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Ahmed A, Dixit K, Singh A, Agarwal A, Mehtab W, Prasad S, Rajput MS, Chauhan A, Agarwal A, Mehta S, Ahuja V, Shouche Y, Dhotre D, Makharia GK. Sieving out non-celiac gluten sensitivity amongst patients with irritable bowel syndrome. Dig Liver Dis 2024; 56:451-457. [PMID: 37985252 DOI: 10.1016/j.dld.2023.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/09/2023] [Accepted: 10/16/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES It is challenging to make diagnosis of non-celiac gluten sensitivity/non-celiac wheat sensitivity (NCGS/NCWS) in clinical practice, since there is no biomarker and diagnosis is based on response to gluten-free-diet (GFD). We used anti-gliadin antibody (AGA) for screening patients with IBS for gluten-sensitivity. METHODS 492 Adult-patients with IBS underwent screening for celiac disease and gluten-sensitivity using IgA anti-tissue transglutaminase antibody and IgA-AGA and IgG-AGA, respectively. Patients with positive AGA (IgA and/or IgG) were invited to follow GFD, those willing were put on GFD for 6-weeks. Responsive patients were given gluten re-challenge. Diagnosis of NCGS was confirmed if they had recurrence of symptoms. RESULTS Of 492 patients with IBS, AGA was positive in 61(12.4 %), hence suspected to have gluten-sensitivity. Of 31 who agreed to participate and followed GFD for 6-weeks, 17 (54.8 %) had complete (>30 % improvement) and 10(32.2 %) had partial (>20 % improvement) response. All 17 complete-responders were given gluten re-challenge for 6-weeks, symptoms recurred in all and hence were confirmed to have NCGS/NCWS. Significant decrease in AGA levels occurred almost in all GFD-responders. CONCLUSIONS 12.4 % IBS patients have biological evidence of gluten/wheat-sensitivity. Almost 87 % patients with IBS having AGA responded to GFD. The value of AGA may further be explored as a biomarker for screening for the presence of NCGS, before recommending this test for the clinical practice.
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Affiliation(s)
- Anam Ahmed
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Kunal Dixit
- Symbiosis School of Biological Sciences, Pune, Maharashtra, India
| | - Alka Singh
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Agarwal
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Wajiha Mehtab
- Department of Home Science, University of Delhi, New Delhi, India
| | - Shubham Prasad
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Mahendra Singh Rajput
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Chauhan
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Agarwal
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Shubham Mehta
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Vineet Ahuja
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Yogesh Shouche
- National Centre for Cell Science, Pune, Maharashtra, India
| | - Dhiraj Dhotre
- National Centre for Cell Science, Pune, Maharashtra, India
| | - Govind K Makharia
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India.
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Hosseinian SZ, Haghighatdoost F, Hajihashemi P, Adibi P. Effects of gluten on dyspeptic symptoms: a systematic review and meta-analysis of clinical trials. Nutr Rev 2023; 82:9-33. [PMID: 37115663 DOI: 10.1093/nutrit/nuad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
CONTEXT Research on the effects of gluten on dyspeptic symptoms has shown conflicting results. OBJECTIVE The aim of this systematic review and meta-analysis of clinical trials was to assess the effects of gluten on dyspeptic symptoms. DATA SOURCES A systematic search of the PubMed, ISI Web of Science, Scopus, Cochrane, and Embase online databases was performed up to May 2022. DATA EXTRACTION Randomized controlled trials (RCTs) and non-RCTs that examined the impact of a gluten-free diet, a low-gluten diet, or a gluten challenge on dyspeptic symptoms, including early satiety, epigastric pain, bloating, and nausea, were selected independently by 2 authors. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework was used to assess the certainty of the evidence. Results were pooled using a random-effects model and expressed as weighted mean differences (WMDs) and 95%CIs. DATA ANALYSIS Of the 7641 citations retrieved, 27 articles (18 RCTs and 9 non-RCTs) were included in the systematic review. Of those, 5 RCTs were eligible for the meta-analysis. The pooled results indicated that gluten challenge significantly increased the severity of bloating (WMD = 0.67; 95%CI, 0.37-0.97; I2 = 81.8%; n = 6), early satiety (WMD = 0.91; 95%CI, 0.58-1.23; I2 = 27.2%; n = 5), and epigastric pain (WMD = 0.46; 95%CI, 0.17-0.75; I2 = 65.8%; n = 6). However, the effect of gluten challenge on the severity of nausea (WMD = 0.13; 95%CI, -0.17 to 0.43; I2 = 0.0%, n = 5) was nonsignificant. CONCLUSION Gluten challenge significantly worsened dyspeptic symptoms, including bloating, early satiety, and epigastric pain, but did not affect nausea. These findings suggest that gluten restriction could be efficient in reducing dyspeptic symptoms. Well-designed large RCTs recruiting homogenous groups of patients with functional dyspepsia are needed to clarify the effectiveness of gluten restriction on dyspeptic symptoms.
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Affiliation(s)
- Seyedeh-Zeynab Hosseinian
- are with the Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fahimeh Haghighatdoost
- is with the Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parisa Hajihashemi
- are with the Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Peyman Adibi
- are with the Isfahan Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Almirall M, Casellas F, Dot J, de Torres I, Segurola H, Marsal S. Prevalence of non-coeliac gluten sensitivity and assessment of the response to gluten-free diet in a cohort of patients with fibromyalgia. Rheumatology (Oxford) 2023; 62:1069-1077. [PMID: 35900154 DOI: 10.1093/rheumatology/keac434] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To establish the prevalence of non-coeliac gluten sensitivity (NCGS) in a cohort of fibromyalgia patients and to evaluate their clinical response to a six-week gluten-free diet (GFD), the improvement in their symptoms, the percentage of diet responders who did not fulfil the diagnostic criteria for NCGS and the baseline characteristics that were associated with diet response and diagnostic criteria fulfilment. METHODS Uncontrolled prospective experimental study in a cohort of patients with fibromyalgia from a specialized hospital unit. The percentage of patients that fulfilled the Salerno Experts' Criteria, that responded to GFD, that improved their symptomatology and baseline characteristics associated with GFD response and diagnostic criteria fulfilment was analysed. RESULTS In total, 142 patients were selected and a NCGS prevalence of 5.6% was observed. A total of 21.8% responded to GFD due to their improvement in intestinal symptoms. In total, 74.2% of the responders did not fulfil the Salerno Experts' Criteria. The presence of diarrhoea and intraepithelial lymphocytosis and lower levels of anxiety were predictive factors of GFD response. No predictive factors of NCGS criteria fulfilment were found due to the low number of discriminators between gluten and placebo. CONCLUSIONS A NCGS prevalence similar to that estimated in the general population was found. A GFD cannot be systematically recommended to all patients with fibromyalgia, although it could be evaluated in those with diarrhoea or intraepithelial lymphocytosis to evaluate if there are improvements in their intestinal symptoms.
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Affiliation(s)
- Miriam Almirall
- Department of Rheumatology, Hospital Universitari Vall d'Hebron.,Rheumatology Research Group, Vall d'Hebron Research Institute
| | | | | | - Inés de Torres
- Department of Pathology, Hospital Universitari Vall d'Hebron.,Department of Morphological Sciences, Autonomous University of Barcelona
| | - Hegoi Segurola
- Nutritional Support Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Sara Marsal
- Department of Rheumatology, Hospital Universitari Vall d'Hebron.,Rheumatology Research Group, Vall d'Hebron Research Institute
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Borrelli DE Andreis F, Schiepatti A, Gibiino G, Fabbri C, Baiardi P, Biagi F. Is it time to rethink the burden of non-coeliac gluten sensitivity? A systematic review. Minerva Gastroenterol (Torino) 2022; 68:442-449. [PMID: 34929997 DOI: 10.23736/s2724-5985.21.03077-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Non-coeliac gluten sensitivity (NCGS) is still a poorly defined clinical condition. This review aims to describe the clinical features of subjects with a symptomatic response to gluten intake, and to estimate the prevalence of NCGS. EVIDENCE ACQUISITION Literature search was conducted in accordance with PRISMA recommendations. The PubMed database was searched for original articles until 1st June 2020. EVIDENCE SYNTHESIS We identified 30 relevant articles, including 14 studies that investigated NCGS through a double-blind, placebo-controlled crossover trial (DBPCC), and 16 that examined the role of gluten in causing symptoms without a DBPCC. We found that regardless of the diagnostic work up, gluten-sensitive patients were predominately middle-aged females complaining of abdominal pain, bloating and diarrhea. The pooled prevalence of NCGS after DBPCC was 24% (5-34%). Subjects with irritable bowel syndrome or self-reporting gluten intolerance accounted for the vast majority of the patients who did not start a DBPCC. A symptomatic response to a gluten-free diet (GFD) occurred in between 7% and 93% of patients. No data on long-term outcomes of NCGS individuals were reported. CONCLUSIONS Clinical features of NCGS patients did not differ among all the included studies, whereas prevalence figures are rather heterogeneous. Long-term benefit of a GFD on these patients still needs to be ascertained.
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Affiliation(s)
- Federica Borrelli DE Andreis
- Gastroenterology Unit, IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
| | - Annalisa Schiepatti
- Gastroenterology Unit, IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy -
| | - Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,M. Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Morgagni-Pierantoni Hospital, Forlì, Italy.,M. Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Paola Baiardi
- Scientific Direction, Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Federico Biagi
- Gastroenterology Unit, IRCCS Pavia Institute, Istituti Clinici Scientifici Maugeri, University of Pavia, Pavia, Italy
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Bojarski C, Tangermann P, Barmeyer C, Buchkremer J, Kiesslich R, Ellrichmann M, Schreiber S, Schmidt C, Stallmach A, Roehle R, Loddenkemper C, Daum S, Siegmund B, Schumann M, Ullrich R. Prospective, double-blind diagnostic multicentre study of confocal laser endomicroscopy for wheat sensitivity in patients with irritable bowel syndrome. Gut 2022; 71:1567-1576. [PMID: 34544843 PMCID: PMC9279748 DOI: 10.1136/gutjnl-2021-325181] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE A considerable proportion of patients with irritable bowel syndrome (IBS) may be wheat-sensitive and respond to a gluten-free diet (GFD) although they do not have coeliac disease. However, a diagnostic test for wheat sensitivity (WS) is missing. Our study evaluated the diagnostic accuracy (sensitivity and specificity) of confocal laser endomicroscopy (CLE) for the identification of WS as primary outcome. DESIGN In this prospective, double-blind diagnostic study 147 non-coeliac patients fulfilling the Rome III criteria for IBS were tested by CLE for duodenal changes after wheat (index test), soy, yeast or milk exposure. Patients with IBS responding to 2 months of GFD were classified as having WS (reference test) using response criteria recommended by regulatory bodies for pharmaceutical trials of patients with IBS. After 2 months, CLE results were unblinded and patients were advised to exclude those food components that had led to a positive CLE reaction. The clinical response was assessed at follow-up after 6 and 12 months. RESULTS Of 130 patients who completed the study per protocol, 74 (56.9%) responded to GFD and were classified as WS after 2 months, and 38 of these 74 patients were correctly identified by CLE (sensitivity 51.4%; 97.5% CI: 38.7% to 63.9%). A total of 38 of 56 patients without WS were correctly identified by CLE (specificity 67.9%; 97.5% CI: 52.9% to 79.9%). At 6 months follow-up, CLE correctly identified 49 of 59 food-sensitive patients (sensitivity 83.1%; 97.5% CI: 69.9% to 91.3%) but specificity was only 32% (97.5% CI: 15.7% to 54.3%). CONCLUSION In light of the high proportion of patients with IBS responding to GFD, the diagnostic accuracy of CLE is too low to recommend widespread use of this invasive procedure. TRAIL REGISTRATION NUMBER This study was registered as clinical trial in the German Registry for Clinical Studies (DRKS00010123).
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Affiliation(s)
- Christian Bojarski
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Department for Internal Medicine (Gastroenterology, Infectious Diseases, Rheumatology, Berlin, Germany
| | - Paul Tangermann
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Department for Internal Medicine (Gastroenterology, Infectious Diseases, Rheumatology, Berlin, Germany
| | - Christian Barmeyer
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Department for Internal Medicine (Gastroenterology, Infectious Diseases, Rheumatology, Berlin, Germany
| | - Juliane Buchkremer
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Department for Internal Medicine (Gastroenterology, Infectious Diseases, Rheumatology, Berlin, Germany
| | - Ralf Kiesslich
- Helios Dr. Horst Schmidt Kliniken Wiesbaden, Internal Medicine II Gastroenterology, Hepatology and Endocrinology, Wiesbaden, Germany
| | - Mark Ellrichmann
- Universitätsklinikum Schleswig-Holstein, Medical Department I, Kiel, Germany
| | - Stefan Schreiber
- Universitätsklinikum Schleswig-Holstein, Medical Department I, Kiel, Germany
| | - Carsten Schmidt
- Universitätsklinikum Jena, Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena, Germany,Klinikum Fulda, Medical Clinic II, Fulda, Germany
| | - Andreas Stallmach
- Universitätsklinikum Jena, Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena, Germany
| | - Robert Roehle
- Charité – Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany,Charité – Universitätsmedizin Berlin, Clinical Study Center, Berlin, Germany,Berlin Institute of Health (BIH), Berlin, Germany
| | | | - Severin Daum
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Department for Internal Medicine (Gastroenterology, Infectious Diseases, Rheumatology, Berlin, Germany
| | - Britta Siegmund
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Department for Internal Medicine (Gastroenterology, Infectious Diseases, Rheumatology, Berlin, Germany
| | - Michael Schumann
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Department for Internal Medicine (Gastroenterology, Infectious Diseases, Rheumatology, Berlin, Germany
| | - Reiner Ullrich
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Campus Benjamin Franklin, Department for Internal Medicine (Gastroenterology, Infectious Diseases, Rheumatology, Berlin, Germany
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Al-Abachi KT. Screening for Celiac Disease in Patients with Irritable Bowel Syndrome Fulfilling Rome III Criteria. JOURNAL OF COLOPROCTOLOGY 2021. [DOI: 10.1055/s-0041-1736645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Background Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. Celiac disease (CD), a treatable autoimmune enteropathy, with varied presentations, may simulate clinically symptoms of IBS. The aim of the present study is to screen for CD in patients with IBS diagnosed based on the Rome III criteria.
Patients and Methods A cross-sectional study was conducted at a secondary care gastrointestinal unit in Al-Salam General Hospital in Mosul city, Iraq, from November 2015 to October 2016. All patients fulfilling the Rome III criteria for IBS were screened for CD using antitissue transglutaminase IgA antibodies (anti-tTG). Patients who tested positive were subjected to endoscopic duodenal biopsy to confirm the diagnosis of CD.
Results A total of 100 patients were included in the present study (58 female and 42 male), the mean age of the participants was 40.8 years old (standard deviation [SD] ± 11.57). Ten patients (10/100, 10%) tested positive for anti-tTG antibodies. Five of the seropositive patients (5/10, 50%) showed positive biopsy results according to the Marsh classification, 3 of whom having diarrhea, and 2 with constipation.
Conclusion Positive serology and biopsy results suggestive of CD are common among patients with IBS. Screening patients with IBS for CD is justified.
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The Gluten-Free Diet for Celiac Disease and Beyond. Nutrients 2021; 13:nu13113993. [PMID: 34836247 PMCID: PMC8625243 DOI: 10.3390/nu13113993] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 12/20/2022] Open
Abstract
The gluten-free diet (GFD) has gained popularity beyond its main medical indication as the treatment for gluten-induced immune-mediated disorders such as celiac disease (CD), dermatitis herpetiformis, gluten ataxia, wheat allergy, and non-celiac gluten sensitivity. However, the diet carries some disadvantages such as elevated costs, nutritional deficiencies, and social and psychological barriers. The present work aims to review indications, proven benefits, and adverse events of a gluten-free diet. Close follow-up with patients following the diet is recommended. More data is needed to assess the effectiveness of the diet in managing mental and cognitive disorders and to establish a connection between the brain and gluten.
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Onyimba F, Crowe SE, Johnson S, Leung J. Food Allergies and Intolerances: A Clinical Approach to the Diagnosis and Management of Adverse Reactions to Food. Clin Gastroenterol Hepatol 2021; 19:2230-2240.e1. [PMID: 33493695 DOI: 10.1016/j.cgh.2021.01.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/18/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
Food allergy is an aberrant immunological response to food antigen, which can result in potentially life-threatening reactions. It is often challenging to differentiate food allergy from other adverse reactions to food because their presentations can be indistinguishable. The purpose of this article is to give an overview of the classification, evaluation, and management of adverse food reactions, key differentiating features of food allergy, roles and limitations of various food allergy testing, and promising areas of emerging research. Case studies are used to highlight some of the clinical pearls in diagnosing and managing food-related diseases.
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Affiliation(s)
- Frances Onyimba
- University of Maryland School of Medicine, Baltimore, Maryland.
| | - Sheila E Crowe
- University of California San Diego, La Jolla, California
| | | | - John Leung
- Boston Food Allergy Center, Boston, Massachusetts; Tufts Medical Center, Boston, Massachusetts.
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Food and Food Groups in Inflammatory Bowel Disease (IBD): The Design of the Groningen Anti-Inflammatory Diet (GrAID). Nutrients 2021; 13:nu13041067. [PMID: 33806061 PMCID: PMC8064481 DOI: 10.3390/nu13041067] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 12/19/2022] Open
Abstract
Diet plays a pivotal role in the onset and course of inflammatory bowel disease (IBD). Patients are keen to know what to eat to reduce symptoms and flares, but dietary guidelines are lacking. To advice patients, an overview of the current evidence on food (group) level is needed. This narrative review studies the effects of food (groups) on the onset and course of IBD and if not available the effects in healthy subjects or animal and in vitro IBD models. Based on this evidence the Groningen anti-inflammatory diet (GrAID) was designed and compared on food (group) level to other existing IBD diets. Although on several foods conflicting results were found, this review provides patients a good overview. Based on this evidence, the GrAID consists of lean meat, eggs, fish, plain dairy (such as milk, yoghurt, kefir and hard cheeses), fruit, vegetables, legumes, wheat, coffee, tea and honey. Red meat, other dairy products and sugar should be limited. Canned and processed foods, alcohol and sweetened beverages should be avoided. This comprehensive review focuses on anti-inflammatory properties of foods providing IBD patients with the best evidence on which foods they should eat or avoid to reduce flares. This was used to design the GrAID.
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Spiller R. Impact of Diet on Symptoms of the Irritable Bowel Syndrome. Nutrients 2021; 13:nu13020575. [PMID: 33572262 PMCID: PMC7915127 DOI: 10.3390/nu13020575] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 02/08/2023] Open
Abstract
Irritable bowel syndrome (IBS), with its key features of abdominal pain and disturbed bowel habit, is thought by both patients and clinicians to be strongly influenced by diet. However, the complexities of diet have made identifying specific food intolerances difficult. Eating disorders can masquerade as IBS and may need specialist treatment. While typical food allergy is readily distinguished from IBS, the mechanisms of gut-specific adverse reactions to food are only just being defined. These may include gut-specific mast cell activation as well as non-specific activation by stressors and certain foods. Visceral hypersensitivity, in some cases mediated by mast cell activation, plays a key part in making otherwise innocuous gut stimuli painful. Rapidly fermented poorly absorbed carbohydrates produce gaseous distension as well as short-chain fatty acids and lowering of colonic pH which may cause symptoms in IBS patients. Limiting intake of these in low FODMAP and related diets has proven popular and apparently successful in many patients. Existing diet, colonic microbiota and their metabolic products may be helpful in predicting who will respond. Wheat intolerance may reflect the fact that wheat is often a major source of dietary FODMAPs. It may also be either a forme fruste of coeliac disease or non-specific immune activation. Wheat exclusion can be successful in some of these patients. More research is needed to fully understand the mechanisms of food intolerances and how to best ameliorate them in a personalised medicine approach to diet in IBS.
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Affiliation(s)
- Robin Spiller
- NIHR Nottingham Biomedical Research Centre, Nottingham NG7 2UH, UK
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Kuwahara Y, Kato I, Inui T, Marunaka Y, Kuwahara A. The effect of Xenin25 on spontaneous circular muscle contractions of rat distal colon in vitro. Physiol Rep 2021; 9:e14752. [PMID: 33600071 PMCID: PMC7891183 DOI: 10.14814/phy2.14752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022] Open
Abstract
Xenin25 has a variety of physiological functions in the Gastrointestinal (GI) tract, including ion transport and motility. However, the motility responses in the colon induced by Xenin25 remain poorly understood. Therefore, the effect of Xenin25 on the spontaneous circular muscle contractions of the rat distal colon was investigated using organ bath chambers and immunohistochemistry. Xenin25 induced the inhibition followed by postinhibitory spontaneous contractions with a higher frequency in the rat distal colon. This inhibitory effect of Xenin25 was significantly suppressed by TTX but not by atropine. The inhibitory time (the duration of inhibition) caused by Xenin25 was shortened by the NTSR1 antagonist SR48692, the NK1R antagonist CP96345, the VPAC2 receptor antagonist PG99-465, the nitric oxide-sensitive guanylate-cyclase inhibitor ODQ, and the Ca2+ -dependent K+ channel blocker apamin. The higher frequency of postinhibitory spontaneous contractions induced by Xenin25 was also attenuated by ODQ and apamin. SP-, NOS-, and VIP-immunoreactive neurons were detected in the myenteric plexus (MP) of the rat distal colon. Small subsets of the SP-positive neurons were also Calbindin positive. Most of the VIP-positive neurons were also NOS positive, and small subsets of the NK1R-positive neurons were also VIP positive. Based on the present results, we propose the following mechanism. Xenin25 activates neuronal NTSR1 on the SP neurons of IPANs, and transmitters from the VIP and apamin-sensitive NO neurons synergistically inhibit the spontaneous circular muscle contractions via NK1R. Subsequently, the postinhibitory spontaneous contractions are induced by the offset of apamin-sensitive NO neuron activation via the interstitial cells of Cajal. In addition, Xenin25 also activates the muscular NTSR1 to induce relaxation. Thus, Xenin25 is considered to be an important modulator of post prandial circular muscle contraction of distal colon since the release of Xenin25 from enteroendocrine cells is stimulated by food intake.
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Affiliation(s)
- Yuko Kuwahara
- Department of Molecular cell PhysiologyGraduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
- Research Unit for Epithelial PhysiologyResearch Center for Drug Discovery and Pharmaceutical Development ScienceResearch Organization of Science and TechnologyRitsumeikan UniversityKusatsuJapan
| | - Ikuo Kato
- Department of Medical BiochemistryKobe Pharmaceutical UniversityKobeJapan
| | | | - Yoshinori Marunaka
- Department of Molecular cell PhysiologyGraduate School of Medical ScienceKyoto Prefectural University of MedicineKyotoJapan
- Research Unit for Epithelial PhysiologyResearch Center for Drug Discovery and Pharmaceutical Development ScienceResearch Organization of Science and TechnologyRitsumeikan UniversityKusatsuJapan
- Research Institute for Clinical PhysiologyKyoto Industrial Health AssociationKyotoJapan
| | - Atsukazu Kuwahara
- Research Unit for Epithelial PhysiologyResearch Center for Drug Discovery and Pharmaceutical Development ScienceResearch Organization of Science and TechnologyRitsumeikan UniversityKusatsuJapan
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Abstract
Irritable bowel syndrome (IBS) is a chronic condition characterized by abdominal pain associated with altered bowel habits. Patients with IBS often complain of food-related gastrointestinal symptoms. Specifically, those with diarrhea-predominant IBS report a significantly higher effect on quality on life because of food avoidance compared with those with other IBS subtypes. Physicians and patients often use dietary therapies to mitigate IBS symptoms. In the last 10 years, several dietary interventions such as a gluten-free diet, a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diets have been studied in several studies. This review summarizes the current literature on the role of diets such as gluten-free diet, low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet, and other carbohydrate malabsorption in the pathophysiology and symptom management in patients with diarrhea-predominant IBS.
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Low Fermentable Oligo- Di- and Mono-Saccharides and Polyols (FODMAPs) or Gluten Free Diet: What Is Best for Irritable Bowel Syndrome? Nutrients 2020; 12:nu12113368. [PMID: 33139629 PMCID: PMC7692077 DOI: 10.3390/nu12113368] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/22/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
Irritable Bowel Syndrome (IBS) is a very common functional gastrointestinal disease. Its pathogenesis is multifactorial and not yet clearly defined, and hence, its therapy mainly relies on symptomatic treatments. Changes in lifestyle and dietary behavior are usually the first step, but unfortunately, there is little high-quality scientific evidence regarding a dietary approach. This is due to the difficulty in setting up randomized double-blind controlled trials which objectively evaluate efficacy without the risk of a placebo effect. However, a Low Fermentable Oligo-, Di- and Mono-saccharides And Polyols (FODMAP) Diet (LFD) and Gluten Free Diet (GFD) are among the most frequently suggested diets. This paper aims to evaluate their possible role in IBS management. A GFD is less restrictive and easier to implement in everyday life and can be suggested for patients who clearly recognize gluten as a trigger of their symptoms. An LFD, being more restrictive and less easy to learn and to follow, needs the close supervision of a skilled nutritionist and should be reserved for patients who recognize that the trigger of their symptoms is not, or not only, gluten. Even if the evidence is of very low-quality for both diets, the LFD is the most effective among the dietary interventions suggested for treating IBS, and it is included in the most updated guidelines.
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Volta U, Caio G, Ghirardi C, Lungaro L, Mansueto P, Carroccio A, De Giorgio R. Minimal Lesions of the Small Intestinal Mucosa: More than Morphology. Dig Dis Sci 2020; 65:2761-2768. [PMID: 32875530 DOI: 10.1007/s10620-020-06571-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Minimal lesions of the small bowel are mucosal changes characterized by an increased number of intraepithelial lymphocytes (with or without crypt hyperplasia) and normal villous architecture. Such changes are associated with a wide spectrum of conditions, ranging from food intolerances to infections, and from drugs to immune diseases, with different clinical profiles and manifestations, which complicates the formulation of a differential diagnosis. Patient history, symptom evaluation, and histopathology are the diagnostic features needed to establish a correct diagnosis. Physicians should assist pathologists in formulating a precise morphological evaluation by taking well-oriented small intestinal biopsies and collecting informative clinical findings that inform histopathology. In this current clinical controversy, the authors provide the reader with an appraisal of the small intestine minimal lesions through a careful analysis of the major conditions (e.g., celiac disease and other non-celiac disorders) responsible for such changes and their differential diagnosis. Also, we acknowledge that some of the diseases detailed in this article may progress from an early minimal lesion to overt mucosal atrophy. Thus, the timing of the diagnosis is of paramount importance.
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Affiliation(s)
- Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giacomo Caio
- Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy
- Celiac Center and Mucosal Immunology and Biology Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Caterina Ghirardi
- Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy
| | - Lisa Lungaro
- Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy
| | - Pasquale Mansueto
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Antonio Carroccio
- Unit of Internal Medicine, "V. Cervello" Hospital, Ospedali Riuniti "Villa Sofia-Cervello", Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Roberto De Giorgio
- Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy.
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Reliability of coeliac serology in monitoring dietary adherence in children with coeliac disease on a gluten-free diet. Trop Doct 2019; 49:192-196. [DOI: 10.1177/0049475519835732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study aimed to determine the utility of coeliac serology for monitoring dietary adherence in coeliac disease. Serum anti-tTg IgA and anti-DGP IgG levels of 42 newly diagnosed patients were measured at diagnosis and at intervals of three, six and 12 months after starting a gluten-free diet. Both anti-tTg and anti-DGP antibodies decreased in all patients. The decline in the former was significantly greater at 3–12 months throughout, while in the latter the decline was seen only at three months but not subsequently. Serial measurement of coeliac serology may help in monitoring adherence to a gluten-free diet.
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Caminero A, McCarville JL, Zevallos VF, Pigrau M, Yu XB, Jury J, Galipeau HJ, Clarizio AV, Casqueiro J, Murray JA, Collins SM, Alaedini A, Bercik P, Schuppan D, Verdu EF. Lactobacilli Degrade Wheat Amylase Trypsin Inhibitors to Reduce Intestinal Dysfunction Induced by Immunogenic Wheat Proteins. Gastroenterology 2019; 156:2266-2280. [PMID: 30802444 DOI: 10.1053/j.gastro.2019.02.028] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 02/08/2019] [Accepted: 02/19/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Wheat-related disorders, a spectrum of conditions induced by the ingestion of gluten-containing cereals, have been increasing in prevalence. Patients with celiac disease have gluten-specific immune responses, but the contribution of non-gluten proteins to symptoms in patients with celiac disease or other wheat-related disorders is controversial. METHODS C57BL/6 (control), Myd88-/-, Ticam1-/-, and Il15-/- mice were placed on diets that lacked wheat or gluten, with or without wheat amylase trypsin inhibitors (ATIs), for 1 week. Small intestine tissues were collected and intestinal intraepithelial lymphocytes (IELs) were measured; we also investigated gut permeability and intestinal transit. Control mice fed ATIs for 1 week were gavaged daily with Lactobacillus strains that had high or low ATI-degrading capacity. Nonobese diabetic/DQ8 mice were sensitized to gluten and fed an ATI diet, a gluten-containing diet or a diet with ATIs and gluten for 2 weeks. Mice were also treated with Lactobacillus strains that had high or low ATI-degrading capacity. Intestinal tissues were collected and IELs, gene expression, gut permeability and intestinal microbiota profiles were measured. RESULTS In intestinal tissues from control mice, ATIs induced an innate immune response by activation of Toll-like receptor 4 signaling to MD2 and CD14, and caused barrier dysfunction in the absence of mucosal damage. Administration of ATIs to gluten-sensitized mice expressing HLA-DQ8 increased intestinal inflammation in response to gluten in the diet. We found ATIs to be degraded by Lactobacillus, which reduced the inflammatory effects of ATIs. CONCLUSIONS ATIs mediate wheat-induced intestinal dysfunction in wild-type mice and exacerbate inflammation to gluten in susceptible mice. Microbiome-modulating strategies, such as administration of bacteria with ATI-degrading capacity, may be effective in patients with wheat-sensitive disorders.
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Affiliation(s)
- Alberto Caminero
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Justin L McCarville
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Victor F Zevallos
- Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marc Pigrau
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Xuechen B Yu
- Department of Medicine, Columbia University, New York, New York; Institute of Human Nutrition, Columbia University, New York, New York
| | - Jennifer Jury
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Heather J Galipeau
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexandra V Clarizio
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Department of Immunology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Stephen M Collins
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Armin Alaedini
- Department of Medicine, Columbia University, New York, New York; Institute of Human Nutrition, Columbia University, New York, New York
| | - Premysl Bercik
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Detlef Schuppan
- Institute of Translational Immunology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany; Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Elena F Verdu
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
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Abstract
PURPOSE OF REVIEW There has been significant interest in gluten over the last decade, with an increase in interest of gluten-related disorders outside coeliac disease. Particularly, there has been a focus on the role of gluten in noncoeliac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS). There is significant overlap between both of these conditions, with the aim of this review to explore their complex relationship. RECENT FINDINGS Gluten has been demonstrated to generate symptoms in individuals with NCGS. However, there appears to be an increasing role for gluten in symptom generation in patients with IBS also. Other components of wheat, other than gluten, are now also thought to be contributing factors in symptom generation. SUMMARY There appears to be significant overlap between IBS and NCGS. It is likely that a subset of patients presenting with IBS actually have NCGS. In addition, it is likely that individuals with IBS may also have symptoms triggered by gluten. With the pathophysiology of both conditions not fully understood, as well as increasing knowledge of wheat components in symptom generation, further research is required to help distinguish between both.
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18
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Zhang Y, Ma ZF, Zhang H, Pan B, Li Y, Majid HA, Lee YY. Low fermentable oligosaccharides, disaccharides, monosaccharides, and polypols diet and irritable bowel syndrome in Asia. JGH Open 2019; 3:173-178. [PMID: 31061894 PMCID: PMC6487812 DOI: 10.1002/jgh3.12125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/07/2018] [Indexed: 02/06/2023]
Abstract
Functional bowel disorders, including irritable bowel syndrome (IBS), are a chronic condition that can significantly reduce patients' quality of life. Therefore, this paper will review the roles of a low fermentable oligosaccharides, disaccharides, monosaccharides, and polypols (FODMAP) diet in treating IBS, particularly in an Asian setting. About 20% of the general population is diagnosed with IBS. However, there are limited effective medical therapies available for treating IBS. Therefore, IBS presents a major challenge to the health-care providers. Recently, there is an increasing interest in the use of a diet low in FODMAP for the treatment of IBS. A low FODMAP diet can decrease the delivery of readily fermentable substrates to the small intestine and colon, thereby improving functional gastrointestinal symptoms.
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Affiliation(s)
- Yihe Zhang
- Division of MedicineSchool of Life and Medical Sciences, University College LondonLondonUK
| | - Zheng Feei Ma
- Department of Health and Environmental SciencesXi'an Jiaotong‐Liverpool UniversitySuzhouChina
- School of Medical Sciences, Universiti Sains MalaysiaKota BharuMalaysia
| | - Hongxia Zhang
- Department of Food ScienceUniversity of OtagoDunedinNew Zealand
| | - Binyu Pan
- Department of Clinical NutritionThe First People's Hospital of Wujiang DistrictSuzhouChina
| | - Yeshan Li
- Department of Respiratory and Critical Care MedicineThe Second People's Hospital of WuhuWuhuChina
| | - Hazreen A Majid
- Department of Social and Preventive Medicine, Faculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains MalaysiaKota BharuMalaysia
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19
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Rej A, Sanders DS. Gluten-Free Diet and Its 'Cousins' in Irritable Bowel Syndrome. Nutrients 2018; 10:nu10111727. [PMID: 30423854 PMCID: PMC6266983 DOI: 10.3390/nu10111727] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 02/08/2023] Open
Abstract
Functional disorders are common, with irritable bowel syndrome (IBS) being the commonest and most extensively evaluated functional bowel disorder. It is therefore paramount that effective therapies are available to treat this common condition. Diet appears to play a pivotal role in symptom generation in IBS, with a recent interest in the role of dietary therapies in IBS. Over the last decade, there has been a substantial increase in awareness of the gluten-free diet (GFD), with a recent focus of the role of a GFD in IBS. There appears to be emerging evidence for the use of a GFD in IBS, with studies demonstrating the induction of symptoms following gluten in patients with IBS. However, there are questions with regards to which components of wheat lead to symptom generation, as well as the effect of a GFD on nutritional status, gut microbiota and long-term outcomes. Further studies are required, although the design of dietary studies remain challenging. The implementation of a GFD should be performed by a dietitian with a specialist interest in IBS, which could be achieved via the delivery of group sessions.
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Affiliation(s)
- Anupam Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2JF, UK.
| | - David Surendran Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield S10 2JF, UK.
- Academic Unit of Gastroenterology, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, S10 2RX, UK.
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20
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Muir JG, Varney JE, Ajamian M, Gibson PR. Gluten-free and low-FODMAP sourdoughs for patients with coeliac disease and irritable bowel syndrome: A clinical perspective. Int J Food Microbiol 2018; 290:237-246. [PMID: 30388591 DOI: 10.1016/j.ijfoodmicro.2018.10.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/15/2018] [Accepted: 10/22/2018] [Indexed: 02/08/2023]
Abstract
Wheat- and gluten-containing products are often blamed for triggering a wide range of gastrointestinal symptoms, and this has fueled demand for gluten-free products worldwide. The best studied 'gluten intolerance' is coeliac disease, an auto-immune disease that affects the small intestine. Coeliac disease occurs in 1% of the population and requires strict, life-long avoidance of gluten-containing foods as the only medical treatment. There is a larger group of individuals (around 10-15% of the population) who report a wide-range of gastrointestinal symptoms that respond well to a 'gluten-free diet', but who do not have coeliac disease - so called 'non-coeliac gluten sensitivity (NCGS)'. The team at Monash University has identified other factors in gluten-containing foods that may be responsible for symptoms in this group of individuals with so-called, NCGS. We have evidence that certain poorly absorbed short chain carbohydrates (called FODMAPs) present in many gluten-containing food products, induce symptoms of abdominal pain, bloating, wind and altered bowel habit (associated with irritable bowel syndrome, IBS). Our research has shown that FODMAPs, and not gluten, triggered symptoms in NCGS. Going forward, there are great opportunities for the food industry to develop low FODMAP products for this group, as choice of grain variety and type of food processing technique can greatly reduce the FODMAP levels in foods. The use of sourdough cultures in bread making has been shown to reduce the quantities of FODMAPs (mostly fructan), resulting in bread products that are well tolerated by patients with IBS. Greater interaction between biomedical- and food-scientists will improve understanding about the clinical problems many consumers face, and lead to the development of food products that are better tolerated by this group.
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Affiliation(s)
- J G Muir
- Department of Gastroenterology, Central Clinical School, Level 6-The Alfred Centre, 99 Commercial Road, Monash University, Melbourne 3004, Australia.
| | - J E Varney
- Department of Gastroenterology, Central Clinical School, Level 6-The Alfred Centre, 99 Commercial Road, Monash University, Melbourne 3004, Australia
| | - M Ajamian
- Department of Gastroenterology, Central Clinical School, Level 6-The Alfred Centre, 99 Commercial Road, Monash University, Melbourne 3004, Australia
| | - P R Gibson
- Department of Gastroenterology, Central Clinical School, Level 6-The Alfred Centre, 99 Commercial Road, Monash University, Melbourne 3004, Australia
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Gargari G, Taverniti V, Gardana C, Cremon C, Canducci F, Pagano I, Barbaro MR, Bellacosa L, Castellazzi AM, Valsecchi C, Tagliacarne SC, Bellini M, Bertani L, Gambaccini D, Marchi S, Cicala M, Germanà B, Dal Pont E, Vecchi M, Ogliari C, Fiore W, Stanghellini V, Barbara G, Guglielmetti S. Fecal Clostridiales distribution and short-chain fatty acids reflect bowel habits in irritable bowel syndrome. Environ Microbiol 2018; 20:3201-3213. [PMID: 29749705 DOI: 10.1111/1462-2920.14271] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/07/2018] [Indexed: 12/16/2022]
Abstract
Irritable bowel syndrome (IBS), a common functional gastrointestinal disorder, is classified according to bowel habits as IBS with constipation (IBS-C), with diarrhea (IBS-D), with alternating constipation and diarrhea (IBS-M), and unsubtyped (IBS-U). The mechanisms leading to the different IBS forms are mostly unknown. This study aims to evaluate whether specific fecal bacterial taxa and/or short-chain fatty acids (SCFAs) can be used to distinguish IBS subtypes and are relevant for explaining the clinical differences between IBS subcategories. We characterized five fecal samples collected at 4-weeks intervals from 40 IBS patients by 16S rRNA gene profiling and SCFA quantification. Finally, we investigated the potential correlations in IBS subtypes between the fecal microbial signatures and host physiological and clinical parameters. We found significant differences in the distribution of Clostridiales OTUs among IBS subtypes and reduced levels of SCFAs in IBS-C compared to IBS-U and IBS-D patients. Correlation analyses showed that the diverse representation of Clostridiales OTUs between IBS subtypes was associated with altered levels of SCFAs; furthermore, the same OTUs and SCFAs were associated with the fecal cytokine levels and stool consistency. Our results suggest that intestinal Clostridiales and SCFAs might serve as potential mechanistic biomarkers of IBS subtypes and represent therapeutic targets.
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Affiliation(s)
- Giorgio Gargari
- Division of Food Microbiology and Bioprocesses, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy
| | - Valentina Taverniti
- Division of Food Microbiology and Bioprocesses, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy
| | - Claudio Gardana
- Division of Food Microbiology and Bioprocesses, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy
| | - Cesare Cremon
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Filippo Canducci
- Dipartimento di biotecnologie e scienze della vita, Università degli Studi dell'Insubria, Varese, Italy
| | - Isabella Pagano
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Maria Raffaella Barbaro
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Lara Bellacosa
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Anna Maria Castellazzi
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Chiara Valsecchi
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sara Carlotta Tagliacarne
- Department of Clinical Surgical Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Massimo Bellini
- Gastroenterology Unit, Department of Gastroenterology, University of Pisa, Pisa, Italy
| | - Lorenzo Bertani
- Gastroenterology Unit, Department of Gastroenterology, University of Pisa, Pisa, Italy
| | - Dario Gambaccini
- Gastroenterology Unit, Department of Gastroenterology, University of Pisa, Pisa, Italy
| | - Santino Marchi
- Gastroenterology Unit, Department of Gastroenterology, University of Pisa, Pisa, Italy
| | - Michele Cicala
- Gastroenterology Unit, University Campus Bio-Medico of Rome, Rome, Italy
| | | | | | - Maurizio Vecchi
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato, Milanese, Italy
| | - Cristina Ogliari
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato, Milanese, Italy
| | | | - Vincenzo Stanghellini
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, Bologna, Italy
| | - Simone Guglielmetti
- Division of Food Microbiology and Bioprocesses, Department of Food, Environmental and Nutritional Sciences, University of Milan, Milan, Italy
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22
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Limketkai BN, Sepulveda R, Hing T, Shah ND, Choe M, Limsui D, Shah S. Prevalence and factors associated with gluten sensitivity in inflammatory bowel disease. Scand J Gastroenterol 2018; 53:147-151. [PMID: 29216767 DOI: 10.1080/00365521.2017.1409364] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Gluten sensitivity (GS) arises with celiac disease and has also been found in non-celiac disorders, although its characteristics in inflammatory bowel disease (IBD) are unclear. This study evaluated the prevalence of GS and factors associated with GS in IBD. METHODS Adult IBD patients at a tertiary-care medical center completed a survey of their demographics, medical history, family history, social history and symptoms. Data on IBD characteristics were abstracted from the medical records. Descriptive analyses estimated the prevalence of GS. Multivariable logistic regression assessed the association between GS and patient or disease factors. RESULTS Of 102 IBD patients (55 Crohn's disease [CD], 46 ulcerative colitis [UC] and 3 IBD-unclassified), GS was reported in 23.6 and 27.3% of CD and UC patients, respectively. Common symptoms included fatigue, abdominal pain, diarrhea, bloating and hematochezia. There was no difference in these symptoms when comparing patients with and without GS. When evaluating IBD-related factors, GS was associated with having had a recent flare (adjusted odds ratio [aOR] 7.4; 95% confidence interval [CI] 1.6-34.1), stenotic disease in CD (aOR 4.7; 95% CI 1.1-20.2) and dermatologic manifestations (aOR 5.5; 95% CI 1.2-24.1). CONCLUSION GS was common in IBD and associated with having had a recent flare. GS may be transient for some patients, whereby dietary recommendations during and after a flare could focus on the avoidance of specific food triggers with possible reintroduction of these foods over time. This study prompts further prospective investigation into the temporal evolution of GS in IBD.
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Affiliation(s)
- Berkeley N Limketkai
- a Division of Gastroenterology & Hepatology , Stanford University School of Medicine , Stanford , CA , USA
| | - Rachel Sepulveda
- a Division of Gastroenterology & Hepatology , Stanford University School of Medicine , Stanford , CA , USA
| | - Tressia Hing
- a Division of Gastroenterology & Hepatology , Stanford University School of Medicine , Stanford , CA , USA
| | - Neha D Shah
- b Department of Clinical Nutrition , Stanford Health Care , Palo Alto , CA , USA
| | - Monica Choe
- a Division of Gastroenterology & Hepatology , Stanford University School of Medicine , Stanford , CA , USA
| | - David Limsui
- a Division of Gastroenterology & Hepatology , Stanford University School of Medicine , Stanford , CA , USA
| | - Shamita Shah
- a Division of Gastroenterology & Hepatology , Stanford University School of Medicine , Stanford , CA , USA
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23
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The Overlapping Area of Non-Celiac Gluten Sensitivity (NCGS) and Wheat-Sensitive Irritable Bowel Syndrome (IBS): An Update. Nutrients 2017; 9:nu9111268. [PMID: 29160841 PMCID: PMC5707740 DOI: 10.3390/nu9111268] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/14/2017] [Accepted: 11/17/2017] [Indexed: 02/07/2023] Open
Abstract
Gluten-related disorders have recently been reclassified with an emerging scientific literature supporting the concept of non-celiac gluten sensitivity (NCGS). New research has specifically addressed prevalence, immune mechanisms, the recognition of non-immunoglobulin E (non-IgE) wheat allergy and overlap of NCGS with irritable bowel syndrome (IBS)-type symptoms. This review article will provide clinicians with an update that directly impacts on the management of a subgroup of their IBS patients whose symptoms are triggered by wheat ingestion.
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25
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Gibson PR, Skodje GI, Lundin KEA. Non-coeliac gluten sensitivity. J Gastroenterol Hepatol 2017; 32 Suppl 1:86-89. [PMID: 28244667 DOI: 10.1111/jgh.13705] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2016] [Indexed: 12/27/2022]
Abstract
Irritable bowel syndrome-like symptoms in response to wheat ingestion is common and well described, but whether the reaction is due to gluten (i.e., non-coeliac gluten sensitivity), other wheat proteins, or FODMAPs (mostly fructans) alone or in combinations has not been clearly defined. Exclusion of coeliac disease in the presence of negative serology, and normal villous architecture but increased density of intraepithelial lymphocytes on duodenal biopsies, is difficult. Furthermore, the confidence by which a positive diagnosis is made or non-coeliac gluten sensitivity is excluded by blinded placebo-controlled rechallenge with wheat protein is reduced by strong nocebo responses generally found in patients with self-reported non-coeliac gluten sensitivity. The absence of a clear biological mechanism of action and difficulties with the design and interpretation of research studies have plunged this entity into even deeper controversy. In the absence of clarity in its diagnosis, the epidemiology, prognosis, and therapeutic approaches to a patient who may be gluten sensitive remain to be determined. Adequate understanding of the issues surrounding the controversy and further research will slowly unravel the truth behind the problem.
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Affiliation(s)
- Peter R Gibson
- Department of Gastroenterology, Monash University and Alfred Hospital, Melbourne, Australia
| | - Gry I Skodje
- Department of Nutrition Research, University of Oslo, Oslo, Norway
| | - Knut E A Lundin
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Camilleri M, Sellin JH, Barrett KE. Pathophysiology, Evaluation, and Management of Chronic Watery Diarrhea. Gastroenterology 2017; 152:515-532.e2. [PMID: 27773805 PMCID: PMC5285476 DOI: 10.1053/j.gastro.2016.10.014] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 09/21/2016] [Accepted: 10/11/2016] [Indexed: 02/08/2023]
Abstract
Chronic watery diarrhea poses a diagnostic and therapeutic challenge and is often a disabling condition for patients. Although acute diarrhea is likely to be caused by infection, the causes of chronic diarrhea (>4 weeks in duration) are more elusive. We review the pathophysiology, diagnosis, and treatment of chronic diarrhea. Drawing on recent insights into the molecular mechanisms of intestinal epithelial transport and barrier function, we discuss how diarrhea can result from a decrease in luminal solute absorption, an increase in secretion, or both, as well as derangements in barrier properties. We also describe the various extraepithelial factors that activate diarrheal mechanisms. Finally, clinical evaluation and tests used in the assessment of patients presenting with chronic diarrhea are reviewed, and an algorithm guiding therapeutic decisions and pharmacotherapy is presented.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Joseph H. Sellin
- Division of Gastroenterology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Kim E. Barrett
- Division of Gastroenterology, Department of Medicine, University of California, San Diego, La Jolla, CA
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Volta U, Caio G, Karunaratne TB, Alaedini A, De Giorgio R. Non-coeliac gluten/wheat sensitivity: advances in knowledge and relevant questions. Expert Rev Gastroenterol Hepatol 2017; 11:9-18. [PMID: 27852116 DOI: 10.1080/17474124.2017.1260003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Non-coeliac gluten/wheat sensitivity (NCG/WS) is a syndrome characterized by intestinal and extra-intestinal symptoms occurring a few hours or days after the ingestion of gluten and wheat proteins in patients testing negative for coeliac disease and wheat allergy. Areas covered: The present review deals with recent scientific acquisitions of this gluten-related syndrome, including pathogenetic mechanisms, clinical picture, symptom score, biomarkers and double-blind placebo-controlled trial for diagnosis, and treatment. The methodology used was a literature search on NCG/WS using Medline and Premedline from 1970 to August 2016. Expert commentary: We discussed the pathogenesis of symptom generation and altered gut physiology in NCG/WS. Possible mechanisms include innate and adaptive immune activation, impaired intestinal epithelial barrier and changes in gut microbiome. These interlinked factors may be exploited for their clinical relevance as possible biomarkers. A systemic immune response to microbial and wheat antigens, together with intestinal cell damage, occurs in patients with NCG/WS. Due to the lack of established biomarkers, it is mandatory to validate the diagnosis of the syndrome by means of a well-defined work-up involving dietary challenge. Finally, dietary and other therapeutic indications have been thoroughly reviewed.
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Affiliation(s)
- Umberto Volta
- a Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.) , University of Bologna, St. Orsola-Malpighi Hospital , Bologna , Italy
| | - Giacomo Caio
- a Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.) , University of Bologna, St. Orsola-Malpighi Hospital , Bologna , Italy.,b Mucosal Immunology and Biology Research Center, Massachusetts General Hospital , Harvard Medical School , Boston , USA
| | - Tennekoon B Karunaratne
- a Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.) , University of Bologna, St. Orsola-Malpighi Hospital , Bologna , Italy
| | - Armin Alaedini
- c Department of Medicine , Columbia University Medical Center , New York , NY , USA.,d Celiac Disease Center , Columbia University Medical Center , New York , NY , USA.,e Institute of Human Nutrition , Columbia University Medical Center , New York , NY , USA
| | - Roberto De Giorgio
- a Departments of Medical and Surgical Sciences and Digestive System, Centro di Ricerca Biomedica Applicata (C.R.B.A.) , University of Bologna, St. Orsola-Malpighi Hospital , Bologna , Italy
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Barmeyer C, Schumann M, Meyer T, Zielinski C, Zuberbier T, Siegmund B, Schulzke JD, Daum S, Ullrich R. Long-term response to gluten-free diet as evidence for non-celiac wheat sensitivity in one third of patients with diarrhea-dominant and mixed-type irritable bowel syndrome. Int J Colorectal Dis 2017; 32:29-39. [PMID: 27695975 PMCID: PMC5219884 DOI: 10.1007/s00384-016-2663-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE Irritable bowel syndrome (IBS) is common but therapies are unsatisfactory. Food is often suspected as cause by patients, but diagnostic procedures, apart from allergy testing, are limited. Based on the hypothesis of non-celiac wheat sensitivity (WS) in a subgroup of IBS patients, we tested the long-term response to a gluten-free diet (GFD) and investigated HLA-DQ2 or -DQ8 expression as a diagnostic marker for WS in diarrhea-dominant (IBS-D) and mixed-type IBS (IBS-M). METHODS The response to a GFD served as reference test for WS and HLA-DQ2/8 expression was determined as index test. Patients were classified as responders if they reported complete or considerable relief of IBS symptoms on at least 75 % of weeks over a 4-month period of gluten-free diet. Established questionnaires (IBS-Quality of Life (IBS-QoL), IBS Symptom Severity Scale (IBS-SSS), European Quality of Life-5 Dimensions (EQ-5D)) were used for secondary outcome measures. RESULTS Thirty-five patients finished the study. Of these, 12 (34 %) were responders and classified as having WS (95 % CI 21-51 %). HLA-DQ2/8 expression had a specificity of 52 % (95 % CI 33-71 %) and sensitivity of 25 % (95 % CI 8-54 %) for WS. Responders showed improvement in quality of life and symptom scores. At 1-year follow-up, all responders and 55 % of non-responders were still on GFD and reported symptom relief. CONCLUSION Using strict criteria as recommended for IBS studies, about one third of patients with IBS-D or IBS-M are wheat sensitive, with a similar proportion in both IBS types. Expression of HLA-DQ2/8 is not useful as diagnostic marker for WS. Long-term adherence to a GFD is high and can sustain symptomatic improvement.
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Affiliation(s)
- Christian Barmeyer
- Medical Department, Division of Gastroenterology, Infectiology, and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
- Institute of Clinical Physiology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Schumann
- Medical Department, Division of Gastroenterology, Infectiology, and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Tim Meyer
- Medical Department, Division of Gastroenterology, Infectiology, and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Christina Zielinski
- Department of Dermatology and Allergy, Allergy-Centre-Charité, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Medical Microbiology, Immunology, and Hygiene, Technische Universität, Munich, Germany
| | - Torsten Zuberbier
- Department of Dermatology and Allergy, Allergy-Centre-Charité, Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Britta Siegmund
- Medical Department, Division of Gastroenterology, Infectiology, and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Jörg-Dieter Schulzke
- Medical Department, Division of Gastroenterology, Infectiology, and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
- Institute of Clinical Physiology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Severin Daum
- Medical Department, Division of Gastroenterology, Infectiology, and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Reiner Ullrich
- Medical Department, Division of Gastroenterology, Infectiology, and Rheumatology, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany.
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Screening for Celiac Disease in Irritable Bowel Syndrome: An Updated Systematic Review and Meta-analysis. Am J Gastroenterol 2017; 112:65-76. [PMID: 27753436 DOI: 10.1038/ajg.2016.466] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/13/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Celiac disease (CD) and irritable bowel syndrome (IBS) share similar symptoms, leading to confusion between the two and diagnostic delay. International guidelines recommend screening individuals with IBS for CD, via serological testing. However, studies published recently have cast doubt on the utility of this. We updated a previous meta-analysis examining this issue. METHODS MEDLINE, EMBASE, and EMBASE Classic were searched through to May 2016. Eligible studies recruited adults with IBS according to symptom-based criteria, physician's opinion, or questionnaire data. Tests for CD included IgA-class antigliadin antibodies (AGA), endomysial antibodies (EMA), tissue transglutaminase antibodies (tTG), or duodenal biopsies following positive serology. The proportion of individuals meeting criteria for IBS testing positive for CD was combined to give a pooled prevalence for all studies, and compared between cases with IBS and, healthy controls without (where reported), using an odds ratio (OR) with a 95% confidence interval (CI). RESULTS There were 36 eligible studies, recruiting 15,256 individuals, of whom 9,275 (60.8%) met criteria for IBS. Pooled ORs for positive IgA AGAs, EMA and/or tTG, and biopsy-proven CD in IBS subjects vs. controls were 3.21 (95% CI 1.55-6.65), 2.75 (95% CI 1.35-5.61), and 4.48 (95% CI 2.33-8.60), respectively. There was no increase in ORs for any test for CD among cases with IBS in North American studies, and results were inconsistent in population-based studies. The prevalence of biopsy-proven CD was significantly higher across all subtypes of IBS. Limitations included heterogeneity in some analyses, and few North American studies. CONCLUSIONS Overall, prevalence of positive celiac serology and biopsy-proven CD was significantly higher in subjects with symptoms suggestive of IBS vs. healthy controls. However, the utility of screening for CD in individuals with suspected IBS in North America or in the community is less clear.
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Volta U, Pinto-Sanchez MI, Boschetti E, Caio G, De Giorgio R, Verdu EF. Dietary Triggers in Irritable Bowel Syndrome: Is There a Role for Gluten? J Neurogastroenterol Motil 2016; 22:547-557. [PMID: 27426486 PMCID: PMC5056565 DOI: 10.5056/jnm16069] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/02/2016] [Indexed: 12/13/2022] Open
Abstract
A tight link exists between dietary factors and irritable bowel syndrome (IBS), one of the most common functional syndromes, characterized by abdominal pain/discomfort, bloating and alternating bowel habits. Amongst the variety of foods potentially evoking "food sensitivity", gluten and other wheat proteins including amylase trypsin inhibitors represent the culprits that recently have drawn the attention of the scientific community. Therefore, a newly emerging condition termed non-celiac gluten sensitivity (NCGS) or nonceliac wheat sensitivity (NCWS) is now well established in the clinical practice. Notably, patients with NCGS/NCWS have symptoms that mimic those present in IBS. The mechanisms by which gluten or other wheat proteins trigger symptoms are poorly understood and the lack of specific biomarkers hampers diagnosis of this condition. The present review aimed at providing an update to physicians and scientists regarding the following main topics: the experimental and clinical evidence on the role of gluten/wheat in IBS; how to diagnose patients with functional symptoms attributable to gluten/wheat sensitivity; the importance of double-blind placebo controlled cross-over trials as confirmatory assays of gluten/wheat sensitivity; and finally, dietary measures for gluten/wheat sensitive patients. The analysis of current evidence proposes that gluten/wheat sensitivity can indeed represent a subset of the broad spectrum of patients with a clinical presentation of IBS.
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Affiliation(s)
- Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Elisa Boschetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giacomo Caio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Mucosal Immunology and Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Roberto De Giorgio
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elena F Verdu
- Department of Medicine, McMaster University, Farncombe Institute, Hamilton, Ontario, Canada
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31
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Sánchez-Vargas LA, Thomas-Dupont P, Torres-Aguilera M, Azamar-Jacome AA, Ramírez-Ceervanes KL, Aedo-Garcés MR, Meixueiro-Daza A, Roesch-Dietlen F, Grube-Pagola P, Vivanco-Cid H, Remes-Troche JM. Prevalence of celiac disease and related antibodies in patients diagnosed with irritable bowel syndrome according to the Rome III criteria. A case-control study. Neurogastroenterol Motil 2016; 28:994-1000. [PMID: 26914655 DOI: 10.1111/nmo.12799] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 01/21/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND The cost-effectiveness for screening for celiac disease (CD) in patients with irritable bowel syndrome (IBS), specifically in the diarrhea (IBS-D) subtype, is beneficial if the prevalence is >1%. However, recent studies have shown controversial results. In this large case-control study, our aim was to determine the prevalence of CD and a panel of related antibodies in patients diagnosed with IBS. MATERIALS AND METHODS Four hundred IBS patients (Rome III) and 400 asymptomatic healthy controls were prospectively evaluated using antihuman tissue transglutaminase (h-tTG IgA) and deamidated gliadin peptide antibodies (DGP II IgA and DGP II IgG). Duodenal biopsy was performed on the patients that were positive for the h-tTG IgA and/or DGP II IgG antibodies. RESULTS The mean age of the population was 44.47 ± 18.01 years and 335 (82%) of the subjects were women. Twenty-one patients and six controls had at least one positive test for CD (5.25% VS 1.5%, p = 0.003, OR 3.63 [95% CI 1.4-9.11]). Eighteen patients were positive for h-tTG and/or DGP-II IgG. Histologic confirmation of CD was 2.5% in the IBS patients vs 0.5% in the controls (p = 0.04, OR 5.21). The IBS-D subtype had the highest prevalence for serological positivity (12.7%). CONCLUSIONS Up to 5.2% of the patients with IBS according to the Rome III criteria were positive for at least one of the CD-related antibodies and 2.5% had biopsy-confirmed CD. Therefore, in our population, screening for CD in subjects with IBS appears to be a reasonable strategy, especially in the IBS-D subgroup.
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Affiliation(s)
- L A Sánchez-Vargas
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico.,Doctorate in Biomedical Sciences, Universidad Veracruzana, Xalapa, Veracruz, Mexico
| | - P Thomas-Dupont
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico.,Doctorate in Biomedical Sciences, Universidad Veracruzana, Xalapa, Veracruz, Mexico
| | - M Torres-Aguilera
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | - A A Azamar-Jacome
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | - K L Ramírez-Ceervanes
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | - M R Aedo-Garcés
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | - A Meixueiro-Daza
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | - F Roesch-Dietlen
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico.,Faculty of Medicine Miguel Alemán Valdés, Veracruz, Veracruz, Mexico
| | - P Grube-Pagola
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | - H Vivanco-Cid
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico
| | - J M Remes-Troche
- Gastrointestinal Motility and Digestive Physiology Laboratory, Medical and Biological Research Institute of the Universidad Veracruzana, Veracruz, Veracruz, Mexico.,Faculty of Medicine Miguel Alemán Valdés, Veracruz, Veracruz, Mexico
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Enck P, Aziz Q, Barbara G, Farmer AD, Fukudo S, Mayer EA, Niesler B, Quigley EMM, Rajilić-Stojanović M, Schemann M, Schwille-Kiuntke J, Simren M, Zipfel S, Spiller RC. Irritable bowel syndrome. Nat Rev Dis Primers 2016; 2:16014. [PMID: 27159638 PMCID: PMC5001845 DOI: 10.1038/nrdp.2016.14] [Citation(s) in RCA: 576] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Irritable bowel syndrome (IBS) is a functional gastrointestinal disease with a high population prevalence. The disorder can be debilitating in some patients, whereas others may have mild or moderate symptoms. The most important single risk factors are female sex, younger age and preceding gastrointestinal infections. Clinical symptoms of IBS include abdominal pain or discomfort, stool irregularities and bloating, as well as other somatic, visceral and psychiatric comorbidities. Currently, the diagnosis of IBS is based on symptoms and the exclusion of other organic diseases, and therapy includes drug treatment of the predominant symptoms, nutrition and psychotherapy. Although the underlying pathogenesis is far from understood, aetiological factors include increased epithelial hyperpermeability, dysbiosis, inflammation, visceral hypersensitivity, epigenetics and genetics, and altered brain-gut interactions. IBS considerably affects quality of life and imposes a profound burden on patients, physicians and the health-care system. The past decade has seen remarkable progress in our understanding of functional bowel disorders such as IBS that will be summarized in this Primer.
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Affiliation(s)
- Paul Enck
- Department of Internal Medicine VI (Psychosomatic Medicine and Psychotherapy), University Hospital Tübingen, Tübingen, Germany
| | - Qasim Aziz
- Wingate Institute of Neurogastroenterology, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, St. Orsola-Malpighi Hospital, Bologna, Italy
| | - Adam D Farmer
- Wingate Institute of Neurogastroenterology, Barts and London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shin Fukudo
- Department of Behavioural Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Emeran A Mayer
- Oppenheimer Center for Neurobiology of Stress, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Beate Niesler
- Department of Human Molecular Genetics, University of Heidelberg, Heidelberg, Germany
| | - Eamonn M M Quigley
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital, Weill Cornell Medical College, Houston, Texas, USA
| | - Mirjana Rajilić-Stojanović
- Department of Biochemical Engineering and Biotechnology, Faculty of Technology and Metallurgy, University of Belgrade, Belgrade, Serbia
| | - Michael Schemann
- Department of Human Biology, Technical University Munich, Freising-Weihenstephan, Germany
| | - Juliane Schwille-Kiuntke
- Department of Internal Medicine VI (Psychosomatic Medicine and Psychotherapy), University Hospital Tübingen, Tübingen, Germany
| | - Magnus Simren
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stephan Zipfel
- Department of Internal Medicine VI (Psychosomatic Medicine and Psychotherapy), University Hospital Tübingen, Tübingen, Germany
| | - Robin C Spiller
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, University of Nottingham, Nottingham, UK
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The prevalence of celiac disease in patients with irritable bowel syndrome and its subtypes. GASTROENTEROLOGY REVIEW 2016; 11:276-281. [PMID: 28053683 PMCID: PMC5209460 DOI: 10.5114/pg.2016.57941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/22/2015] [Indexed: 12/13/2022]
Abstract
Introduction Irritable bowel syndrome (IBS) and celiac disease (CD) share some gastrointestinal symptoms. Celiac disease should be considered in a differential diagnosis of IBS. Aim To estimate the prevalence of predispositions to CD in patients with IBS and its subtypes. Material and methods The study included 48 patients (40 women, 8 men; average age: 41.1 ±14.6 years) with IBS, and a control group: 20 healthy volunteers. All participants completed a questionnaire on their current gastrointestinal symptoms and had a blood sample taken to determine the HLA-DQ2/DQ8 antigens and serum concentration of anti-tTG IgA and anti-DGP IgA and IgG. Results The presence of HLA-DQ2 or DQ8 was found in 50% of patients (n = 24) with IBS. In the control group the presence of HLA-DQ2 was found in 4 (20%) patients and nobody had HLA-DQ8. Increased levels of anti-tTG IgA were found in 5 (10.42%) patients with IBS, anti-DGP in 4 (8.33%), and anti-DGP IgG in 3 (6.25%). In the control group positive test result for anti-tTG was found in 2 (10%) patients; nobody had elevated anti-DGP IgA or IgG. A concomitant positive result of genetic testing and any elevated serum antibodies specific to CD was found in 12.5% of IBS patients (n = 6) and in none of the control group. Conclusions Patients with IBS, regardless of the subtype, significantly more often than healthy controls have the predisposing genetic factors (HLA-DQ2/DQ8) underlying the development of CD.
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De Giorgio R, Volta U, Gibson PR. Sensitivity to wheat, gluten and FODMAPs in IBS: facts or fiction? Gut 2016; 65:169-78. [PMID: 26078292 DOI: 10.1136/gutjnl-2015-309757] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/29/2015] [Indexed: 12/11/2022]
Abstract
IBS is one of the most common types of functional bowel disorder. Increasing attention has been paid to the causative role of food in IBS. Food ingestion precipitates or exacerbates symptoms, such as abdominal pain and bloating in patients with IBS through different hypothesised mechanisms including immune and mast cell activation, mechanoreceptor stimulation and chemosensory activation. Wheat is regarded as one of the most relevant IBS triggers, although which component(s) of this cereal is/are involved remain(s) unknown. Gluten, other wheat proteins, for example, amylase-trypsin inhibitors, and fructans (the latter belonging to fermentable oligo-di-mono-saccharides and polyols (FODMAPs)), have been identified as possible factors for symptom generation/exacerbation. This uncertainty on the true culprit(s) opened a scenario of semantic definitions favoured by the discordant results of double-blind placebo-controlled trials, which have generated various terms ranging from non-coeliac gluten sensitivity to the broader one of non-coeliac wheat or wheat protein sensitivity or, even, FODMAP sensitivity. The role of FODMAPs in eliciting the clinical picture of IBS goes further since these short-chain carbohydrates are found in many other dietary components, including vegetables and fruits. In this review, we assessed current literature in order to unravel whether gluten/wheat/FODMAP sensitivity represent 'facts' and not 'fiction' in IBS symptoms. This knowledge is expected to promote standardisation in dietary strategies (gluten/wheat-free and low FODMAP) as effective measures for the management of IBS symptoms.
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Affiliation(s)
- Roberto De Giorgio
- Department of Medical and Surgical Sciences, Centro di Ricerca Bio-Medica Applicata (C.R.B.A.) and Digestive System, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Umberto Volta
- Department of Medical and Surgical Sciences, Centro di Ricerca Bio-Medica Applicata (C.R.B.A.) and Digestive System, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Peter R Gibson
- Department of Gastroenterology Alfred Hospital, Monash University, Melbourne, Australia
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Extrinsic Sensory Innervation of the Gut: Structure and Function. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 891:63-9. [DOI: 10.1007/978-3-319-27592-5_7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
The past 5 years have seen an increase in the use of a gluten-free diet outside a diagnosis of coeliac disease or IgE-mediated wheat allergy. This trend has led to the identification of a new clinical entity termed noncoeliac gluten sensitivity (NCGS). In this Review, we discuss the evidence for NCGS as demonstrated by the results of double-blind, placebo-controlled dietary rechallenge studies. Furthermore, the characteristic phenotype of individuals with NCGS is described as well as the symptom manifestations commonly reported after gluten exposure, which include intestinal symptoms consistent with IBS, and extraintestinal symptoms such as neurological dysfunction, psychological disturbances, fibromyalgia and skin rash. Moreover, emerging evidence suggests that NCGS can be associated with organic gastrointestinal pathologies, such as IBD, in which its presence might be a reflection of severe or stricturing disease. However, NCGS is not without its controversies and uncertainties, in particular pertaining to whether it is gluten or nongluten components of the grain evoking symptoms; evidence suggests that fermentable carbohydrates, amylase trypsin inhibitors and wheat-germ agglutinin can also be responsible culprits. Finally, we discuss the novel techniques that might help diagnose NCGS in the future.
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Affiliation(s)
- Imran Aziz
- Department of Gastroenterology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
| | - Marios Hadjivassiliou
- Department of Neurosciences, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
| | - David S Sanders
- Department of Gastroenterology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
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Abstract
Wheat-related disorders have become a growing area of clinical and scientific interest and can be categorized broadly as: autoimmune-mediated; allergic; and non-autoimmune/non-allergic conditions. Non-celiac gluten sensitivity (NCGS) and non-celiac wheat sensitivity (NCWS) present on this spectrum as disorders associated with adverse gastrointestinal and extra-intestinal manifestations following exposure to gluten and/or other wheat-related constituents. NCGS/NCWS is increasingly considered in patients with unexplained symptoms after the exclusions of celiac disease and wheat allergy. As objective diagnostic data and specific biomarkers are lacking, response to a gluten-free/wheat-free diet can confirm the presence of NCGS/NCWS. An association with irritable bowel syndrome has been detected, and the effects of other food components, such as fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, may contribute. Our organization and synthesis of extant knowledge pertaining to wheat-related disorders may advance current practice and research efforts toward an improved understanding of NCGS/NCWS as an evolving clinical entity.
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Affiliation(s)
- Renée M Marchioni Beery
- Division of Gastroenterology and Hepatology, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-1845, USA
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Molina-Infante J, Santolaria S, Sanders DS, Fernández-Bañares F. Systematic review: noncoeliac gluten sensitivity. Aliment Pharmacol Ther 2015; 41:807-20. [PMID: 25753138 DOI: 10.1111/apt.13155] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 01/27/2015] [Accepted: 02/15/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Noncoeliac gluten sensitivity (NCGS) is a controversial emerging disorder. Despite reported symptoms related to the ingestion of gluten, NCGS remains a diagnosis based on the exclusion of coeliac disease, given the absence of reliable biomarkers. AIM To evaluate the prevalence, diagnostic exclusion of coeliac disease and the efficacy of a gluten-free diet (GFD) for NCGS patients. METHODS A PubMed search was performed up to December 2014. According to consensus diagnostic criteria, NCGS was defined as self-reported gluten intolerance, negative coeliac serology and absence of villous atrophy. Studies evaluating the impact of a GFD on patients with irritable bowel syndrome (IBS) were also included. RESULTS Prevalence rates of NCGS (0.5-13%) differed widely. Seventeen studies, including 1561 patients (26 children), met the inclusion criteria for NCGS. HLA haplotypes could not be linked to histology [normal or lymphocytic enteritis (LE)] in 1123 NCGS patients. HLADQ2/DQ8 haplotypes were present in 44% of NCGS patients. After advanced diagnostic techniques in 189 NCGS patients combining LE and HLADQ2/DQ8 haplotypes, 39 (20%) were reclassified as coeliac disease. There was a higher than expected family history of coeliac disease and autoimmune disorders in NCGS patients. A GFD resulted in variable results for variable, but significantly improved stool frequency in HLADQ2 positive diarrhoea-predominant IBS patients. CONCLUSIONS Prevalence rates for NCGS are extremely variable. A subset of NCGS patients might belong in the so-called 'coeliac-lite' disease. The benefit of a GFD for NCGS patients is currently controversial. HLADQ2 positive diarrhoea-type IBS patients might gain symptom improvement from a GFD.
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Affiliation(s)
- J Molina-Infante
- Department of Gastroenterology, Hospital San Pedro de Alcantara, Caceres, Spain
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Biesiekierski JR, Iven J. Non-coeliac gluten sensitivity: piecing the puzzle together. United European Gastroenterol J 2015; 3:160-5. [PMID: 25922675 DOI: 10.1177/2050640615578388] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 02/27/2015] [Indexed: 12/11/2022] Open
Abstract
The avoidance of wheat- and gluten-containing products is a worldwide phenomenon. While coeliac disease is well-established, much remains unknown about whether gluten can be a trigger of gastrointestinal and/or extra-intestinal symptoms in patients without coeliac disease. In this article, we discuss the latest scientific evidence and our current understanding for the possible mechanisms of this largely ambiguous group, termed 'non-coeliac gluten sensitive' (NCGS). We can conclude that NCGS should be regarded as an independent disease outside of coeliac disease and wheat allergy, and that the number of patients affected is likely to be limited. Many questions remain unanswered and it needs to be verified whether the elimination of dietary gluten alone is sufficient for the control of symptoms, and to understand the overlap with other components of wheat.
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Affiliation(s)
| | - Julie Iven
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
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Abstract
PURPOSE of review Those who suffer from irritable bowel syndrome (IBS) have long reported the frequent precipitation of their symptoms in relation to food ingestion and have often been convinced that certain foods were especially problematic. However, until very recently, research on the responses to food or individual dietary constituents, in IBS, has been scarce. This review addresses recent literature on diet and IBS. RECENT FINDINGS The complexity of food-symptom interactions in IBS is being revealed in recent and ongoing research. Such studies have revealed the variable effects of fibre in IBS and the susceptibility of IBS individuals to the ingestion of poorly digested and absorbed carbohydrates. The latter has led to the widespread adoption of the low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) diet. Less certain is the role of another widely adopted dietary strategy, gluten restriction. Diet-microbe interactions are critical to the homeostasis of the gut microbiome in health and may well be disturbed in disease; enthusiasm continues, therefore, for the use of probiotics in IBS. SUMMARY Food is a common precipitant of symptoms in IBS and recent research has focused on the role(s) of individual dietary constituents in IBS and on fibre, FODMAPs, gluten and probiotics, in particular. Each may have a role in certain IBS sufferers.
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Kucek LK, Veenstra LD, Amnuaycheewa P, Sorrells ME. A Grounded Guide to Gluten: How Modern Genotypes and Processing Impact Wheat Sensitivity. Compr Rev Food Sci Food Saf 2015; 14:285-302. [PMID: 33401796 DOI: 10.1111/1541-4337.12129] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 01/04/2015] [Indexed: 12/30/2022]
Abstract
The role of wheat, and particularly of gluten protein, in our diet has recently been scrutinized. This article provides a summary of the main pathologies related to wheat in the human body, including celiac disease, wheat allergy, nonceliac wheat sensitivity, fructose malabsorption, and irritable bowel syndrome. Differences in reactivity are discussed for ancient, heritage, and modern wheats. Due to large variability among species and genotypes, it might be feasible to select wheat varieties with lower amounts and fewer types of reactive prolamins and fructans. Einkorn is promising for producing fewer immunotoxic effects in a number of celiac research studies. Additionally, the impact of wheat processing methods on wheat sensitivity is reviewed. Research indicates that germination and fermentation technologies can effectively alter certain immunoreactive components. For individuals with wheat sensitivity, less-reactive wheat products can slow down disease development and improve quality of life. While research has not proven causation in the increase in wheat sensitivity over the last decades, modern wheat processing may have increased exposure to immunoreactive compounds. More research is necessary to understand the influence of modern wheat cultivars on epidemiological change.
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Affiliation(s)
- Lisa Kissing Kucek
- School of Integrated Plant Science, Plant Breeding and Genetics Section, 240 Emerson Hall, Cornell Univ., Ithaca, NY, 14853, U.S.A
| | - Lynn D Veenstra
- School of Integrated Plant Science, Plant Breeding and Genetics Section, 240 Emerson Hall, Cornell Univ., Ithaca, NY, 14853, U.S.A
| | - Plaimein Amnuaycheewa
- Dept. of Agro-Industrial, Food, and Environmental Technology, Faculty of Applied Science, King Mongkut's Univ. of Technology North Bangkok, Bangkok, 10800, Thailand
| | - Mark E Sorrells
- School of Integrated Plant Science, Plant Breeding and Genetics Section, 240 Emerson Hall, Cornell Univ., Ithaca, NY, 14853, U.S.A
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Lauwers GY, Fasano A, Brown IS. Duodenal lymphocytosis with no or minimal enteropathy: much ado about nothing? Mod Pathol 2015; 28 Suppl 1:S22-9. [PMID: 25560597 DOI: 10.1038/modpathol.2014.135] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 09/18/2014] [Accepted: 09/18/2014] [Indexed: 02/06/2023]
Abstract
Duodenal lymphocytosis is a nonspecific finding that is being detected with heightened frequency. Although increased intraepithelial lymphocytosis with normal villous architecture classically corresponds to grade 1 of the Marsh classification, many other conditions have been reported to be associated with this histologic pattern. In this article, we offer a broad review of the associations of isolated increased intraepithelial lymphocytosis with celiac and nonceliac gluten sensitivity, as well as of the broadening nonceliac etiologies.
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Affiliation(s)
- Gregory Y Lauwers
- Gastrointestinal Pathology Service, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Alessio Fasano
- Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Boston, MA, USA
| | - Ian S Brown
- Envoi Pathology, Brisbane, Queensland, Australia
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Tavío Hernández E, Cano Ruiz A. Sensibilidad al gluten no celíaca: ¿una verdadera entidad o solo una quimera? Med Clin (Barc) 2014; 143:446-7. [DOI: 10.1016/j.medcli.2014.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 06/26/2014] [Accepted: 07/07/2014] [Indexed: 02/08/2023]
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Spencer M, Chey WD, Eswaran S. Dietary Renaissance in IBS: Has Food Replaced Medications as a Primary Treatment Strategy? ACTA ACUST UNITED AC 2014; 12:424-40. [PMID: 25219357 DOI: 10.1007/s11938-014-0031-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT The medical community has only recently started to focus attention on the role of food in the pathogenesis of irritable bowel syndrome (IBS), though the association between food and gastrointestinal (GI) symptoms has been recognized by patients for decades. Health care providers receive little formal training in the dietary management of IBS and have traditionally viewed dietary interventions with skepticism. There is mounting evidence that links food to changes in motility, visceral sensation, microbiome, permeability, immune activation, and brain-gut interactions-all key elements in the pathogenesis of IBS. The role of specific dietary modification in the management of IBS has not been rigorously investigated until recently. There is now credible evidence suggesting that targeted dietary carbohydrate exclusion provides clinical benefits to IBS patients. There is emerging evidence to suggest that proteins such as gluten, as well as food chemicals, may play a role in IBS.
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Affiliation(s)
- Marisa Spencer
- Division of Gastroenterology, University of Michigan Health System, 3912 Taubman Center, SPC 5362, Ann Arbor, MI, 48109-5362, USA,
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Mansueto P, Seidita A, D'Alcamo A, Carroccio A. Non-celiac gluten sensitivity: literature review. J Am Coll Nutr 2014; 33:39-54. [PMID: 24533607 DOI: 10.1080/07315724.2014.869996] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND A significant percentage of the general population report problems caused by wheat and/or gluten ingestion, even though they do not have celiac disease (CD) or wheat allergy (WA), because they test negative both for CD-specific serology and histopathology and for immunoglobulin E (IgE)-mediated assays. Most patients report both gastrointestinal and nongastrointestinal symptoms, and all report improvement of symptoms on a gluten-free diet. This clinical condition has been named non-celiac gluten sensitivity (NCGS). AIM We attempt to define the current pathogenic, clinical, and diagnostic criteria of this "new" disease, to provide a practical view that might be useful to evaluate, diagnose, and manage NCGS patients. METHODS We reviewed the international literature through PubMed and Medline, using the search terms "wheat (hyper)sensitivity," "wheat allergy," "wheat intolerance," "gluten (hyper)sensitivity," and "gluten intolerance," and we discuss current knowledge about NCGS. RESULTS It has been demonstrated that patients suffering from NCGS are a heterogeneous group, composed of several subgroups, each characterized by different pathogenesis, clinical history, and, probably, clinical course. NCGS diagnosis can be reached only by excluding CD and WA. Recent evidence shows that a personal history of food allergy in infancy, coexistent atopy, positive for immunoglobulin G (IgG) antigliadin antibodies and flow cytometric basophil activation test, with wheat and duodenal and/or ileum-colon intraepithelial and lamina propria eosinophil counts, could be useful to identify NCGS patients. CONCLUSIONS Future research should aim to identify reliable biomarkers for NCGS diagnosis and to better define the different NCGS subgroups. Key teaching points: • Most patients report both gastrointestinal and nongastrointestinal symptoms, and all agree that there is an improvement of symptoms on a gluten-free diet. • NCGS diagnosis can be reached only by excluding celiac disease and wheat allergy. • Patients suffering from NCGS are a heterogeneous group, composed of several subgroups, each characterized by different pathogenesis, clinical history, and, probably, clinical course. • A personal history of food allergy in infancy, coexistent atopy, positive IgG antigliadin antibodies (AGA) and flow cytometric basophil activation test, with wheat and duodenal and/or ileum-colon intraepithelial and lamina propria eosinophil counts, could be useful to identify NCGS patients. • Future research should aim to identify reliable biomarkers for NCGS diagnosis and to better define the different NCGS subgroup.
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Affiliation(s)
- Pasquale Mansueto
- a Internal Medicine, University Hospital of Palermo , Palermo , ITALY
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Czaja-Bulsa G. Non coeliac gluten sensitivity - A new disease with gluten intolerance. Clin Nutr 2014; 34:189-94. [PMID: 25245857 DOI: 10.1016/j.clnu.2014.08.012] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 08/11/2014] [Accepted: 08/22/2014] [Indexed: 12/18/2022]
Abstract
Until recently gluten intolerance has been believed to be typical of celiac disease (CD) and wheat allergy (WA). In the last few years, however, several study results have been published that have proved that gluten intolerance can also affect people who do not suffer from any of the above mentioned diseases. The new syndrome has been named non-celiac gluten sensitivity (NCGS) or gluten sensitivity (GS). It has been included in the new list of gluten-related disorders published in 2012. Researchers believe that NCGS is the most common syndrome of gluten intolerance. This review discusses many aspects of NCGS epidemiology, pathophysiology, clinical spectrum, and treatment and current tools to identify patients suffering from CD, WA, and NCGS.
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Affiliation(s)
- Grażyna Czaja-Bulsa
- Paediatric and Paediatric Nursery Unit of The Pomeranian Medical University in Szczecin, Poland; Division of Paediatrics, Gastroenterology and Rheumatology of The "Zdroje" Hospital in Szczecin, Poland.
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Gasbarrini G, Mangiola F. Wheat-related disorders: A broad spectrum of 'evolving' diseases. United European Gastroenterol J 2014; 2:254-62. [PMID: 25083282 DOI: 10.1177/2050640614535929] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 04/14/2014] [Indexed: 12/31/2022] Open
Abstract
Throughout the world, cereals have always been recognized as a fundamental food. Human evolution, through the development of cooking, led to the production of food rich in gluten, in order to take full advantage of the nutritional properties of this food. The result has been that gluten intolerance has arisen only in those populations that developed the art of cooking wheat. It is also recognized that wheat, one of the central elements of the Mediterranean diet, cannot be tolerated in some individuals. Among the wheat-related pathologies, coeliac disease is the best known: it is a chronic inflammatory condition affecting the gastrointestinal tract, which develops in genetically predisposed individuals. The most common manifestation is the malabsorption of nutrients. Recently, another wheat-related disease has appeared: non-coeliac gluten sensitivity, defined as the onset of a variety of manifestations related to wheat, rye and barley ingestion, in patients in whom coeliac disease and wheat allergy have been excluded. In this paper we will explore the damaging power of wheat, analysing the harmful process by which it realizes the onset of clinical manifestations associated with wheat-related disorders.
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Affiliation(s)
- Gb Gasbarrini
- Fondazione Ricerca in Medicina ONLUS, Bologna, Italy
| | - F Mangiola
- Department of Internal Medicine, Gastroenterology Division, Catholic University of Sacred Heart, Policlinico "A. Gemelli" Hospital, Roma, Italy
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Zanini B, Lanzarotto F, Villanacci V, Carabellese N, Ricci C, Lanzini A. Clinical expression of lymphocytic duodenosis in "mild enteropathy" celiac disease and in functional gastrointestinal syndromes. Scand J Gastroenterol 2014; 49:794-800. [PMID: 24941349 DOI: 10.3109/00365521.2014.919017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Abnormally high number of duodenal intraepithelial lymphocytes is frequently found in many conditions including mild enteropathy celiac disease (CD) and functional gastrointestinal syndromes, but is unclear whether lymphocytosis affects the clinical phenotype particularly in functional syndromes. MATERIALS AND METHODS We compared clinical characteristics of celiac patients with lymphocytic duodenosis and normal villous structure with those of patients with functional gastrointestinal syndromes with and without lymphocytic duodenosis. We retrospectively identified 3 cohorts among patients referred for suspected CD: (1) "CoelD", 135 patients (age 36 ± 14 years) with mild enteropathy CD; (2) "LymD", 245 patients (38 ± 12 years) with functional gastrointestinal syndromes and lymphocytic duodenosis; and (3) "NorD", 147 patients (37 ± 15 years) with functional syndromes and normal duodenal histology. RESULTS Prevalence of gastrointestinal symptoms was similar in the three cohorts, but prevalence of extra-intestinal manifestations (42% vs. 27% vs. 18%, p < 0.003) and of associated diseases (35% vs. 15% vs. 14%, p < 0.0001) was higher in "CoelD" than in "LymD" and "NorD", respectively. Prevalence of Helicobacter pylori infection was similar in the three cohorts. The proportion of patients with final diagnosis of irritable bowel syndrome-diarrhea (38% vs. 37%), dyspepsia (31% vs. 27%), functional pain (14% vs. 19%), and functional diarrhoea (14% vs. 11%) was virtually the same in the cohorts with (LymD) and without (NorD) lymphocytic duodenosis. CONCLUSIONS Lymphocytic duodenosis has different clinical presentation in patients with mild enteropathy CD than those with functional gastrointestinal syndromes, and is not specific for any particular functional syndrome.
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Affiliation(s)
- Barbara Zanini
- Gastroenterology Unit, University and Spedali Civili , Brescia , Italy
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Molina-Infante J, Santolaria S, Montoro M, Esteve M, Fernández-Bañares F. Sensibilidad al gluten no celiaca: una revisión crítica de la evidencia actual. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:362-71. [DOI: 10.1016/j.gastrohep.2014.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/21/2013] [Accepted: 01/16/2014] [Indexed: 12/13/2022]
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Lu W, Gwee KA, Siah KTH, Kang JY, Lee R, Ngan CCL. Prevalence of Anti-deamidated Gliadin Peptide Antibodies in Asian Patients With Irritable Bowel Syndrome. J Neurogastroenterol Motil 2014; 20:236-41. [PMID: 24840376 PMCID: PMC4015193 DOI: 10.5056/jnm.2014.20.2.236] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 12/27/2013] [Accepted: 01/08/2014] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND/AIMS Non-celiac gluten sensitivity has been increasingly recognized as a predisposing factor for irritable bowel syndrome (IBS)-like symptoms in Western populations where celiac disease (CD) is relatively common. In Asia where CD is rare, we wish to de-termine the prevalence of gluten protein associated serology in IBS patients, which has not been formally studied, and its rela-tion to histological and human leukocyte antigen (HLA) markers. METHODS We reviewed a consecutive cohort of Asian patients with IBS, who had undergone serologic testing for IgA against deamidated gliadin peptide antibodies (IgA DGP) and IgA anti-endomysium antibodies, and who also had duodenal biopsies during clinical workup. In addition, a subset of Chinese patients with positive serology was further tested for HLA-DQ2 and HLA-DQ8. RESULTS Of 186 patients, 34 (18%) were positive for IgA DGP; bloating, abdominal pain, belching and diarrhea were the most com-monly reported symptoms but diarrhea as the most bothersome symptom was significantly more common in IgA DGP positive patients. Mildly increased intra-epithelial lymphocytes on duodenal biopsy was also more common (29% vs. 9%, P = 0.001). Nine of 21 Chinese patients tested as IgA DGP positive undertook HLA-DQ2/DQ8 testing, with only 2 being positive for HLA-DQ8. All patients with positive IgA DGP reported symptom improvement with gluten withdrawal. CONCLUSIONS We have described a series of Asian, mainly Chinese, patients with IBS who were tested positive for IgA DGP, and improved on a gluten exclusion diet. We believe this is the first report of non-celiac gluten sensitivity in Asia, a region where CD is uncommon.
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Affiliation(s)
- Wei Lu
- Department of Gastroenterolgy and Hepatology, National University Health System, Singapore
| | - Kok-Ann Gwee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kewin Tien Ho Siah
- Department of Gastroenterolgy and Hepatology, National University Health System, Singapore
| | - Jin Yong Kang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rumin Lee
- Stomach, Liver and Bowel Center, Gleneagles Hospital, Singapore
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