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Recurrent diarrhoea and weight loss associated with cessation of smoking in undiagnosed coeliac disease
  1. O Jolobe1
  1. 1Department of Adult Medicine, Tameside General Hospital, Fountain St, Ashton under Lyne OL6 9RW, UK
  1. S J O Veldhuyzen van Zanten2
  1. 2Queen Elizabeth II Health Sciences Centre, Victoria General Hospital Site, Room 928, South Wing, Centennial Bldg, Halifax, Nova Scotia B3H 2Y9, Canada Zanten{at}is.dal.ca

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This report on recurrent diarrhoea and weight loss associated with cessation of smoking in a patient with undiagnosed coeliac disease (Gut 2001;49:588), highlighting as it does the importance of documentation of body weight regardless of symptomatology, resonates with the evolution of the weight chart and haematological profile in a patient of mine with an eventual diagnosis of coeliac disease who first presented at the age of 79 years (when he weighed 70 kg) with a history of diarrhoea alternating with constipation, in association with radiographic documentation of colonic diverticular disease, to which his symptoms were subsequently attributed. By the time he was re-referred 15.5 months later, his weight had fallen to 64.8 g, and he now complained of vomiting and diarrhoea. His haemoglobin (Hb), mean corpuscular volume (MCV), and mean corpuscular haemoglobin (MCH) gave values of 12.0 g/dl, 96.6 fl, and 31.7 pg, respectively, and haematinic assays gave the following results (with reference ranges): serum vitamin B12 60 ng/l (170–900), serum folate 1.4 μg/l (2–14), red cell folate 90 μg/l (125–600), and serum ferritin 28 μg/l. Coeliac disease was subsequently validated by duodenal biopsy, and his weight then increased from a nadir value of 59 kg to a peak of 71.7 kg, seven months after implementation of a gluten free diet. Concurrently, his Hb, MCV, and MCH increased from nadir values of 11 g/dl, 81 fl, and 25.8 pg, respectively, to peak values of 13.1 g/dl, 86.4 fl, and 28.4 pg, respectively, during the course of replacement therapy with vitamin B12 and iron supplements.

COMMENT

In old age, underrecognition of other, and sometimes more clinically significant, gastrointestinal diseases can easily occur when they coexist with a strongly age related disorder such as colonic diverticulosis due to misattribution of many categories of gastrointestinal symptomatology. Weight loss is one of the “alerting” signs, warning against misattribution to colonic diverticulosis.

Author's reply

I concur with Dr Jolobe's comments that it is important to document simple demographic information such as the weight of the patient. Especially in the elderly, symptoms of coeliac disease can be subtle although this patient eventually declared himself because of progressive weight loss, diarrhoea, and a low serum folate level. The point of our report was that smoking may further mask symptoms of coeliac disease making it even more difficult to make the diagnosis.

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