Long-Standing Ulcerative Colitis and Sulphasalazine Treatment Complicated by Adult Celiac Disease

Hugh James Freeman^1,

¹Department of Medicine (Gastroenterology), University of British Columbia, Vancouver, BC, Canada

Cite this paper:
Hugh James Freeman. Long-Standing Ulcerative Colitis and Sulphasalazine Treatment Complicated by Adult Celiac Disease. International Journal of Celiac Disease. 2020; 8(4):117-119. doi: 10.12691/ijcd-8-4-1

Abstract

The risk of celiac disease may be increased in patients with inflammatory bowel disease (IBD), however, the precise pathogenetic mechanisms involved remain controversial. In this report, an elderly man with long-standing and extensive ulcerative colitis was treated with daily salazopyrine for over 30 years. His medication was eventually discontinued although endoscopic surveillance studies showed healed colitis with minimal inflammatory change and no dysplasia. He subsequently volunteered as an IBD control in a celiac disease research study. Endomysial and tissue transglutaminase antibodies were unexpectedly positive and a small bowel biopsy showed changes of celiac disease that later responded to a gluten-free diet. Earlier historical duodenal and ileal biopsies had been normal suggesting that changes were new, developing after cessation of the salazopyrine. This unusual presentation “unmasking” celiac disease after cessation of long-standing salazopyrine for colitis raises the potential that the drug may have acted to suppress the inflammatory process in celiac disease and may offer another alternate and inexpensive therapeutic approach.

Keywords:
celiac disease Sulphasalazine ulcerative colitis serological screening

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References:

[1]	Salem SN, Truelove SC, Richards WC. Small intestinal and gastric changes in ulcerative colitis: a biopsy study. Br Med J 1964; 1: 394-398.
[2]	Shah A, Walker M, Burger D, et al: Link between celiac disease and inflammatory bowel disease. J Clin Gastroenterol 2019; 53: 514-522.
[3]	Pinto-Sanchez MI, Seiler CL, Santesso N, et al: Association between inflammatory bowel diseases and celiac disease: a systematic review and meta-analysis. Gastroenterology 2020; 159: 684-903.
[4]	Singh S, Feuerstein JD, Pinien DG, et al. American Gastroenterological Association Technical Review on the management of mild to moderate ulcerative colitis. Gastroenterology 2019; 156: 769-808.e29.
[5]	Freeman HJ. Medical management of ulcerative colitis with a specific focus on 5-aminosalicylates. Clin Med Insights Gastroenterology 2012; 5:77-83.
[6]	Van der Heijden J, de Jong MC, Dijkmans BA, et al. Acquired resistance of human T cells to sulphasalazine: stability of the resistant phenotype and sensitivity to non-related DMARDS. Ann Rheum Dis 2004; 63: 131-137.
[7]	Ransford RA, Langman MJ. Sulphasalazine and mesalazine: serious adverse reactions re-evaluated on the basis of suspected adverse reaction reports to the Committee on Safety of Medicines. Gut 2002; 51: 536-539.
[8]	Watanabe T, Fujiwara Y, Chan FK. Current knowledge on non-steroidal anti-inflammatory drug-induced small bowel damage: a comprehensive review. J Gastroenterol 2020; 55: 481-495.
[9]	Taha AS, Dahill S, Nakshabendi I, et al. Duodenal histology, ulceration, and Helicobacter pylori in the presence or absence of non-steroidal anti-inflammatory drugs. Gut 1993; 34: 1162-1166.
[10]	Lang J, Price AB, Levi AJ, et al. Diaphragm disease: pathology of disease of the small intestine induced by non-steroidal anti-inflammatory drugs. J Clin Pathol 1988; 41: 516-526.
[11]	Freeman HJ. Sulindac-associated small bowel lesion. J Clin Gastroenterol 1986; 8: 569-571.
[12]	Swinson CM, Perry J, Lumb M, et al. Role of sulphasalazine in the ethology of folate deficiency in ulcerative colitis. Gut 1981; 22: 456-461.
[13]	Bianchi A, Chipman DW, Dreskin A, et al. Nutritional folic acid deficiency with megaloblastic changes in the small bowel epithelium. N Engl J Med 1970; 2828: 859-861.
[14]	Lewin KJ, Riddell RH, Weinstein WM. Gastrointestinal Pathology and Its Clinical Implications. 1992. Igaku-Shoin, New York and Tokyo. p.193.
[15]	Schwartz AG, Tarzan SR, Saxon A, et al. Sulfasalazine-induced exacerbation of ulcerative colitis. N Engl M Med 1982; 306: 409.
[16]	Freeman HJ, Steinbrecher UP, Kwan WC, et al. Sulphasalazine-induced pseudomembranous colitis. Can J Gastroenterol 1991; 5: 167.
[17]	Freeman HJ. Sulphasalazine-induced forms of colitis. Inflammopharmacology 1993; 2: 301-305.
[18]	Freeman HJ, Webber D. Ileal intra-epithelial lymphocytosis: a pathological clue to clinically occult adult celiac disease. Int J Celiac Dis 2017; 5:40-42.
[19]	Wolber R, Owen R, Freeman HJ. Colonic lymphocytosis in patients with celiac sprue. Human Pathol 1990; 21: 1092-1096.
[20]	Freeman HJ. Collagenous colitis as the presenting feature of biopsy-defined celiac disease. J Clin Gastroenterol 2004; 38: 664-668.
[21]	Freeman HJ. Collagenous mucosal inflammatory disorders of the gastrointestinal tract. Gastroenterology 2005 129: 321-333.
[22]	Freeman HJ. Evaluation of non-dietary alternatives for treatment of adults with celiac disease. In: Non-Dietary Therapies for Gluten-Related Disorders. Ed. Lenti MV, Di Sabatino A, Gianfrani C, Corrazza GR. Frontiers in Nutrition, Nutritional Immunology, Lausanne. 2020; Front Nutr 7: 562503.