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Q1: Some years ago I was diagnosed with IBS. Over time I have always had bowel problems. However, by pure chance it was discovered that in fact I was suffering with coeliac disease. Reading your article I notice that no mention of coeliac was made, which I find very strange as it is now thought that as many as 1 in 100 have this disease and yet so little is made of it. I am sure that many people who are told they have IBS are in fact undiagnosed coeliacs and a simple blood test or the gold standard of a gut biopsy would confirm this. What are your thoughts on this? Mrs Dorothy Kerron.

A: IBS is unfortunately a disease that can only be diagnosed with certainty by the exclusion of the other possible causes of the symptoms that have aroused suspicion of an irritable bowel.

Regrettably there is rarely enough room in a newspaper to cover all aspects of such a large and important subject as IBS and to include details of its diagnosis in the few hundred words available in a standard newspaper article. Last week's piece on IBS essentially concentrated on the aetiology of IBS, either the factors that may cause it, or lead to someone having an exacerbation of its symptoms, together with some description of the symptoms.

I deliberately didn't mention the differential diagnosis of IBS, those other conditions that can be confused with it, nor did I venture into the question of treatment. You are absolutely right. Adult coeliac disease is far more common than people realise and is frequently missed as once someone is no longer a child the classic symptoms of coeliac disease, as found in nearly all children and many adults, may not be apparent in older patients.

The obvious conditions that need to be excluded before accepting a diagnosis of IBS are benign and malignant tumours, diverticulosis and diverticulitis (the latter is the same problem other than that the surrounding tissue has become inflamed and infected), coeliac disease, the inflammatory bowel diseases, chronic metabolic disorders and infections including giardiasis. Some people have a marked gastro colic reflex so that a sensitive upper gastro intestinal tract can lead to a sharp and sudden attack of diarrhoea, one manifestation of an irritable bowel so that it may also be necessary to exclude problems in the upper GI tract such as gastritis duodenitis or even ulcers. This is only a short list of the causes of IBS when diarrhoea and flatulence are the prominent symptoms. When IBS mainly causes constipation the list of troubles that can cause confusion is equally long. Nor should it be forgotten that other systems and organs as well as the guts may be affected by IBS. Some people with IBS have abdominal pain from gynaecological symptoms, headaches and a host of other troubles. It is little wonder that so many patients attending gastro enterologists are finally diagnosed with IBS.

So far as coeliac disease is concerned, the common gut problems associated with this usually include diarrhoea with stools that have a greater than average concentration of fat and hence smell. There is muscle weakness, some damage to the peripheral nerves, weight loss and a failure to put on weight and, of course, abdominal pain. Recurrent mouth ulcers are sometimes a sign of hitherto unsuspected adult coeliac disease and there is an increased incidence of a few other conditions in patients with adult coeliac disease such as chronic liver disease, thyroid problems, diabetes, and even such rarities as chronic fibrosing lung troubles. There is often a family history.

The supreme test for the diagnosis of coeliac disease is a biopsy of the gut lining in the small intestine, but chronic anaemia and folate deficiency should arouse suspicions. The standard blood tests are useful but the important one is the presence of specific antibodies that are found in most cases of coeliac disease. The improvement of the diagnosis of coeliac disease is improving.

Q2: I was diagnosed with IBS when I was 17 and I'm now 37. I have tried conventional medicine, herbal medicine, kinesiology, acupunture, and other alternative therapies, and have even been hooked up to a machine which somehow measures intolerance to foodstuffs. I am now fairly wheat-free, dairy-free, have cut down on my alcohol intake, tried probiotics, eat fruit and veg and drink peppermint tea all day long, but I still suffer from such terrible wind that it is ruining my life. I don't want to have a relationship, and am constantly trying to avoid people as I am terrified they will notice. I have changed jobs to avoid stress and I also try to go to the gym to help, but nothing, NOTHING seems to help. What more can I do? I am at my wits end. Even if I don't eat, I get wind! Name and address withheld.

A: It is a myth that people with IBS should all take huge quantities of vegetables. When I started in medicine patients with IBS were discouraged from taking vegetables but now we are rather more selective and understand that not all vegetables cause trouble. Furthermore not all those that sometimes do upset the gut have this effect on every occasion they are eaten. It is as much where and with whom a patient is eating that can be as important as what they are eating. The fruits and vegetables that most readily give rise to trouble are Brussels sprouts, broccoli, artichokes, broad beans, baked beans, citrus fruits, cashew nuts, onions and garlic - but it is a matter of trial and error to find out what an individual patient can't take especially when they are eating in company. Equally if they know that a food can cause troubles they need to know what quantity they can take in each and every type of surroundings.

Intolerance/tolerance tests that I have discussed on other occasions are available but the results are not easy to correlate with patients' symptoms because of their natural variability of response to the food. Great efforts are being made to improve tolerance testing but doctors are very conscious that they shouldn't make so many exclusions that their patients swop flatulence and bloating for malnutrition and vitamin deficiency.