Carcinoma, villous atrophy, and steatorrhoea

Coeliac disease and malignancies

When compared with the general population, patients with coeliac disease (CD) have an increased risk of developing enteropathy-associated T-cell lymphoma (EATCL), esophageal and pharyngeal squamous carcinomas and small intestinal adenocarcinomas. The prevalence of histologically confirmed CD in Edinburgh and the Lothians in 1979 was 61 per 100,000. The National Health Service Central Records of all 653 subjects registered at that time have been flagged, allowing us to analyse mortality in CD. At a mean of 13.5 years, mortality overall was 1.9-fold that of the general population (115 deaths observed. 61.8 expected; p < 0.0001). For both sexes the early mortality was much greater than expected, but the excess steadily diminished with time from diagnosis. Much of the increased mortality from malignant disease was accounted for by deaths from lymphoproliferative disease and esophageal cancer. Interim re-analysis after a further 9 years shows that the pattern of later deaths is consistent with these trends. Clinical and pathological features of lymphomas in CD are described. In serum samples of 41 patients with normal villus architecture while taking a normal diet, but with minor pathological and/or immunological abnormalities, i.e. potential CD, IgA antiendomysium antibodies were positive in 7 with dermatitis herpetiformis but in only 3 others.

Increased levels of plasma 5-hydroxytryptamine in patients with coeliac disease

In 17 patients with coeliac disease the 5-hydroxytryptamine (5-HT) concentration was measured in platelet-poor plasma (PPP) and in whole blood and compared with that of a control group of 30 healthy persons. The 5-HT level was determined by high-pressure liquid chromatography and electrochemical detection. In patients with coeliac disease the concentration of 5-HT in whole blood was elevated compared with the control group (p less than 0.001). The 5-HT level in PPP was significantly increased in patients with coeliac disease in whom the disease was untreated or treated with gluten-free diet for less than a year (p less than 0.01) but also compared with the patients with coeliac disease treated with a gluten-free diet for more than a year (p less than 0.01). In some untreated patients with newly diagnosed disease the 5-HT levels in PPP were markedly elevated and exceeded the levels ordinarily found in PPP in patients with carcinoid tumours. In these patients with coeliac disease the 5-HT concentration in PPP was reduced when the enteropathy was healed. There was no significant correlation between the 5-HT concentration in PPP versus whole blood in the different groups.

Small intestinal ulceration: diagnostic difficulties in relation to coeliac disease

Seven cases of ulceration of the small intestine are described and the relationship to coeliac disease is discussed. Evidence for coeliac disease is found in all cases but is less strong in some than in others, and coeliac disease was proved in only two cases. The ulcers were examined histologically in each case and in three cases were associated with malignant histiocytosis but the others showed only non-specific chronic inflammation. This suggests a spectrum of disorders with an inconsistent relationship to gluten sensitivity and small intestinal lymphoma.

Coeliac disease and malignancy

Patients with coeliac disease are at greater risk than the general population for the development of malignant neoplasms, particularly lymphomas. Of 259 histologically confirmed malignancies in 235 patients with histologically proven coeliac disease, 133 were malignant lymphomas, the predominant histological type being malignant histiocytosis and the commonest site of this lesion the small intestine. Patients with coeliac disease also have a greatly increased risk for the development of small-intestinal adenocarcinomas. Among 116 invasive non-lymphomatous malignancies there were 19 small-intestinal adenocarcinomas, compared with 0 . 23 expected from national cancer registrations adjusted for sex and age. There were also more oesophageal and pharyngeal squamous carcinomas than expected.

Coeliac disease, adenocarcinoma of jejunum and in situ squamous carcinoma of oesophagus

The development of both adenocarcinoma of the jejunum and in situ squamous carcinoma of the oesophagus in an adult coeliac patient is described. Good evidence that adenocarcinoma of jejunum occurs more frequently in patients with coeliac disease has recently become available though this association has been suggested for some time. While oesophageal carcinoma has long been associated with coeliac disease, in situ carcinoma of oesophagus has not been previously described in these circumstances. We feel that the risk of this complication, as calculated from published series, warrants a screening programme for oesophageal malignancy in adult coeliacs.

Coeliac disease, splenic function, and malignancy

Blood films from 41 cases of coeliac disease complicated by malignancy were examined and evidence of hyposplenism found in 12 cases (29%). This is similar to the proportion of adult coeliacs without malignancy who have hypoplenism and it is concluded that impaired splenic function is not associated with the development of malignancy in coeliac disease.

Adenocarcinoma of the upper small bowel complicating coeliac disease

Adenocarcinoma of the small intestine complicating coeliac disease is uncommon. Only 14 cases have been reported, and in only one of these was a jejunal biopsy carried out more than eight months before the diagnosis of malignancy. We describe four more patients with this association, all with long histories of coeliac disease, confirmed in three by jejunal biopsy over five years before the diagnosis of malignancy. Important presenting features of carcinoma were abdominal pain, anaemia, occult gastrointestinal bleeding, abdominal mass, and intestinal obstruction, and these were the main indications for operation. After resection of the tumour survival may be prolonged, as evidenced by one of our cases who remains well eight years after surgery.

Adenocarcinoma of the jejunum associated with nontropical sprue

A patient with a thirty-year history of celiac disease, developed malabsorption and ultimately intestinal obstruction. He failed to respond to a strict gluten-free diet, steroids, and antibiotics. Postmorten examination revealed primary adenocarcinoma of the small bowel. The relationship between adenocarcinoma of the jejunum and celiac disease is reviewed.

Coeliac disease and small bowel carcinoma

Small bowel carcinoma can occur in association with villous atrophy in the jejunum. In most reported cases there is doubt as to which of these represents the primary lesion. These cases are reviewed here. A further case is reported in which a carcinoma developed in a patient known to be suffering from coeliac disease for some years, although he was not on a gluten-free diet for the time preceding the diagnosis of carcinoma. On dietary restriction he remains well at 2-year follow-up. Possible aetiological factors are discussed.