Calcium malabsorption, hypocalcemia and skeletal demineralization are well-recognized features of untreated celiac disease. This study investigates calcium absorption and bone mineral density (BMD) after a prolonged, over 4 years, treatment with a gluten-free diet. Twenty-four adult females with treated celiac disease and twenty age- and sex-matched control subjects were studied. Mean body mass index (MBI), energy intake, serum calcium, and serum 25(OH)D concentrations in treated celiacs did not differ from controls. However, while both dietary calcium and protein intake were significantly higher in celiacs (P<0.012), fractional calcium absorption was lower (mean percentage+/-SD; treated 39.8+/-12 versus controls 52.3+/-10, P<0.001). Thus, after adjusting for calcium intake, the estimated amount of calcium absorbed daily was similar in both groups. Whole body, spine and trochanter BMD were significantly lower in treated celiac patients compared with controls (P<0.05). There were significant inverse correlations between: serum parathyroid hormone (PTH) and femoral neck or total body BMD (P<0.01), PTH and duration of gluten-free diet (P=0.05), and fractional calcium absorption and alkaline phosphatase (P=0.022). Increased calcium intake could potentially compensate for the reduced fractional calcium absorption in treated adult celiac patients, but may not normalize the BMD. In addition, the inverse correlation between PTH and time following treatment is suggestive of a continuing long-term benefit of gluten withdrawal on bone metabolism in celiac patients.

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SummaryThis case report illustrates the difficulties in making the clinical diagnosis of gallstone ileus. In addition to an unusual clinical picture, the changes normally expected on abdominal X-ray in gallstone ileus were subtle and missed in our patient. The diagnosis was made using abdominal computerised tomography (CT). We recommend the early use of abdominal CT scanning in the investigation of clinical bowel obstruction, especially in the elderly, where gallstone ileus is a more common condition.

Animal studies have demonstrated that the highest concentration of vitamin D receptors (and greatest capacity for active calcium absorption) occurs in the proximal duodenum. By passing the duodenum following Polya/Billroth II gastrectomy could result in the development of a metabolic bone disease and low bone mineral density (BMD). We thus compared the vitamin D receptor (VDR) concentration in mucosal biopsies taken at endoscopy from two functionally corresponding areas of the small intestine: the jejunum (or efferent loop) in 21 patients with a history of Polya/Billroth II gastrectomy and the second part of the duodenum in age/sex-matched control subjects. We also measured the BMD by dual energy X-ray absorptiometry. The mean VDR concentration was not significantly different between the two groups (patients vs controls, fmol/mg protein, mean +/- SE: 34.99 +/- 2.57 vs 34.67 +/- 3.71; P = 0.22), even when subgrouped as males (36.22 +/- 3.16 vs 31.2 +/- 4.24; P = 0.351) or females (31.93 +/- 4.7 vs 43 +/- 6.76; P = 0.193). In Polya/Billroth II gastrectomy patients, the VDR concentration in the efferent loop declined with age (r = -0.78, P = 0.02). In the same group, BMD, as compared with matched controls, was significantly reduced at the lumbar spine (Z-score: patients vs controls: -1.138 vs 0.099, P = 0.01), but not at the femoral neck (Z-score: -0.69 vs 0.7, P = 0.084). There was no correlation between VDR and time since operation or BMD. These results suggest that following Polya/Billroth II gastrectomy, the functional capacity of the jejunal efferent loop in reference to VDR concentration is similar to that of the second part of the duodenum in normal subjects. Therefore, the reduced BMD in our patients, also a common finding in other studies, may not be secondary to the reduced capacity of the VDR system that facilitates the active calcium transport pathway in the proximal small intestine.

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