Celiac disease is a gluten-sensitive enteropathy with a broad spectrum of clinical manifestation. Most celiac patients respond to a gluten-free diet.
However, in rare cases celiac patients continue to experience GI symptoms despite adherence to a gluten-free diet.
In this study, researchers from Italy evaluated the persistence of GI symptoms in a series of consecutive celiac patients on a gluten-free diet.
|10 of 15 patients had small intestinal bacterial overgrowth.|
|American Journal of Gastroenterology|
The team studied 15 celiac patients (5 men, 10 women, mean age 36.5 years) who continued to experience GI symptoms after 6 to 8 months on a gluten-free diet.
They performed antigliadin antibody (AGA), antiendomysial antibody (EMA), and sorbitol H2-breath (H2-BT) tests, before starting patients on a gluten-free diet.
In addition, patients underwent esophagogastroduodenoscopy (EGD) with histological evaluation. The team obtained bioptic samples from the second duodenal portion during EGD, and histopathology was expressed according to the Marsh classification.
In order to investigate the causes of persistent GI symptoms, the researchers performed AGA and EMA tests, stool examination, EGD with histological examination of small bowel mucosa, and sorbitol-, lactose-, and lactulose H2-breath tests.
The research team found that histology improved in all patients after 6 to 8 months of adherence to a gluten-free diet. This enabled the team to excluded refractory celiac disease as a cause of the persistent GI symptoms.
They determined that 1 patient with Marsh II lesions, although fully compliant to his diet, had mistakenly taken an antibiotic containing gluten.
Of the remaining patients, 2 showed lactose malabsorption, 1 Giardia lamblia and 1 Ascaris lumbricoides infestation, and 10 showed small intestinal bacterial overgrowth (SIBO).
The research team prescribed a diet without milk to the patient with lactose malabsorption. They treated the patients with parasite infestation with mebendazole 500 mg per day for 3 days for 2 consecutive weeks.
In addition, the team treated the patients with SIBO with rifaximin 800 mg per day for 1 week.
The researchers re-evaluated all patients 1 month after the end of treatment, and at this time all patients were symptom-free.
Dr Antonio Tursi's team concluded, "This study showed that SIBO affects most celiacs with persistence of GI symptoms after gluten withdrawal".