Intestinal permeability assessed by excretion ratios of two molecules: results in coeliac disease.

In this patient it merged into what, in retrospect, was the first symptom of the shoulder-hand syndrome.Whether the pain itself or the resulting immobility with impairment of the venous and lymphatic pumping mechanism4 triggers the development of the syndrome is unknown, but in any event it seems that laparoscopic sterilisation can be added to the long list of potential precipitating factors.'The history of psychiatric illness in this patient may also be relevant.5As this case shows, the illness can be lengthy, disabling, and resistant to treatment, particularly when diagnosis is delayed.2 3 The syndrome is uncommon, particularly in young people,2 and early diagnosis will depend on being alert to the possibility.