Incidence and clinical significance of lactose malabsorption in adult coeliac disease

Fifty-one adult patients with coeliac disease, verified by a proximal small-intestinal biopsy, were investigated. Before treatment with a gluten-free and low-lactose diet 52% showed a slight rise in blood glucose during the lactose tolerance test. Seventy-nine per cent of these patients had watery stools, and 88% had three or more bowel movements a day--statistically significantly different from the coeliac patients with a normal lactose tolerance test. After treatment 12% had a flat lactose tolerance curve. Half of them (6%) had specific lactase deficiency. This is approximately the incidence of lactose malabsorption in the general Danish population. The small-intestinal disaccharidases and alkaline phosphatase levels were severely depressed before treatment. After treatment the activities increased, but not to normal. We conclude that lactose malabsorption is a clinically important condition in many patients with untreated coeliac disease, giving rise to more frequent and more watery stools. In well-treated coeliac disease lactose malabsorption is not commoner than in the general population. The lactose activity in a proximal intestinal biopsy specimen was found to be an unreliable indicator of lactose malabsorption in coeliac disease.     

High frequency of coeliac disease in adult patients with type-I diabetes

Anti-reticulin antibodies were measured by an indirect immunofluorescence method in 195 consecutive patients with insulin-dependent diabetes mellitus, and positive titres were found in 8 patients. A jejunal biopsy was performed in these patients, all of whom had small-intestinal atrophy. Thus the frequency of coeliac disease in adult diabetes patients was 4.1%. The patients had no signs of malabsorption or of significant abdominal complaints. We conclude that coeliac disease is commoner in type-I diabetes than in the normal population, and measurement of anti-reticulin antibodies seems to be a suitable screening method.     

Reinvestigation of lactose intolerant children: lack of correlation between continuing lactose intolerance and small intestinal morphology, disaccharidase activity, and lactose tolerance tests.

Thirty children on a lactose-free diet aged from 2-38 months who had previously been diagnosed as having secondary lactose intolerance were reinvestigated on 32 occasions by an oral lactose tolerance test, small intestinal biopsy, and measurement of disaccharidase activity in order to detect the presence of continuing lactose intolerance before reintroduction of milk. No correlation was found between continuing lactose intolerance, as diagnosed by the development of watery stools containing excess reducing substances after an oral load of lactose, and maximum blood glucose rise during a lactose tolerance test, lactase levels, and small intestinal morphology.     

Measurement of the 10,000-molecular weight calcium-binding protein in small-intestinal biopsy specimens from patients with malabsorption syndromes

Calcium-binding protein (CaBP) (molecular weight, 10,000) was measured in small-intestinal biopsy specimens from 36 patients with malabsorption syndromes: short-bowel syndrome (n = 13), untreated coeliac disease (n = 4), coeliac disease in remission (n = 7), patients with intestinal bypass owing to morbid obesity (n = 5), and in patients with chronic diarrhoea of unknown cause (n = 7). Twelve patients with no signs of malabsorption who had the irritable bowel syndrome were used as controls. Patients with small-bowel resections showed reduced concentrations of CaBP (p less than 0.01) and low intestinal calcium absorption (p less than 0.05). Small amounts of CaBP were found in intestinal specimens from patients with coeliac disease in remission (p less than 0.01), and CaBP was almost undetectable in patients with a newly diagnosed coeliac disease and avillous jejunal biopsy findings (p less than 0.001). Patients with chronic diarrhoea and patients with an intestinal bypass had CaBP concentrations comparable to those of the control group. A direct correlation was found between CaBP and the fractional calcium absorption in all patients (p less than 0.05). CaBP may therefore be considered an indicator of the efficiency of the small intestine to absorb calcium.     

Effect of Ulcer Surgery on Disaccharidase Activities of the Small Bowel and on Lactose Absorption

In 14 patients with peptic ulcer, admitted to hospital for surgical treatment, the lactose tolerance test and a small-intestinal biopsy with disaccharidase (maltase, sucrase, lactase) assays were performed before and 1 month and 6 months after operation. In 10 patients without evident organic disease of the gastrointestinum, the small-intestinal biopsy with disaccharidase assays was repeated at an average interval of 1 week, and these form the control group. The mean maltase, sucrase and lactase activities in the 1 and 6-month follow-up studies were increased over the preoperative values. When the changes were compared with the alterations noted in the control group, no statistically significant difference could be noted. In 3 patients with small-intestinal lactase deficiency the symptoms following lactose tolerance test became worse in one and a history of milk intolerance appeared in one after ulcer surgery.     

Acid microclimate in coeliac and Crohn's disease: a model for folate malabsorption.

The surface pH of human proximal jejunum was measured in biopsy samples and found to be more acid than the phosphate buffer in which they were incubated. The in vitro jejunal surface pH was 5.93 +/- 0.05 in control subjects and 6.19 +/- 0.09 in treated coeliac patients. A group of untreated coeliac patients with a surface pH of 6.56 +/- 0.14 had a significantly less acid surface pH compared to controls, as did a group of Crohn's patients with a surface pH of 6.21 +/- 0.04. These two groups with a significantly raised surface pH were subdivisible into 'high' and 'low'groups. Surface pH was found to remain low in the treated coeliac and control groups but became more acid over the incubation period reaching almost normal values in the Crohn's group and the untreated coelic initial surface pH. The raised surface pH in untreated coeliac disease and Crohn's disease would alter the amount of a weak acid available for non-ionic diffusion. Therefore the present results may help to explain the folate malabsorption known to occur in untreated coeliac disease and the frequently seen low serum folate levels in Crohn's disease.     

Hydrogen concentration in expired air analyzed with a new hydrogen sensor, plasma glucose rise, and symptoms of lactose intolerance after oral administration of 100 gram lactose

A rapid breath hydrogen analyzer to detect lactose malabsorption is described. After ingestion of a lactose solution the patient expires into a mouthpiece attached to a hydrogen sensor at 30-min intervals for 3 1/2 h. The hydrogen of the expired air causes a voltage change that can be transformed into ppm from a calibration curve. A tolerance test with a load of 100 g lactose was performed in 43 consecutive patients with various gastrointestinal disturbances, referred to the laboratory for the commonly used lactose tolerance test based on plasma glucose measurements. Eleven patients developed symptoms of lactose intolerance during the test. Biopsy specimens from the distal duodenum or proximal jejunum showed partial villous atrophy in one, in whom celiac disease with lactose intolerance was diagnosed; the other 10 had normal specimens. In nine of them lactose intolerance was diagnosed and confirmed by observation for months on a lactose-poor diet. The 10th patient (H.P.L.) did not improve on such a diet. He also showed pronounced symptoms of intolerance during a test with monosaccharides (glucose + galactose). His intestinal disease remained undiagnosed. The 11 patients with symptoms of intolerance and 3 patients without symptoms during the lactose load showed a flat plasma glucose curve after drinking the lactose solution--that is, a maximum rise of the glucose concentration of 1.5 mmol/l. One of the symptom-free patients dropped out and could not be observed, another did not improve on a lactose-poor diet, and the third noticed a favorable effect of the diet on stool consistency but not on other abdominal symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prospective screening for biopsy proven coeliac disease, autoimmunity and malabsorption markers in Belgian subjects with Type 1 diabetes.

AIMS: To determine prospectively the prevalence of biopsy proven coeliac disease (CD) in an adult Type 1 diabetic population from Belgium with regards to associated auto-immunity and malabsorption. METHODS AND RESULTS: Determination in 400 Type 1 diabetic patients of serum anti-endomysial and/or anti-transglutaminase auto-antibodies. All subjects with abnormal serology underwent an intestinal biopsy. Ten patients (2.5%) had positive antibodies. Diagnosis of CD was confirmed by an intestinal biopsy. Eight patients were symptom-free, although laboratory findings suggesting malabsorption were prominent in the presence of CD [microcytic anaemia, iron and folate deficiencies, low levels of 25(OH)vitamin D3, calcium and cholesterol]. Other auto-immune conditions, especially vitiligo, were found in patients with CD. CONCLUSIONS: Asymptomatic coeliac disease occurs frequently in adult Type 1 diabetic patients, and is often associated with subclinical malabsorption. Screening should be part of routine evaluation, to implement life-long dietary gluten avoidance.     

Incidence and clinical significance of lactose malabsorption in ulcerative colitis and Crohn's disease

The incidence of lactose malabsorption was investigated in 85 patients with ulcerative colitis and 71 patients with Crohn's disease by means of lactose tolerance tests and disaccharidase determinations in small intestinal mucosa. Eight patients with ulcerative colitis (9%) and four with Crohn's disease (6%) had lactose malabsorption. A control group displayed a similar incidence. It is concluded that lactose malabsorption is not particularly common in ulcerative colitis and Crohn's disease. If it is present, its aetiology seems to be unrelated to the intestinal disease.Transitional lactose malabsorption was detected in two cases during a relapse of ulcerative colitis.Institution of a lactose-free (or lactose-poor) diet was an important supporting measure in seven patients who were unaware of their milk intolerance, in particular in two with ileostomy. Therefore, it is recommended that a lactose tolerance test should always be performed in patients with ulcerative colitis or Crohn's disease.Twenty-one patients with ulcerative colitis and nine with Crohn's disease, none of whom had lactose malabsorption, were placed on milk-free diets. A beneficial effect was noticed in five of the patients with ulcerative colitis, and in three of those with Crohn's disease. The mechanism is unknown.Evidence is presented that milk allergy is not responsible for the beneficial effect of a lactosefree diet in patients with associated lactose malabsorption.     

Disaccharidase levels in the small intestine in patients with diarrhoea following vagotomy and pyloroplasty

Diarrhoea is a common sequel to vagotomy and pyloroplasty but its cause is unknown. One of our patients who developed this complication had an abnormal lactose barium meal and responded well to a lactose-free diet. This led us to make a systematic study of disaccharidase activity in the small intestine in patients with diarrhoea following vagotomy and pyloroplasty.The small-intestinal disaccharidases have been estimated in jejunal biopsy specimens taken from 23 patients suffering from persistent diarrhoea, either continuous or episodic, after vagotomy and pyloroplasty. The disaccharidase values were normal in all but one of these patients. This patient showed hypolactasia but the sucrase and maltase levels were normal. The jejunal biopsy specimen taken from this patient showed a convoluted pattern under the dissecting microscope and severe partial villous atrophy under the light microscope. A repeat jejunal biopsy taken 20 cm beyond the duodeno-jejunal flexure showed similar appearances and also had a low level of lactase. However, two lactose tolerance tests and a lactose barium meal yielded normal results, suggesting that the low level of lactase in the upper jejunum was not a limiting factor in lactose absorption.The finding of one example of a low lactase level among 23 postvagotomy patients corresponds with what is being found in a study of normal subjects at present in progress.In effect, almost all patients with persistent diarrhoea after vagotomy and pyloroplasty have normal small-intestinal disaccharidase activity.     

Red cell distribution width as a marker of coeliac disease: a prospective study

BACKGROUND: Coeliac disease is frequently underdiagnosed because of its protean presentations. Serological tests may be helpful in screening programmes for populations at risk, but they are costly. AIM: To determine prospectively whether a commonly available haematological test such as the red cell distribution width (RDW) could be of help in detecting unrecognized coeliac disease. METHODS: Of 353 consecutive adult patients referred to our outpatient malabsorption clinic, 198 in whom clinical suspicion was strong were referred for further investigations and intestinal biopsy. Seventy-six inflammatory bowel disease outpatients and 90 subjects admitted for diseases other than malabsorption were enrolled as the control group. RESULTS: RDW was increased in 94 (47.4%) and normal in 104 (52.5%) of 198 patients. Duodenal biopsy confirmed coeliac disease in 80 (85.1%) of the former patients and 69 (66.3%) of the latter patients. No correlation between RDW values and histological scores was found. Overall RDW increase was found in 80/149 (53.7%) patients with a definite diagnosis of coeliac disease, and in 14/49 (28.6%) patients in whom biopsy excluded the disease. A 1-year gluten withdrawal led to a significant decrease in RDW value, even in patients with obdurate mucosal impairment. CONCLUSIONS: In patients in whom there is a strong clinical suspicion of coeliac disease, an elevated RDW despite normal haemoglobin concentration may be a reliable predictor of the disease.     

Bile acid malabsorption

Opinion statement Patients with bile acid malabsorption typically present with chronic, watery diarrhea. Bile acids recirculate between the liver and small intestine in the enterohepatic circulation. They are reabsorbed in the distal small intestine, and normally only a small fraction of the bile acid pool is lost to the colon during each cycle. In patients with bile acid malabsorption, a larger amount of bile acids is spilled into the colon, where the acids stimulate electrolyte and water secretion, which results in loose to watery stools. The common causes of bile acid malabsorption are ileal resection and diseases of the terminal ileum (Crohn’s disease and radiation enteritis), which result in a loss of bile acid transporters and, consequently, diminished reabsorption. Bile acid malabsorption also has been documented in a small group of patients with chronic, watery diarrhea who have no demonstrable ileal disease (idiopathic bile acid malabsorption). The amount of bile acid loss to the colon determines the clinical presentation. Patients with mild to moderate bile acid malabsorption present with watery diarrhea and generally respond very well to treatment (with abolishment of diarrhea) with bile acid binders such as cholestyramine. Patients with more severe bile acid malabsorption have both diarrhea and steatorrhea. Treatment with cholestyramine is of no benefit in this group of patients and may, in fact, worsen steatorrhea. These patients are best treated with a low-fat diet supplemented with medium-chain triglycerides.     

Systematic evaluation of the causes of chronic watery diarrhea with functional characteristics

BACKGROUND Causes of chronic watery diarrhea are multiple. There is not definite scientific evidence about AND AIMS: which are the recommended explorations to be performed in the diagnostic workup of patients with functional diarrhea. The aim was to assess prospectively the presence of gluten-sensitive enteropathy, bile acid malabsorption, and sugar malabsorption in consecutive patients with chronic watery diarrhea of obscure origin fulfilling Rome II criteria of functional disease. METHODS: A total of 62 patients with chronic watery diarrhea, defined as more than 3 loose or liquid bowel movements a day for at least 4 wk and a stool weight >200 g/day were included. The following tests were performed: (a) HLA-DQ2/DQ8 genotyping, and if positive, endoscopic biopsies from distal duodenum were obtained, and intestinal damage assessed; (b) SeHCAT (Se-homotaurocholate) abdominal retention test; (c) small bowel follow-through; and (d) hydrogen breath test (lactose, fructose + sorbitol). Gluten- or sugar-free diet, or cholestyramine was administered according to results. Functional disease was diagnosed if all tests performed were normal or if either there was no response to specific therapy or diarrhea relapsed during a 12-month follow-up. RESULTS: Bile acid malabsorption was considered to be the cause of diarrhea in 28 (45.2%) patients, sugar malabsorption in 10 (16.1%), gluten-sensitive enteropathy in 10 (16.1%), and both bile acid and sugar malabsorption in 2 patients. Twelve (19.4%) patients remained without a specific diagnosis and were considered as functional bowel disease. Diarrhea stopped in the 50 patients after specific treatment, decreasing the daily stool number from 5.4 +/- 0.3 to 1.5 +/- 0.1 (P < 0.0005), without relapse after the 12-months follow-up. CONCLUSIONS: The diagnosis of functional disease in patients with chronic watery diarrhea should be performed with caution since in most cases there is an organic cause that justifies diarrhea.     

Screening for antibodies against gliadin in patients with osteoporosis.

Intestinal disease might contribute to osteopenia. Measurements of IgA antibodies to gliadin have been established as an accepted screening procedure for detection of coeliac disease. When we applied these measurements to 92 patients with verified osteoporosis, 11 subjects (12%) were found to have elevated levels. This is markedly higher than the incidence in healthy subjects (3%). However, the patients with raised levels of IgA antibodies displayed no clinical symptoms and no laboratory evidence of calcium malabsorption. Thus their values for serum calcium, phosphate, parathyroid hormone (PTH), alkaline phosphatase and osteocalcin, as well as the fasting urinary excretion of hydroxyproline and calcium, were similar to those found in other patients with osteoporosis. Intestinal biopsy verified coeliac disease in three patients and was normal in another three. This gives an incidence of verified coeliac disease in this patient group that is approximately tenfold higher than that in the healthy population. Subclinical coeliac disease appears to be unusually over-represented among patients with idiopathic osteoporosis, and screening for gliadin antibodies might therefore be a valuable addition to the routine assessment of the osteopenic patient. The mechanisms underlying the relationship are not clear, but calcium malabsorption is not evident.     

Regression of lactose malabsorption in coeliac patients after receiving a gluten-free diet

OBJECTIVE: In a recent study by our group, it was shown that a large proportion of patients with lactose malabsorption and with no bacterial overgrowth are affected by silent coeliac disease (CD). Our aim was to evaluate the effect of a gluten-free diet on lactose malabsorption assessed using the hydrogen lactose breath test (LBT) and also the relationship with normalization of duodenal biopsies in coeliac patients. MATERIAL AND METHODS: Fifteen patients (11 F, 4 M; mean age 35.8+/-6) affected by CD with a positive LBT and negative glucose breath test were enrolled. All were started on a gluten-free diet and were re-evaluated after 6 months by LBT and after 12 months by both LBT and upper gastrointestinal endoscopy with biopsies. RESULTS: LBT normalization was observed in 1 out of 15 patients (6.7%) after 6 months and in 9 of the remaining 14 (64.2%) after 12 months. Duodenal biopsies showed normal villi in 8 patients, partial villous atrophy in 5 and total atrophy in 2. CONCLUSIONS: The present study shows that a large proportion of CD patients experience a regression of lactose malabsorption after receiving a gluten-free diet. This may be related to normalization of the brush border with an improvement of lactase enzyme activity. LBT should be performed after 12 months in CD patients on a gluten-free diet in order to assess the persistence/disappearance of lactose malabsorption, thus avoiding an unnecessary lactose-free diet.     

Osteomalacia and fatigue fractures in celiac disease

We report on a 36-year-old female patient suffering from bilateral inguinal pain. The x-ray revealed significant osteoporosis of both proximal femurs with an impacted fatigue fracture of the right calcar and Looser zones at the left subtrochanteric femur. The intestinal biopsy proved coeliac disease, resulting in a secondary malabsorption. The authors conclude that osteomalacia in young patients could indicate coeliac-induced malabsorption.     

Impact of bile acid malabsorption on steatorrhoea and symptoms in patients with chronic diarrhoea

OBJECTIVE: Bile acids are important for fat absorption. The relationship between bile acid malabsorption and steatorrhoea and gastrointestinal symptoms in patients with chronic diarrhoea has only been studied on a limited scale. DESIGN: Ninety-four patients referred for chronic diarrhoea were prospectively investigated with the 75SeHCAT test, a faecal fat excretion test and registration of symptoms in addition to the standard clinical work-up. METHODS: The correlation between the 75SeHCAT value and the faecal fat excretion was calculated for different groups of patients. Symptoms were registered in a questionnaire over a period of seven consecutive days. RESULTS: Forty-two patients had a 75SeHCAT value < 10%. Mild steatorrhoea was common in patients with non-organic bile acid malabsorption (50%) and in patients with functional diarrhoea (38%). There was no correlation between low 75SeHCAT values and steatorrhoea, although some patients with severe organic disease had a concomitant malabsorption of fat and of bile acids. In coeliac disease, severe steatorrhoea was common even in patients with high 75SeHCAT values. Patients with bile acid malabsorption had more frequent (P < 0.008) and looser (P= 0.0021) stools compared with patients with functional diarrhoea. There was no difference in abdominal pain, distension or flatulence. CONCLUSION: Mild steatorrhoea is common in both non-organic bile acid malabsorption and functional diarrhoea. The 75SeHCAT value cannot predict the risk of steatorrhoea. The high prevalence of bile acid malabsorption in patients with chronic diarrhoea and the absence of specific symptoms, except frequent and more liquid stools, indicates that the 75SeHCAT test should be performed early in the investigation of these patients.     

Antiendomysium versus Antigliadin Antibodies in Screening the General Population for Coeliac Disease

Background: It has recently been shown that mass screening for coeliac disease, using either the serum antigliadin (AGA) or antiendomysium antibodies (EMA) as screening test, can detect large numbers of cases that had escaped clinical diagnosis. The influence of the diagnostic algorithm on the results of the coeliac screening has not yet been evaluated. Our aim was to compare the validity of the AGA and the EMA protocols in 2096 students living in northwest Sardinia, who took part in a serologic screening for coeliac disease. Methods: The sample included 2096 of 2345 eligible students (89%) aged 11-15 years who underwent serum IgG AGA, IgA AGA, and IgA EMA determinations. Total serum IgA level was measured in sera showing isolated IgG AGA positivity. Subjects showing at least one of the following: a) EMA positivity, b) IgA AGA positivity, or c) IgG AGA positivity and IgA deficiency (&lt;5 mg/dl) were asked to submit to a small-intestinal biopsy. Results: The prevalence of coeliac disease was 19 (16 showing typical enteropathy, 1 potential case, and 2 known cases) of 2096 (0.91%; 95% confidence interval = 0.50-1.31). Seventeen small-intestinal biopsy specimens were needed to confirm 16 cases of manifest coeliac disease (positive predictive value (PPV) = 94%) by the EMA protocol, whereas the AGA protocol required 21 biopsy specimens for 12 cases of coeliac disease (PPV = 57%). None of six IgA-deficient, IgG AGA-positive cases detected by the AGA protocol also had coeliac disease. Conclusions: The EMA protocol is superior to the AGA protocol for mass screening of coeliac disease because of higher sensitivity, decreased need for intestinal biopsy, and possibility to detect potential cases of coeliac disease.     

Antiendomysium versus antigliadin antibodies in screening the general population for coeliac disease

BACKGROUND: It has recently been shown that mass screening for coeliac disease, using either the serum antigliadin (AGA) or antiendomysium antibodies (EMA) as screening test, can detect large numbers of cases that had escaped clinical diagnosis. The influence of the diagnostic algorithm on the results of the coeliac screening has not yet been evaluated. Our aim was to compare the validity of the AGA and the EMA protocols in 2096 students living in northwest Sardinia, who took part in a serologic screening for coeliac disease. METHODS: The sample included 2096 of 2345 eligible students (89%) aged 11-15 years who underwent serum IgG AGA, IgA AGA, and IgA EMA determinations. Total serum IgA level was measured in sera showing isolated IgG AGA positivity. Subjects showing at least one of the following: a) EMA positivity, b) IgA AGA positivity, or c) IgG AGA positivity and IgA deficiency (<5 mg/dl) were asked to submit to a small-intestinal biopsy. RESULTS: The prevalence of coeliac disease was 19 (16 showing typical enteropathy, 1 potential case, and 2 known cases) of 2096 (0.91%; 95% confidence interval = 0.50-1.31). Seventeen small-intestinal biopsy specimens were needed to confirm 16 cases of manifest coeliac disease (positive predictive value (PPV) = 94%) by the EMA protocol, whereas the AGA protocol required 21 biopsy specimens for 12 cases of coeliac disease (PPV = 57%). None of six IgA-deficient, IgG AGA-positive cases detected by the AGA protocol also had coeliac disease. CONCLUSIONS: The EMA protocol is superior to the AGA protocol for mass screening of coeliac disease because of higher sensitivity, decreased need for intestinal biopsy, and possibility to detect potential cases of coeliac disease.     

The association between primary biliary cirrhosis and coeliac disease: a study of relative prevalences

Background—Coexistent primary biliary cirrhosis(PBC) and coeliac disease has been recorded but the association has notbeen systematically studied.
Aims—To determine relative prevalences of PBC andcoeliac disease in a defined population over a 12 year period.
Patients and methods—All patients with PBCor coeliac disease in a stable population of 250 000 in South Waleswere identified from a clinical register and laboratory records.
Results—Sixty seven patients with PBC and 143 patients with coeliac disease have been diagnosed and followed over amedian of 86 (4-135) months; point prevalences in 1996 were 20 per100 000 for PBC and 54 per 100 000 for coeliac disease. PBC inpatients with coeliac disease was sought by investigating abnormalliver function tests. Ten (7%) had persistent abnormalities and three had PBC. Coeliac disease in patients with PBC was sought byinvestigating malabsorption, haematinic deficiency, positiveantigliadin antibody, or coeliac disease family history. Elevenpatients underwent duodenal biopsy revealing one further coeliacdisease case. Four patients (three women) have both conditions giving apoint prevalence for patients with both conditions of 1.6 per 100 000(95% confidence limits 0.44 to 4.1 per 100 000). Prevalence of PBC inpatients with coeliac disease was 3% and of coeliac disease inpatients with PBC was 6%.
Conclusion—A 12 year study of a stable 250 000population revealed a relative prevalence of PBC in 3% of 143 patientswith coeliac disease and of coeliac disease in 6% of 67 patients with PBC. PBC and coeliac disease are therefore associated. Screening forPBC in patients with coeliac disease using antimitochondrial antibodytesting and screening for coeliac disease in patients with PBC withantigliadin antibody testing or duodenal biopsy are recommended.

Keywords:primary biliary cirrhosis; coeliac disease; prevalence