Small bowel carcinoma and coeliac disease

We thank Howdle et al for their comments on our study, detailed recently in their letter (Gut 2003;53:470). In their British Society of Gastroenterology (BSG) National Survey,¹ Howdle et al relied mainly on gastroenterologists and surgeons to report cases of small bowel carcinoma and whether they were associated with either coeliac or Crohn’s disease. This may have resulted in underestimation of associated coeliac disease. In our series, we had two cases in which the original pathologist had failed to recognise the histological features of coeliac disease in mucosa adjacent to the adenocarcinoma.² The diagnosis of coeliac disease was made after review of the original resections. This problem has been recognised previously³ and results in the underdiagnosis of coeliac disease and further diagnostic delay for the patient with coeliac disease.

While the individual risk for patients with coeliac disease in developing adenocarcinoma of the small intestine is not great, poor survival should prompt rapid evaluation when symptoms occur. In addition, there should be a consideration of whether there is a subset of patients with coeliac disease who would benefit from screening for these cancers. Because patients with coeliac disease do not have a significantly increased risk of duodenal adenomas,⁴ the role of video capsule endoscopy of the entire small intestine needs to be explored.