A 24-year-old woman with a history of diffuse, crampy abdominal pain on and off for years saw a doctor after she recently started having diarrhoea once or twice a day. No weight loss was recorded and there was no blood in her stool.
Because of her age and long duration of symptoms, the doctor felt that this was probably not a malignancy. He asked her if drinking milk or eating dairy products made her symptoms worse, in order to find out if she was lactose intolerant, a common problem in our part of the world. (Milk and milk product contain lactose, and many people in South Asia lack the enzyme, lactase, necessary for digesting milk and suffer from diarrhoea with crampy stomach pain). But she drank a glass of milk every day, and doing so did not exacerbate her problem.
A simple stool test was done and repeated three times to increase the result of finding ova and parasites which are common causes of diarrhoea here. But all tests showed negative for the usual suspects like giardia. In fact, she had already taken adequate treatment for giardia and that too had not helped relieve her pain. The doctor then asked her if she had nocturnal diarrhoea or if the stool floated in the commode which would be an indication of fatty diarrhoea, termed steatorrhea. These too were absent.
When the doctor recommended a high fiber diet for possible irritable bowel syndrome (IBS), one of the most common problems that a doctor (especially a gastroenterologist, a bowel doctor) treats in his clinic in Nepal, she told him that she had been treated for this too. IBS is a clinical diagnosis: the doctor takes a careful history of the patient’s problems and does a simple physical exam. There are no special blood tests, scoping procedures of the bowel, or radiological tests to make the diagnosis of IBS.
Finally the doctor concluded her disease could be consistent with celiac disease, an affliction of the small intestine where the lining, which absorbs vital nutrients into the blood stream, is damaged and inflamed leading to pain and diarrhoea. This is triggered by the protein called gluten which is found in wheat, chapattis, bread, and in alcoholic beverages like beer and whisky. The doctor suggested she stop eating wheat and wheat products. When she returned to the clinic after a month, she said that her abdominal symptoms had completely subsided. She even mentioned tha the problem seemed to return when she ate wheat products.
In all likelihood the patient had celiac disease. Where facilities are available, a blood test called antiendomysial antibody test can be done. While this is a reliable test, a more complete diagnosis would involve biopsies of the small intestine where the problem lies. But this is an invasive procedure and for this patient, staying away from wheat appeared to be an easier solution.
Because IBS is common and may resemble celiac disease, it is important to ensure that celiac disease is not lumped together with IBS. One practical reason is that the treatment for celiac disease is specific (remove wheat from the diet) whereas treating IBS may be more challenging. Of course many diseases may have to be considered in a patient with long-standing abdomen pain and diarrhoea in Nepal but celiac disease which is eminently treatable has to be kept in mind while making the diagnosis.