+/+
+/-
+/+
-/-
+/-
+/+
+/+
+/+
-/+
+/-
+/-
-/-
+/+
+/-
12/7
+/-
+/+
+/+
+/+
+/-
+/+
+/+
+/-
+/-
-/+
+/-
+/+
-/-
+/+
+/-
13/8
Type 1
Type2
Type3a
Type 1
Normal
Type3b
Type2
Type2
Type 1
Normal
Type1
Type2
Normal
Type2
Normal
11
Normal
Type 2
Normal
Normal
Normal
Type 2
Type 2
Type 1
Type2
Normal
Normal
Type 1
Normal
Type1
Normal
7
After gluten free died for about 6 months, seroconversion to negative tests occurred in 6 patients for
AGA-IgA, 4 for AGA- IgG, 3 for EMA IgA, 5 for Anti-TG2 IgA and 5 for Anti-TG2 IgG. * GFD:
gluten-free diet. + these patients have family history of coeliac disease in first degree relatives.
It is clear from these results that patients number 10, and 13 were only positive for one test (IgG-AGA
and IgA-AGA respectively) and patient number 5 is positive for three of the five tests; IgA AGA,
EMA and IgG anti-TG2. The three patients showed normal histopathology in addition to patient
number15. Thus, only 11 patients (74.44% of those with positive serology and 3.49% of total patients)
were diagnosed by biopsies as compatible with coeliac disease. Two patients have family history of
coeliac disease in first degree relatives. One of them; patient number 3 was found to have positive
serology for all tests and type 3a histopathology. The other patient had similar serology but type 1
histopathology. All patients with positive serology were subjected to GFD for at least 6 months. Then
all serological tests and tissue biopsies were repeated and showed some improvement.
Table 9: Summery of histopathological findings in the 15 AGA positive patients:
Normal Positive histopathology
Type 1 Type 2 Type 3 Type 4 Total
At diagnosis 4 4 5 2 0 11 (74.44%)
After GFD 8 3 4 0 0 7 (46.67%)
The grade of histopathology showed complete healing in 4 patients and improvement to lower grades
in 4 patients (one type 3 changed to type 1 and 3 cases of type 2 changed to type 1). Worsening
occurred in one case from type 1 to type 2. 7 cases still showed type 1 or type 2 diseases.
Discussion:
Coeliac disease is a T-lymphocyte-mediated autoimmune gastrointestinal disorder induced
by ingestion of gluten found in wheat, rye and barley.[44,45] It meets the World Health
Organization (WHO) criteria for mass screening because the disease is common, difficult to
detect based on clinical symptoms, has sensitive and fairly specific screening tests for

8. diagnosis, it can be treated effectively, and, if left untreated, substantial morbidity and even
severe complications may ensue. However, uncertainties about the natural course and
management of subclinical CD have turned mass screening into a controversial issue (51).
The active disease is characterized by gluten-dependent autoantibodies against endomysium
(EMA), a complex connective tissue structure surrounding smooth muscle cells, and more
precisely, against the protein type 2 ('tissue') transglutaminase (TG2), the coeliac autoantigen
anchored to endomysial collagen by fibronectin.[46,47] Detection of these autoantibodies in the
serum is a useful means of identifying new coeliac patients presenting with only mild
gastrointestinal symptoms, non-specific general complaints or extraintestinal manifestations, or
in populations in general.[47-50] However, the benefits of serologic screening for coeliac disease
in asymptomatic individuals are debatable. Symptoms may be similar to that of IBS.[6,7] and
both diseases might have similar natural history. Many studies suggest that the prevalence of
coeliac disease is 3-11% [6,7,8] among patients diagnosed with IBS, compared with 0.02-
1.0%[6,7,8,9,40,41] in the general population. Screening studies have further shown that many
patients suffer only minimal if any symptoms and the prevalence of this disease thus remains
underestimated, when only patients with classical coeliac disease are recognized (42,43). The
purpose of identifying coeliac disease in such patients with suspected IBS is to improve quality
of life and decrease the cost of un-needed tests, non-specific medicines, and frequent
consultation.
In our study, patients who attended GIT clinic with manifestations indicating primary
diagnosis of IBS were selected and investigated for coeliac disease. Those who showed positive
serology were subjected to upper endoscopy for histopathological confirmation of the disease
to be given a course of gluten free diet for at least 6 months. The impact of such therapeutic
modality on patient symptomatology and blood parameters was studied.
A total number of 320 patients with highly suggestive, symptoms-based diagnosis of IBS
were enrolled. Positive serology was found in 15 cases (4.69%). The anti-gliadin antibodies
showed the highest positivity and sensitivity when both IgG and IgA were performed together.
Other tests showed slightly lower positivity. However, tissue examination showed positive
diagnosis in only 11 cases (74.44% of those with positive serology and 3.49% of total patients).
Anti-TG2 was the most specific one particularly IgA antibody which showed matching with
tissue diagnosis in 14/15 cases. The differences between these tests were not statistically
significant because the number of positive cases was small. Therefore, from this study we can
not determine the tests with higher sensitivity or specificity in the diagnosis of coeliac disease.
These findings were similar to the previous studies showing prevalence of 3-11% in patients
with IBS (6,7,8)
.
Symptoms, with some overlap related to IBS or coeliac disease, were significantly higher
in patients with positive serology than those with negative serology for coeliac disease. These
symptoms included abdominal pain, post-prandial stress, dyspepsia, epigastric pain, abdominal
distension, diarrhea, eructation and anorexia in this order. Thus, the high prevalence of these
symptoms and the presence of many of them could be considered as premonitory or green light
for testing for coeliac disease.
Haemoglobin, serum iron, calcium, albumin levels were found to be significantly lower in
those with positive serology and histopathology than negative patients. Also the levels of these
parameters were significantly elevated after the induction of gluten free diet. However, this
increase did not reach the level in those with negative serology. These parameters are reflective
of the nutritional deficiencies found in these patients. But because being mild reductions, such

9. deficiencies were not clinically manifest by these patients. After putting the patients on GFD,
their levels started to increase significantly. Cholesterol and triglycerides were found to be
lower in serologically positive patients with some increase after GFD but all these changes
were statistically insignificant.
Also, liver transaminases were found to be lower in serologically positive patients but
statistically insignificant. Liver enzymes elevations were found in coeliac disease in many
studies (37,38,39). But because of the subclinical nature of patients of this study, the elevation
was not above the normal range. The liver might be involved in this disease as a cryptogenic
nature, primary biliary cirrhosis, and occasionally severe liver disease and cirrhosis due to
autoimmune hepatitis.
In this study also, the disease activity in those with subtle symptoms was mild and found to
be of type1 and 2 in 9/11 cases with only 2 cases of type 3. This finding may explain the
minimal symptomatology in these patients. After a period of gluten free diet for these patients
with positive serology of about 6-12 months, their tissue pathology has improved in most cases.
The grade of histopathology has shifted to the left with complete healing in 4 patients and
improvement to lower grades in 4 patients (one type 3 changed to type 1 and 3 cases of type 2
changed to type 1). Worsening occurred only in one case from type 1 to type 2. This may be
due to non-compliance or non-adherence to gluten free diet. Still 7 cases had type 1 or type 2
diseases. The improvement; however, was not satisfactory in these patients. This might be due
to the mild nature of the disease manifestations and previous diagnosis of IBS and therefore;
the patients did not stick to gluten free diet.
It is concluded from this study that minimally symptomatic coeliac disease can easily be
mistaken for IBS. The presence of many persistent gastrointestinal symptoms in addition to
signs and lower serum levels of some nutritional parameters must alert the physicians to screen
for coeliac disease. Any serological test can be used for the screening but this must be
confirmed by tissue diagnosis which is the gold standard for diagnosis of this disease. Finally,
screening for this disease among patients with IBS must be considered to offer better prognosis
to these patients simply by gluten free diet.
معدل وجود مرض داء الزلقىى فى مرضى القولون العصبى السعوديين البالغين
شندى محمد شندى شريف*، نهال العسلى**و نعيمة العشرى** قىسم المراض المتوطنة*و قىسم الكيمييياء الكللينيكييية**,
معهد تيودور بحلهارس للبححاث.
لقد أوجدت القليل من الدراسات الحديثة معدل أعلى لميرض داء الزلقىيى فيى مرضيى القوليون العصيبى بحالمقارنية بحعامية النياس وذليك
۲,٠ %. كلما أوجدت دراسات مماثليية معييدل مميياثل للمييرض فييى دول - 11 % بحالمقارنة بحالمعدل العام مابحين ٦,٠ - بحمعدل يتراوح بحين 3
الشرق الوسط والدول الوربحية وذلك فى العامة واللذين هم معرضين أكلثر للمرض.
وكلان الهدف من هذا البحث هو تحديد معدل مرض داء الزلقىى والتوابحع الكللينيكة الممكنة للختتبارات المصلية له فى مرضى القولييون
العصبى السعوديين البالغين. وقىد شملت الدراسة 320 مريضا من البالغين تم أختذ التاريخ المرضى لهم وفحصهم فحصا سريريا وعمييل
التحاليل الضرورية ثم التحاليل الخاصة بحداء الزلقىى. وتم عمل منظار الجهاز الهضمى العاوي للحالت اليجابحية لختذ ختيذع مين الثنييى
عشر لفحصها مجهريا مع منع تناول الغذذية التى تحتوى على الجلوتين ثم إعادة هذه الفحوص بحعد ستة أشهر إليى أثنييى عشير شيهرا
320 حالية ايجابحيية بحالتحلييل المصيلي 0السييرولوجى) وكليانت كلالتيالى: 15 حالية ( / من هذه التغذية. وقىد أظهيرت الدراسية وجيود 15
13 حالة بحالجسام المضادة الخترى.و 11 حالة فقيط بحيالفحص المجهيرى. - %4.69 ) بحاستخدام الجسام المضادة ضد الجليادين و 12
وكلانت أعراض المرض مثل ألم البطن و والسهال وعسر الهضم وغذيرها أكلثر شيييوعا فييى هييؤلء المرضييى عنهييا فييى المرضييى ذات
التحاليل السلبية. كلما وجد ذلك أيضا بحالنسبة لنخفاض معدل الهيموجلوبحين والحديد و الزلل و الكالسيوم فى الدم. وقىييد تحسيينت جميييع
العوامل تحسنا ذات دللة إحصائية بحعد منع تناول الغذذية التى تحتوى على الجليوتين سيتة أشيهر إليى أثنييى عشير شيهر. كلميا تحيولت
6 حالت حسب نوع التحليل. وتم شفاء 4 حالت شفاءا تاما وتحسينت 4 حيالت أختيري اليى درجيات أقىيل فيى - النحاليل الى سلبية قىى 3
حين ساءت حالة واحدة حسب الفحص المجهري لخذع الثنى عشر. يستخلص مين هيذا البحيث أن ميرض داء الزلقىييى ذات العيراض
الضئيلة غذالبا ما يشخص ختطئا كلقولون عصبى (متلزمة المعاء المتهيجة). ولكن الوجود اليدائم لعيدد مين أعيراض الجهياز الهضيمى
بحالضافة لنقص معدل الهيموجلوبحين والحديد و الزلل و الكالسيوم فى الدم كلدللت سوء التغذية يجب أن تكون مؤشيرا لتنييبيه الطبياء

10. المعالجين للبحث عن المرض وذلك بأي من التحاليل المصلية لهذا الداء وتأكيد ذلك بالفحص المجهري لخذع المعاء الدقيقة وذلك مممن
أجل التحسن الفضضل علي المدي الطويل لهؤلء المرضى وذلك بمنع تناول الغذذية التى تحتوى على الجلوتين.
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