In the JournalsPerspective

Non-celiac wheat sensitivity differentiated in two subject populations

Results from a recent study indicate that non-celiac wheat sensitivity is a clinical condition with two types of subjects, one exhibiting characteristics similar to Crohn’s disease and one to food allergies.

Researchers reviewed the charts of 276 patients diagnosed with non-celiac wheat sensitivity (WS) between 2001 and 2011. The study also incorporated 100 patients with celiac disease (CD) and 50 with IBS as controls. All patients in the WS cohort had initially received an IBS diagnosis, became asymptomatic after incorporating an elimination diet, and were diagnosed with WS when symptoms returned following a double blind, placebo-controlled wheat challenge.

Within the WS cohort, 70 patients were diagnosed with WS alone and 206 were diagnosed with hypersensitivity to multiple foods. Patients with WS more frequently experienced coexistent atopic diseases (P=.0001), self-reported wheat intolerance (P=.0001) and food allergy at infancy (P=.01) than patients with either CD or IBS, and also had undergone more GI endoscopy exams than either group (P<.001 for both). Anemia and weight loss were more common among patients with WS than those with IBS (P=.02 and P=.0001, respectively), but not CD.

Symptoms common among CD patients, including anemia and weight loss, were more frequent among patients with WS alone than in those with multiple hypersensitivities (P=.0001 for anemia and P=.02 for weight loss). Factors associated with allergies, such as coexistent atopy, were more common among patients with multiple hypersensitivities (P=.0001).

Eosinophil infiltration of the duodenal and colon mucosa was the primary histologic characteristic of patients with WS, with 63% indicating intra-epithelial (P<.0001 compared with IBS patients) and 60% in the lamina propria (P<.0002 compared with IBS) in the colon, and an eosinophil count of 63 ± 20 per 10 HPF in the duodenum (P<.0005 compared with IBS and CD). Infiltration in the duodenum and colon was significantly more frequent among patients with multiple hypersensitivities compared with those with WS alone (P=.0001 for all).

“Our data clearly identified a patient population suffering from non-CD WS and described their clinical, serological and histologic characteristics,” the researchers wrote. “We also suggest the possibility of distinct populations of subjects with WS: one with characteristics more similar to CD and the other with characteristics strongly pointing to food allergy.”

Results from a recent study indicate that non-celiac wheat sensitivity is a clinical condition with two types of subjects, one exhibiting characteristics similar to Crohn’s disease and one to food allergies.

Researchers reviewed the charts of 276 patients diagnosed with non-celiac wheat sensitivity (WS) between 2001 and 2011. The study also incorporated 100 patients with celiac disease (CD) and 50 with IBS as controls. All patients in the WS cohort had initially received an IBS diagnosis, became asymptomatic after incorporating an elimination diet, and were diagnosed with WS when symptoms returned following a double blind, placebo-controlled wheat challenge.

Within the WS cohort, 70 patients were diagnosed with WS alone and 206 were diagnosed with hypersensitivity to multiple foods. Patients with WS more frequently experienced coexistent atopic diseases (P=.0001), self-reported wheat intolerance (P=.0001) and food allergy at infancy (P=.01) than patients with either CD or IBS, and also had undergone more GI endoscopy exams than either group (P<.001 for both). Anemia and weight loss were more common among patients with WS than those with IBS (P=.02 and P=.0001, respectively), but not CD.

Symptoms common among CD patients, including anemia and weight loss, were more frequent among patients with WS alone than in those with multiple hypersensitivities (P=.0001 for anemia and P=.02 for weight loss). Factors associated with allergies, such as coexistent atopy, were more common among patients with multiple hypersensitivities (P=.0001).

Eosinophil infiltration of the duodenal and colon mucosa was the primary histologic characteristic of patients with WS, with 63% indicating intra-epithelial (P<.0001 compared with IBS patients) and 60% in the lamina propria (P<.0002 compared with IBS) in the colon, and an eosinophil count of 63 ± 20 per 10 HPF in the duodenum (P<.0005 compared with IBS and CD). Infiltration in the duodenum and colon was significantly more frequent among patients with multiple hypersensitivities compared with those with WS alone (P=.0001 for all).

“Our data clearly identified a patient population suffering from non-CD WS and described their clinical, serological and histologic characteristics,” the researchers wrote. “We also suggest the possibility of distinct populations of subjects with WS: one with characteristics more similar to CD and the other with characteristics strongly pointing to food allergy.”

    Perspective
    Anthony J. DiMarino, Jr.

    Anthony J. DiMarino, Jr.

    This trial is significant because it reinforces the theory that non-celiac gluten sensitivity, gluten intolerance despite negative celiac testing, does exist.

    In the March 2011 issue of The American Journal of Gastroenterology, an Australian group reported similar findings. Throughout the course of this particular trial, about one-third of patients experiencing symptoms of irritable bowel syndrome were found to have gluten sensitivity, suggesting that primary care physicians, and especially gastroenterologists, should consider gluten sensitivity in patients who feel better on a gluten-free diet but do not test positive for celiac disease.

    We’re still searching for a serologic or specific histologic marker to identify patients with gluten sensitivity. Although a consistent marker has yet to be discovered, there are indications that measurable differences do exist in such patients; for example, an increased incidence of anti-gliadin antibodies. Also, a higher proportion of eosinophils are noted in the small and large bowel of patients with gluten sensitivity. Our current focus should be establishing a strong statistical foundation for a reliable gluten sensitivity marker.

    • Anthony J. DiMarino, Jr., MD
    • Chief, Division of Gastroenterology and Hepatology Thomas Jefferson University Hospital