Background: Inflammatory bowel disease (IBD) and coeliac disease (CD) are conditions associated with chronic inflammation of the gastrointestinal tract. Underlying aetiology includes genetic susceptibility, abnormal immune response and various environmental factors not fully understood to date. Both entities can overlap in paediatric patients although this is uncommon and difficult to confirm. We present our experience with patients who developed both conditions during early years of life.
Methods: We retrospectively reviewed all IBD patients seen in our centre who also had a diagnosis of coeliac disease over a 10-year- period. Data were collected from electronic notes and laboratory registries. Demographics, consultations, laboratory and endoscopic findings were extracted to a STATA database. Descriptive analysis was performed using absolute value, percentage and mean functions trough STATA software version 14.
Results: Only 8/578 patients were found to have both diagnosis, this accounts for 1.4% of all paediatric IBD patients seen in our centre (mean 57 new patients per year, past 10 years). 5 of them were female, 1 male had Down syndrome, and 1 patient had incomplete records. Mean age of diagnosis was 7.1 and 8.9 years for CD and IBD respectively. In terms of the IBD subtype, 4 patients suffered of Crohn's disease, 3 of ulcerative colitis and 1 of IBD unclassified. 3 patients were diagnosed with both entities within 3 months, other 4 had a previous history of CD and developed IBD years later (mean in years 3.0), despite having a well-controlled disease. Positive anti-transglutaminase (TTG) serology was found in 4/7 patients. Endoscopic findings were difficult to interpret, complementary specific biopsy immunostaining, small bowel imaging (MRI, CT) and video capsule endoscopy were required in order to support both diagnoses. Endoscopic assessment when there was a previous diagnosis of CD obeyed to persistent gastrointestinal symptoms despite normal TTG values, these 4 known CD patients had significant IBD features including granulomata and cryptitis in small bowel (3/4) and pancolitis (1/4).
Conclusions: Inflammatory bowel disease can overlap with coeliac disease in paediatric IBD patients although this association is rare. IBD can follow the appearance of CD years later despite TTG normalization and can also present at the same time of CD. Proving the coexistence of IBD and CD in children is a challenge, and requires of a multidisciplinary team involving expert histopathologists, gastroenterologists, dieticians and clinical laboratory scientists. IBD must be considered in CD patients with new onset of gastrointestinal symptoms or in CD patients whose gastrointestinal symptoms do not seem to respond to a gluten-free diet.