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Good Article By Dr. Hoggan (on Celiac .com)
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Challenging the Gluten Challenge - By Dr. Ron Hoggan, Ed.D. See your ad here!

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This article appeared in the Autumn 2005 edition of Celiac.com's Scott-Free Newsletter.

There is an abundance of stories about people who begin a gluten-free diet, find that they feel better then decide they want a firm diagnosis of celiac disease. They are facing several problems. First, they may be gluten sensitive without the intestinal lesion of celiac disease. This is very likely since about twelve percent of the population is gluten sensitive, but only a little more than one percent of the general population has celiac disease. Another problem faced by gluten-free individuals who want a diagnosis is that it can take more than five years after returning to a regular gluten-containing diet before the characteristic damage of celiac disease can be seen on a biopsy1. Simply put, after beginning a gluten-free diet, only a positive biopsy is meaningful. A negative biopsy does not rule out celiac disease.

A variety of opinions have been offered regarding how much gluten, for how long, should result in a definitive biopsy. The reality is that no such recommendation is consistent with the medical literature1-4. Some people with celiac disease will experience a return of intestinal damage within a few weeks of consuming relatively small amounts of gluten. Such brief challenges are valuable for these individuals. However, many people with celiac disease or dermatitis herpetiformis will require much larger doses of gluten, over much longer periods, to induce characteristic lesions on the intestinal wall. Unfortunately for these latter individuals, a negative biopsy after a brief gluten challenge can, and often is, misinterpreted as having ruled out celiac disease. Blood tests can compound this problem. If, as seems likely, celiac patients who are slow to relapse are also the ones who develop milder intestinal lesions, they are the very celiac patients for whom blood tests are very unreliable5. Claims to have ruled out celiac disease based on brief challenges with small quantities of gluten is a mistake that could lead to serious, even deadly, consequences.

We may forget that gluten consumption by a person with celiac disease can lead to deadly cancers and a variety of debilitating autoimmune diseases. Any recommendation of a gluten challenge should be accompanied by a clear warning that the process may overlook many cases of celiac disease. The absence of such warnings is inexcusable.

And what about non-celiac gluten sensitivity? The absence of an intestinal lesion does not rule out gluten induced damage to other tissues, organs, and systems. Evidence and research-based information in this area is sadly lacking but we do know that undigested or partly digested gliadin can damage a wide range of human cells6. Thus, one need only be consuming gluten and experience increased intestinal permeability for gluten-induced damage to be a factor in an almost infinite number of ailments.

There are several partial answers to this problem. One, which I’ve raised before, is to employ Dr. Michael N. Marsh’s rectal challenge for the diagnosis of celiac disease, particularly when the individual has already begun a gluten-free diet. This test permits a definitive diagnosis of celiac disease for up to six months after beginning a gluten-free diet. That would catch a great number of celiac patients who have found relief through a gluten-free diet and now want a diagnosis. Another piece of this puzzle is to test for IgG anti-gliadin antibodies. Although these antibodies are considered “non-specific,” they inarguably identify an immune response to one of the most common foods in a regular North American diet. Although these individuals may experience improved wellness on a gluten-free diet, we just don’t know enough about non-celiac gluten sensitivity to do more than recommend that they continue on this diet since it makes them feel better.

Ron Hoggan is an author, teacher and diagnosed celiac who lives in Canada. His book “Dangerous Grains” can be ordered at Celiac.com. Ron’s Web page is: www.DangerousGrains.com.

References:

Kuitunen P, Savilahti E, Verkasalo M. Late mucosalrelapse in a boy with coeliac disease and cow’s milk allergy.Acta Paediatr Scand.1986 Mar;75(2):340-2.

Bardella MT, Fredella C, Trovato C, Ermacora E, Cavalli R, Saladino V, Prampolini L. Long-term remission in patients with dermatitis herpetiformis on a normal diet. Br. J. Dermatol. 2003 Nov;149(5):968-71.

Shmerling DH, Franckx J. Childhood celiac disease: a long-term analysis of relapses in 91 patients.J Pediatr Gastroenterol Nutr. 1986 Jul-Aug;5(4):565-9.

Chartrand LJ, Seidman EG. Celiac disease is a lifelong disorder. Clin Invest Med. 1996 Oct;19(5):357-61.

Rostami K, Kerckhaert J, von Blomberg BM, Meijer JW, Wahab P, Mulder CJ. SAT and serology in adult coeliacs, seronegative coeliac disease seems a reality.Neth J Med. 1998 Jul;53(1):15-9.

Hudson DA, Cornell HJ, Purdham DR, Rolles CJ. Non-specific cytotoxicity of wheat gliadin components towards cultured human cells.Lancet. 1976 Feb 14;1(7955):339-41.

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Thank you for sharing! And sorry for such a delay; I am wading through 14 pages of new posts...haven't been on for a week since I've been studying for midterms.

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That was very interesting. Thanks!

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      Hi Elle, The celiac testing process usually includes a blood test for gliaden antibodies first, and then an endoscopy to take biopsy samples of the small intestine to check for damage.  So while it's good to get the celiac panel done, don't go gluten-free until the whole testing process (including endoscopy) is completed. Vitamin deficits are a problem in celiac disease, so that issue does match up.  Anxiety and digestion problems are common too.  Celiac is tied to a few genes, so if your mom has it, you might have it also or might develop it at some point in life. Don't be too scared of it if it does turn out to be celiac disease.  The gluten-free diet can be a big change but the end result of it is you'll feel better.  You'll probably end up eating better more nutritious food than most people also. Celiac is a great disease in one way, because we know the trigger (gluten) and can treat ourselves with diet.  Most times doctors don't know the cause of autoimmune diseases and can't do anything but medicate the patient.  Our medicine is food.  Yum!  
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    • Eeek confused! Positive biopsy, negative blood test???
      the whole celiac/doctor issue is as frustrating as it is common, unfortunately   my gp, who knows full well that i have celiac, tried to give me this new 'miracle drug' for ibs-d when i told him i was still having indigestion/inflammation for seemingly no reason.  "it's expensive, but i have a coupon for the first month"  O BOY LUCKY ME!  i told him, ok, that i would try it.  (i think i have an idea of what my problem is and i originally asked for something different to try to see if it would work.  he didn't even know what it was)  i'm not gonna try it.  it's a narcotic, it has side effects i don't need or are the same as my symptoms.  i'm gonna switch doctors.  and switch doctors again and again until i find one that KNOWS MORE ABOUT THIS THAN ME.  on top of that, they computerized all their records, which i have been going there for 20 years, ASKING WHAT I'M ALLERGIC TO!  i said:   umm, don't you have that in my MEDICAL RECORDS??!!  well, we have your paper records.  i said, i'm HERE.  don't ya think ya shoulda pulled my file out??  i mean, y'all knew i was coming.  you know, the appointment thing....... LOLZ yeah, i've been gluten free for 6 years, and this clown tells me 'you know, you can't drink beer'  i said yes i can.  he says no, you can't.  i said why not?  because of the alcohol, haha?  no, because it has hops in it and if you're celiac, you can't have hops.  i said it's BARLEY.  O MY GOSH!!!!!!!!!!!!  i said, you're the doctor.  rolled my eyes and left. welcome to the board  sorry for all the yelling, lolz.  
    • Eeek confused! Positive biopsy, negative blood test???
      Thank you! My PA said that she still thinks it's celiac....but I don't feel like she's fully explained why. Some people are hard to get a solid answer out of! I think I'm gonna get a second opinion somewhere else.....appreciate the feedback. Makes me feel a little less crazy
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