Non coeliac gluten sensitivity

In the past, the terms gluten sensitivity and coeliac disease have been used synonymously but this is not acceptable since gluten sensitivity can occur in subjects who do not have coeliac disease. The entity of non coeliac gluten intolerance has been regarded as a new diagnosis (1) but it is better to consider it an old diagnosis recently rediscovered and embellished. In the late 1970s brief case reports indicated that that some patients were wheat sensitive but did not have coeliac disease (2-4). During this time 17 patients with chronic diarrhoea who had received no definitive diagnosis or effective treatment were investigated at the Birmingham General Hospital, UK (5). Of these, nine, all women, had suffered persistent diarrhoea for up to 20 years, averaging five years, which was often socially incapacitating and nocturnal and which responded to a gluten free diet. The eight remaining patients showed no such sustained benefit. Among the responders, abdominal pain, abdominal distension, malaise and lassitude were also common symptoms. Routine blood tests were normal and of six tested, none had steatorrhoea. Only three carried the HLA-B8 phenotype. Multiple jejunal biopsies taken from these nine patients generated 54 pieces of macroscopically normal jejunum although with a slight increase in cellularity. Plasma cell counts in the lamina propria and intraepithelial lymphocytes were significantly increased compared with 17 normal controls and the eight non-responders. The cell counts however, were much lower than in untreated coeliac disease (6). The response of these nine patients to a gluten free diet was dramatic. Within two weeks each noted a marked improvement in their symptoms. All of the patients elected to remain on the gluten free diet and at the time of the report had taken it for 4-6 years. Repeat jejunal biopsies revealed a return to normal of the cellular infiltrate. Gluten challenge resulted in a recurrence of symptoms within 8-12 hours and which could last as long as a week. The mucosal plasma cell numbers increased slightly (mean rise of 297 cells/mm2) 24 hours after challenge but there were no changes in eosinophil or intraepithelial lymphocyte counts. Apart from these changes in plasma cell numbers no other immunological abnormalities were detected after gluten challenge. Of interest, in the eight patients who did not respond to the gluten free diet, the cell counts were within normal limits even after gluten challenge. It was concluded from this study that non coeliac gluten intolerance affected some patients and could be successfully treated by diet but the mechanisms responsible for producing ill-health were unknown.