Case 40-2000: gastric cancer in a young woman

A new insight into non-specific abdominal pain

This review aims to change clinical practice and alert clinicians to consider that unrecognised coeliac disease may present acutely with abdominal pain. Targeting patients who have non-specific abdominal pain or coeliac-associated symptoms/diseases may improve diagnosis.

Do patients with unrecognized coeliac disease present as an emergency?

Screening studies of healthy volunteers have determined that coeliac disease affects 1% of the European population. Despite this the majority of cases are unrecognized. Coeliac disease may occasionally present as an acute emergency. Recent data, however, suggest that cases of undiagnosed coeliac disease may present to emergency departments with nonspecific abdominal pain. This review provides an update of the published data on coeliac disease. We discuss the relationship between coeliac disease and abdominal pain and ways in which this may change emergency physicians practice.

Clinical and pathological features of 14 non-Hodgkin's lymphomas associated with coeliac disease

BACKGROUND

It is well established that enteropathy associated T-cell lymphoma is associated with malabsorption which is due to gluten sensitivity (coeliac disease). Our study was performed to define the clinical features, histological subtypes, response to treatment, and outcome of the association of coeliac disease and T-cell lymphoma.

PATIENTS AND METHODS

A retrospective study was performed in the UCL Group of Hematology to collect data on patients with a diagnosis of non-Hodgkin's lymphoma and coeliac disease. Fifteen cases were observed between 1985 and 1999. Case records for all but one patient were available and the pathological specimens of 14 patients were reviewed by two pathologists.

RESULTS

Six previously diagnosed coeliac patients developed lymphoma; interval between coeliac symptoms and onset of the lymphoma ranged from 2 to 48 years (median 16 years). Five patients had coeliac disease and non-Hodgkin's lymphoma diagnosed concomitantly or less than 6 months before the symptoms leading to the diagnosis of lymphoma. Three patients had the diagnosis of coeliac disease after lymphoma diagnosis (1, 8 and 10 years later respectively). Ten non-Hodgkin's lymphomas were of T-cell origin and 4 were B-cell lymphomas. Eight out of 14 presented on a surgical emergency. Thirteen were treated using chemotherapy. The median survival from the diagnosis of enteropathy associated T-cell lymphoma was 12 months (range 1-126).

CONCLUSIONS

Lymphomas associated with coeliac disease are heterogeneous and their diagnosis is difficult. The enteropathy-associated T-cell lymphoma is the most frequent, aggressive and fatal complication of coeliac disease but it is not rare to observe association with B-cell lymphoma. Chemotherapy is highly toxic in those patients. Despite a poor prognosis, long-term survival can be expected in a fraction of these patients.

Recognizing and managing celiac disease in primary care

PURPOSE

To heighten the awareness of primary care clinicians regarding the prevalence, clinical manifestations, diagnosis, and treatment of celiac disease (CD) in the primary care setting.

DATA SOURCES

Selected research, clinical guidelines, research and clinically based articles from current scientific literature, and current medical textbooks.

CONCLUSIONS

Celiac disease is commonly under diagnosed or misdiagnosed. Until recently, it was considered rare in the United States. New data indicate that 1:150 Americans are affected and demonstrate the protective effects of early diagnosis and treatment.

IMPLICATIONS FOR PRACTICE

Delays in the diagnosis and treatment of CD increase the risk of early mortality, associated autoimmune disease, neurologic complications, gastrointestinal malignancy, and fetal growth retardation, where pregnancy precedes diagnosis. Primary care clinicians must cultivate a high index of suspicion for CD in the primary care setting and bear it in mind as a differential diagnosis in many clinical situations.