Review for 10.1186/1471-230X-13-75 (2013)

Reviewer's report
Title:Predictors of persistent symptoms and reduced quality of life in treated
coeliac disease patients: a large cross-sectional study
Version: 1Date:28 January 2013
Reviewer: Umberto UV Volta
Reviewer's report:
The present paper aimed to identify predictors of poor response and reduced
quality of life in treated coeliac disease. It is generally acknowledged that a
number of coeliac patients continue to experience symptoms leading to an
impaired quality of life despite a strict compliance with gluten free diet (GFD).
The Authors have taken into consideration a very interesting topic that has been
forgotten in the past years and it is object of several studies nowadays.
I have some observations which should be analyzed and expanded by the
Authors.
1) Background, page 3, line 6: The Authors define “poor growth in children and
osteoporosis as complications of coeliac disease”. This is not correct since the
scientific community agrees that only intestinal malignancies (lymphoma, small
bowel carcinoma), refractory celiac disease, ulcerative jejunoileitis, collagenous
sprue are true complications of coeliac disease, whereas poor growth and
osteoporosis as well as many other signs and symptoms are part of the clinical
presentation of coeliac disease. So, poor growth and osteoporosis should be
defined as “clinical manifestations of coeliac disease” and not ”complications”.
2) Result section (page 7, line 2): It has been reported that “non-coeliac food
intolerance also increased the risk of persistent symptoms.” I agree with this
statement, but I think that this concept should be expanded since it is mandatory
to define which food intolerances are involved in the persistence of functional
gastrointestinal symptoms in treated coeliac disease. In the literature it has been
reported that both lactose and fructose intolerance can have a role in maintaining
symptoms after GFD, so for the reader it could be interesting to have some
information on the prevalence of these 2 food intolerances (and others, if
detected) in the large series of coeliac patients studied.
3) Result section (page 7, line 9): It would be useful for the reader to define the
nature of gastrointestinal co-morbidities responsible for persisting symptoms in
treated coeliac disease. As stated in the discussion, irritable bowel syndrome is
probably a frequent cause, but what about gastro-esophageal reflux disease,
which, based on literature data, has been found in 66% of coeliac patients
(Barratt SM, Eur J Gastroenterol Hepatol 2011)? The Authors should specify the
nature of gastrointestinal co-morbidities and their relative occurrence in
determining the persistence of symptoms in treated coeliac disease.
4) In the discussion the Authors should take into consideration the possible role
of a high intake of commercial gluten free-products, rich in additives and
preservatives in inducing functional gastrointestinal symptoms in treated coeliac
disease, as reported by previous paper (Hopman E et al, Scand J Gastroenterol
2008).
5) Discussion section (page 9, line 14): It has been rightly underlined the role of
psychiatric disturbances in the persistence of symptoms in treated coeliac
disease, but the Authors do not indicate the kind of psychiatric disorders and this
information should be provided to the reader.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests