Thursday, 05 July 2012

YOUR HEALTH Dr Jame Le Fanu: 6 July

Gluten-related diarrhoea and morbid thoughts; how to reduce nocturnal visits to the loo, and drugs for forgetfulness

Written by Dr James Le Fanu
Bread is a marvel, a cheap, nutritious, filling food, for centuries the staple ingredient of the Western diet – other than for those people, approximately one in 1,000, who are intolerant of the protein gluten in the wheatgerm. The damage to the lining of the gut prevents the absorption of vital nutrients to cause the familiar symptoms of coeliac disease: anaemia, diarrhoea and, in infants, failure to thrive.

So far, so (relatively) straightforward, as these symptoms tend to resolve with a gluten-free diet. It is, however, less well appreciated that coeliac disease can also give rise to a range of other mental and neurological symptoms. This is well illustrated by the case of a former RAF pilot who, in his early 40s, developed both diarrhoea and morbid thoughts of death.

Determined to see the world before being summoned by the Grim Reaper, he arranged a fortnight's holiday up the Amazon. The food supplies were erratic so for a few days it was rice only. He cheered up no end as his bowels started behaving themselves – but then when he had a slice of bread his miseries, both mental and physical, returned. It did not take long for him to work out that he must be intolerant to wheat – so much so that on his return he found a single communion wafer was sufficient to spark a recurrence of his symptoms.

Coeliac disease can also mimic other serious illnesses – as with a 46-year-old woman from Cornwall whose gait became increasingly uncoordinated. This warranted a brain scan which, she was informed by her neurologist, was strongly suggestive of multiple sclerosis. Simultaneously her bowels had started playing up which, she was convinced, must be caused by something in her diet.

After the usual trial and error she found that the exclusion of gluten cured her diarrhoea, and there was an added bonus – her mobility improved, her near zombie-like fatigue vanished and she 'felt like a human being again'.

'Bread may be the staff of life for most,' she writes, 'but for me it was anything but.'

This week's conundrum comes courtesy of a lady from Essex, writing on behalf of her husband who is now in his mid-70s. He passes a normal amount of urine during the day but at night is plagued by the need to rise four or more times to visit the toilet. His family doctor has checked out his prostate and that seems fine, but has no suggestions as to possible treatment.

This is almost certainly the condition known as benign nocturnal polyuria (literally, passing a lot of urine at night) due to a deficiency of the hormone ADH, which concentrates the urine. This can be corrected either by taking the hormone in the form of the nasal spray desmopressin or more simply, if surprisingly, in an anti-inflammatory drug such as Nurofen, which is similarly effective.


Whenever a forgetful elderly relative starts finding activities such as cooking difficult, the question arises as to whether medication may be necessary. Findings from trials investigating more commonly prescribed drugs such as galantamine and donepezil are modest, but, suggests Dr Joanne Rodda of London's University College Hospital in the BMJ, a minority may benefit substantially. However, determining who they are is not possible, so it might be best to 'suck it and see'. The drugs are mostly well tolerated, and side effects 'are usually mild and subside after a few days as the body gets used to the drug.'

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