July’s blog focuses on a really important topic- persistent symptoms in patients with Coeliac disease after establishment of a gluten-free diet. This article is accompanied by an excellent editorial which provides a highly appealing appraisal of the literature. As always, there are a fantastic range of articles published in BMJOG within the last month and these can all be accessed free-of-charge on the website.

Vuolle et al study persistent symptoms in adult patients with a diagnosis paediatric-onset Coeliac disease, despite adherence to a strict gluten-free diet. This is an extremely interesting and challenging area for primary and secondary care. The role of co-existing functional pathology, or the slow recovery of normal bowel function following a period of enteropathy, is difficult to discuss with patients and difficult to treat.

Here the study team included 239 patients and collected data from patient records, concurrently patients completed a structured questionnaire and the authors compared groups with and without symptoms. 180 patients reported strict adherence to a GFD, with nearly 1/5 (18%) reporting ongoing GI symptoms, fatigue, arthralgia, skin symptoms or psychological issues. This group were more likely to have restriction of daily activity, concurrent comorbidities or general health concerns, when compared to asymptomatic patients. In all other ways the group were comparable. Interestingly, no biochemical, clinical or treatment factors from childhood appeared to predict symptoms in adulthood.

Vasant’s accompanying editorial provides further details and concludes with some excellent advice for clinicians, specifically pointing to the existence of functional gastrointestinal disorders in patients with concurrent organic pathology, something evident in inflammatory bowel disease, Coeliac disease and a multitude of other pathologies. It is also possible that concurrent organic pathology exists, and clinicians should be vigilant for other conditions.

In this study the authors conclude that ongoing symptoms are very common, even in the absence of additional organic pathology, and this impact on well-being, general quality of life and may require alterative treatment strategies including psychological input. Previous data reported functional symptoms consistent with ROME FGID criteria in patients with Coeliac disease occurring in up to 50% of those on a GFD. In adult patients, additional conditions such as non-responsive, or refractory Coeliac disease, may be considered. An excellent review in Frontline Gastroenterology seeks to provide more details and proposes useful, clinically focused, guidelines on how to approach and manage these patients.