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    Allergy and Intolerance by Lydia S. Boeken M.D.


    Scott Adams


    Introduction

    Through his writings, we know that Hippocrates, the father of medicine, had already recognized the presence of allergic reactions in people as early as ancient times. However, the term allergy is a relatively new one, as compared to many other commonly used medical terms. In 1906, Viennese pediatrician Baron Clemens von Pirquet used the term for the first time to describe an altered response of his patients bodies. Von Pirquet believed that this altered reaction manifested itself in changes of the immune system, effected by external influences on the body, such as: food intake, the air breathed or direct skin contact. The term allergen (the substance responsible for the altered reaction) was born. At that point in time, however, von Pirquet had no means of scientifically proving that these immunological changes actually occurred in the body. It was not until the mid-1920s, that a second significant event occurred.

    Researchers found that, by injecting a minute quantity of purified allergen under the skin, certain individuals would develop a clear skin response; a welt, with or without itching and redness, could be provoked. This positive skin test for allergies would show itself most prominently in patients with hay fever, asthma, chronic rhinitis, hives and eczema. The prick test became a method of demonstrating the involvement of the immune system in allergic reactions. However, the precise biological reason for the reaction continued to remain a mystery.

    It was not until the Sixties, when an important discovery occurred which provided long-awaited scientific support for the classical allergy theory and removed any doubts about the relationship of the immune system with allergies. This breakthrough came about with the scientific discovery of immunoglobulin E (IgE) by a Japanese couple named Ishizaka.

    Classical Allergic Reaction

    The following are the chain of events which happen in allergic reactions:

    • An allergen must be present in the body. This allergen is the substance which causes us to have an abnormal immunological response. Allergens tend to be protein molecules. Interestingly enough, the immune system only detects particles of a certain size as potential troublemakers and protein molecules are just the right size. In a small number of cases, the body actually responds to molecules other than proteins. These molecules, which are generally much smaller, are called haptens. By combining with protein molecules, haptens form larger complexes which can then be detected by the immune system.
    • The allergen is detected by the B cells. These are specialized immune cells, capable of producing antibodies. Just like allergens, antibodies are protein molecules, which have the capacity to neutralize allergens.
    • Every B cell produces its own, specific antibody, depending on the type of intruder it needs to respond to. It is easy to understand why the body must have a ready pool of millions of antibodies, in order to combat these numerous offenders. There are five main categories of antibodies (IgG, IgA, IgM, IgD and IgE) which the body releases under different circumstances (for instance to fight off various infections, etc.). In the case of allergies, the body produces the antibody immunoglobulin E (IgE), first discovered by the Ishizakas.
    • Usually, antibodies will bind directly to the appropriate damaging substance and neutralize it. However, IgE deviates from this common path. It first attaches one of its legs to one of the bodys numerous mast cells. The other leg is used to hold on to the offending allergen. This action signals the mast cells to begin disintegrating, thereby releasing histamine.

    Histamine is a chemical substance responsible for a great number of complaints which may arise during allergic reactions. It causes muscle cramps and an inflammation-like process with redness and swelling of mucous membranes.

    Allergic reactions can occur under a variety of circumstances. For instance, inhaling certain substances, such as grass pollen, house dust, etc., may cause an allergic response. However, the consumption of certain foods may do the same. Allergies typically bring on complaints very rapidly upon contact with the allergen. Complaints may vary from a runny nose, sinusitis, earache or runny eyes to itching of the skin, eczema and shortness of breath.

    Intolerance

    Conventional medicine can easily diagnose and treat allergies for foods or inhalants. Here, the so-called RAST test plays a very important role, because this test can demonstrate the presence of IgE.

    However, demonstrating the presence of intolerance is more difficult. In this situation, similar to the case of classical allergies, the body responds abnormally and, in addition, the immune system does not produce IgE. It quite often takes much longer for complaints to come on, thereby masking the possible link between the offensive substance and the complaints themselves.

    These are only a few of the reasons why food intolerance is considered a fairly controversial concept in conventional medicine. Intolerance can be responsible for a wide variety of complaints which, at first glance, seem to lack a plausible explanation. Intolerance can manifest themselves as the following:

    • Gastrointestinal complaints: stomach ache, irritable bowel, Crohns disease, ulcerative colitis
    • Skin complaints: itching, eczema, hives, acne (in adults)
    • Joint and muscle complaints: ranging from atypical pains to rheumatoid arthritis
    • Headache and migraine
    • Chronic fatigue
    • Asthma, chronic rhinitis or sinusitis
    • Pre-menstrual syndrome
    • Hypoglycemia
    • Depression, anxiety
    • Sleeping disorders

    Diagnosing Intolerance

    It is impossible to accurately demonstrate intolerance through conventional testing methods.

    The Amsterdam Clinic currently uses the following test, which is very reliable.

    • Another useful test is the IgG(4) antibody test. Here, the presence of IgG(4) antibodies is determined. These antibodies are the slowly occurring variety, which do not appear in the blood until 24 to 48 hours after exposure to an offending food or substance. The reliability of this test varies between 80 and 90%.

    Treatment

    Diet

    In the treatment of inhalant allergies (such as asthma, hay fever) and food allergies and intolerance, avoidance (elimination) of allergens plays an extremely important role. In the case of food sensitivities, either the cytotoxic test or IgG(4) test can help determine reactions to specific foods. Based on the test results, an elimination/rotation diet can be specifically tailored.

    Foods causing strong reactions in these tests, should (temporarily) be excluded from the diet. More moderate reactions allow for rotation of certain food items in the diet. These may be eaten once every four days. Especially during the first week(s) of the diet, withdrawal symptoms, similar to complaints stemming from the cessation of coffee, tobacco or alcohol consumption, may occur. The body seems to crave offending food items. Generally, these withdrawal symptoms disappear after a couple of weeks. Concurrently, those complaints relating to food sensitivity also diminish.

    Using this dietary approach, the reaction to food allergens may decrease in the course of time. After a three month moratorium, reintroduction of forbidden food items can be attempted, one at a time. In this way, food items still causing reactions can be isolated more easily. Often, at least part of existing intolerance completely disappear after an elimination/rotation diet.

    With the treatment for inhalant allergies, elimination is also the first step. It is obvious that patients having an allergy for cats or dogs, should avoid any contact with these pets. The situation becomes more difficult when dealing with allergies to grass or tree pollen, since total elimination is basically impossible. The same goes for house dust mite allergy. The house dust mite lives in mattresses, pillows, carpeting, drapes, upholstery, etc. Through mite-killing pesticides, special mattress and pillow covers, non-carpeted floors, etc. reasonable results can be obtained.

    Medication

    Medicines for inhalant allergies, such as antihistamines (Triludan), corticosteroids (Prednisone, Pulmicort, Becotide), cromoglycates (Lomudal, Lomusol), and airway dilating medication (Ventolin, Berotec, Atrovent) do suppress symptoms, however, they do not cure the allergy! In the realm of conventional medicine, effective medications for food allergy and intolerance do not exist at all.

    Desensitisation

    Enzyme-potentiated desensitisation (EPD) and the provocation/neutralization method are very effective treatments for food allergy/intolerance and inhalant allergy problems. These methods tackle allergy problems at the root.

    • During EPD treatment, a small quantity of a food or inhalant allergen mixture is injected intradermally into the skin, in conjunction with the enzyme beta-glucuronidase. This combination causes the body to gradually adjust its exaggerated responses to food and inhalant allergens. In this way, the immune system is readjusted and reset. Initially, the injections have to be given once every two months. Gradually, however, the intervals between injections become longer and the injections can often be discontinued after a time. According to conservative estimates, at least 80% of those patients treated with EPD show considerable improvement in the course of time.
    • Provocation/neutralization can be used both diagnostically and therapeutically. Here, separate extracts of food or inhalants, suspected as possibly offending, are injected intradermally. This causes a welt to appear in the skin. After 10 minutes, the size and nature (firmness, color, etc.) of the welt are evaluated. A positive welt will generally bring on symptoms (provocation). Depending on the size and nature of the welt, as well as, the presence of symptoms, varying concentrations are injected, until a dose is found which does not cause any welt changes or symptoms. This is the neutralizing dose. Injections with the proper neutralizing dose will bring on immediate protection against the symptoms caused by the offending food and/or inhalant.

    Copyright © 1996 the Amsterdam Klikiek

    For further information please contact:

    Also in THE NETHERLANDS:
    Amsterdam Kliniek
    Reigersbos 100
    1107 ES Amsterdam Z.O.
    Telephone 31 (0)20 697 53 61
    Telefax 31 (0)20 697 53 67
    Lydia S. Boeken M.D. London/Amsterdam


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    Guest Elizabeth Van Sickle

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    Excellent resource and very helpful.

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    Guest charles lynn

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    Extremely informative, thought provoking, and written so that it is easy to understand.

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    Very clearly written; fully answered my question.

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    Guest Jodi Zeller

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    I was just diagnosed with celiac disease and I found a lot of good information in this article.

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    Guest Dale Jones

    Posted

    Very informative, my husband came up negative for celiac disease, though he displays all of the symptoms when not kept on a gluten free diet. His sister was diagnosed in her mid 50's with celiac. Your site has been so helpful and I have learned so much. thank you Scott.

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    Guest Jean emery

    Posted

    I have not been diagnosed with celiac but instead have a history of diverticulitis for almost 6 years. last year I had a colon resection and they removed 4 inches of my colon. I felt much better till 3 months ago when I had a questionable diverticulitis attack and was put on antibiotics. 1 month ago I had another attack very similar left-lower quadrant pain and was again put on antibiotics. In fact my MD even suggested I should probably consider surgery again which made me very depressed. SO another health care provider suggested that maybe I had a gluten allergy as I did eat tons of wheat products. SO for 3 weeks I have been doing gluten free and am feeling so much better--very little pain and gas and it is a wonderful feeling. Have you ever heard of someone getting relief with symptoms like mine? Thanks JEAN

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    I live in a small town in North Carolina and most people have never heard of celiac disease so I read everything I can on this disease because I know so little about it ....

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    Guest K beams

    Posted

    My son has both celiac and diverticulitis-please stay on the diet. He also has trouble with popcorn-the hulls stick to his intestines and cause the diverticulitis-as long as stays on the gluten-free diet and off popcorn, he is well!!

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    Guest T.Parker

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    Very interesting reading...Will find out myself this week if I have celiac disease.

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    Very informative. Thank you. I am in the process of being tested for celiac disease. I had never heard of it until I decided to give an Asthma/Allergist doctor a try.

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  • About Me

    In 1994 I was diagnosed with celiac disease, which led me to create Celiac.com in 1995. I created this site for a single purpose: To help as many people as possible with celiac disease get diagnosed so they can begin to live happy, healthy gluten-free lives. Celiac.com was the first site on the Internet dedicated solely to celiac disease. In 1998 I founded The Gluten-Free Mall, Your Special Diet Superstore!, and I am the co-author of the book Cereal Killers, and founder and publisher of Journal of Gluten Sensitivity.

  • Related Articles

    Scott Adams
    The following is a March 11, 1998 post by Kemp Randolph krand@PIPELINE.COM.
    According to Dr. Hugh Sampson, Mt. Sinai Medical Center, at an AMA sponsored press briefing on Nutrition, in a list of Facts vs. Fictions, Fiction: Skin tests or blood tests can be used to diagnose food sensitivities. Fact: ...A positive test does not mean a person will react to a food...furthermore these tests do not tell whether a person has a non-IgE mediated sensitivity to food.
    He describes these tests only as useful guides and points out that diet testing is the only reliable way to identify a food allergy, preferably where the person does not know whether they have eaten the suspect food.
    Q: If I am sensitive to milk and eggs...could they damage my villi in the same way as gluten?
    A: Theres a specific note in Michael Marshs book about food allergies causing villi damage. Thats the book On Coeliac Disease, page 155. Table there shows that the Type 3 stage of intestinal response, flat destructive does occur with milk, egg, soy and chicken or fish allergies. It differs from the celiac response in that only 1 or 3 of the 5 stages of lesion connected with celiac disease occur with an allergy.
    Whats unclear from this reference and from Medline searches Ive made is whether food allergies in adults cause villi damage. All the references I found were for children. Villi destruction does occur in children with milk allergy, but this like other pediatric allergies, apparently is usually outgrown.

    Paul Smith
    Celiac.com 06/29/2009 - Hypersensitive reactions to food are becoming increasingly problematic in society. Allergy experts report that the prevalence of food allergies appears to be rising and while there are no exact figures for this in Australia, some studies have shown marked increases overseas.
    For example, a study from the Isle of Wight in the U.K. has shown a tripling in the rate of peanut allergies over the past 10 years. However, the reason for this is not yet clear.  Auckland allergy expert Dr. Vincent Crump has three theories regarding the increase in peanut allergies.
    More people are eating peanuts and, up until recently, many eczema creams contained peanut oil, possibly exposing an allergy prone person to the food.
    There’s also the 'hygiene theory' of disease, which suggests that children are not exposed to enough dirt and bacteria these days, and therefore do not build up a normal immunity to harmless substances. So when they are exposed, their immune system overreacts and they develop an allergy.
    Despite the overall increase in food allergies, the rate in adults is still pretty low – around one per cent. However, the rate is higher in children, where up to five per cent are believed to have a food allergy.

    Allergy vs. intolerance
    The most common and best understood type of allergy is a reaction in which the body's immune system overreacts to a food and mistakenly produces antibodies (called IgE) to the food. This can cause reactions, sometimes severe, that affect the skin, breathing, gut and heart.
    An intolerance is an adverse reaction to a food that does not involve the immune system. Symptoms are generally less severe, and can include headaches, gut problems and worsening of skin conditions such as eczema. Intolerance is much less likely to be life-threatening than a true allergy.

    What is an allergy?
    According to the Australian Society of Clinical Immunology and allergy (ASCIA) education resources website, the word “allergy” is frequently overused and misused to include any irritating or uncomfortable symptoms after eating.
    Strictly speaking the term should only be used for the symptoms which develop after eating certain foods as part of the immune response.
    In an allergic reaction, the body’s immune system mistakenly believes the food is harmful and tries to protect itself. In doing so it overreacts and produces, for example, harmful antibodies to fight the food “allergens”. In turn, these special antibodies (called IgE) make the body produce histamines and other chemicals, causing reactions that affect the skin, breathing, gut and heart.
    IgE antibodies can also “cross react “with other allergens. For example, someone with a latex allergy may also react after eating a banana, kiwi fruit or avocado. According to allergy specialist Professor Rohan Ameratunga, up to 50 per cent of people who react to one tree nut (including almonds, brazil nuts, Cashews, hazelnuts, macadamias, pecans, pine nuts, pistachios and walnuts) will react to other tree nuts.
    A recently recognized form of food allergy is the “oral allergy syndrome”, where a person experiences a cross reaction between pollens and fresh fruit and vegetables.
    This “cross-reactivity” is also the reason why some adults with a predisposition to other allergies suddenly develop a food allergy.
    For example, a person with a birch pollen allergy can suddenly became allergic to apple or kiwi fruit allergens.
    Dr Crump says more and more adults prone to allergies are developing cross reactions after they are overexposed to certain foods (such as acquiring wheat allergies after working in a bakery).

    What are the most common food allergies?
    Allergies are mostly triggered by nuts, shellfish, fish, milk, eggs, wheat and soybeans.Adults are more likely to be allergic to fish, shellfish and nuts, with children suffering more from allergies to milk, eggs and peanuts.  Reactions to seeds and fruits are also becoming more common.
    There are cultural differences in allergy patterns, according to professor Ameratunga.
    In Japan, rice allergy is common. In the Middle East and Australia, sesame allergy is on the rise.
    We know the treatment for coeliac disease is a gluten-free diet for life. Although people with coeliac disease produce antibodies the allergic process is different from that seen in most other allergic reactions.
    In coeliac disease, gluten reacts with the small intestine, and activates the immune system to attack the delicate lining of the bowel.
    The normally rippled lining of the intestine becomes damaged and inflamed, and forms the characteristic flat appearance of celiac disease.
    The surface area, which enables the absorption of nutrients and minerals from food, is seriously depleted, leading to gastrointestinal and malabsorptive symptoms.

    Common Intolerances
    Almost any food can cause an intolerance, but the repeat offenders are;OFFENDER:
    Lactose
    FOUND IN:
    Milk and milk products. Yoghurts have little lactose and hard cheeses have none.
    OFFENDER:
    Salicylates
    FOUND IN:
    Natural food chemicals found in a wide variety of fruits and vegetables such as cauliflower, eggplant, broccoli, tomato, apple, orange, and pineapple. Also found in nuts, spices and aspirin.

    OFFENDER:
    Amines
    FOUND IN:
    Histamines and histamine-like chemicals produced during fermentation, and the ageing and ripening of foods. Found in wine, processed meats, hard cheese, tomato paste, chocolate, and many fruits and vegetables.

    OFFENDER:
    Glutamate
    FOUND IN:
    An amino acid found naturally in all protein foods such as cheese, processed meats and milk. MSG (additive621) is a type of glutamate, and natural glutamates are also found in soy sauce, broccoli, mushrooms, spinach, tomatoes, grapes, plums and many others foods.
    Anything else you'd like to add?
    Leave a comment
     

    Dr. Vikki Petersen D.C, C.C.N
    This article originally appeared in the Autumn 2010 edition of Celiac.com's Journal of Gluten-Sensitivity.
    Celiac.com 12/06/2010 - The hazards to health created by celiac disease and gluten sensitivity are well understood.  From nutritional deficiencies to osteoporosis, from depression to autoimmune disease, and from psoriasis to thyroid disease, there are few areas of the human body that gluten doesn’t touch in a negative way. 
    There is so much emphasis on our inadequate abilities to diagnose gluten intolerance, that when we do finally make the diagnosis I believe we are guilty of another problem—lack of adequate education to those affected patients.
    Just last month a research study was released by the American Journal of Gastroenterology, 2010 Jun; 105(6):1412-20.  The article was entitled “Mucosal recovery and mortality in adults with celiac disease after treatment with a gluten-free diet”.  The research team hailed from the Division of Gastroenterology and Hepatology at Mayo Clinic College of Medicine.
    They stated that while a positive clinical response is typically observed in most adults with celiac disease after treatment with a gluten-free diet, the rate of small intestine recovery is less certain.  Their aims were to estimate the rate of intestinal recovery after a gluten free diet in a cohort [a group of people with statistical similarities] of adults with celiac disease, and to assess the clinical implications of persistent intestinal damage after a gluten-free diet. 
    Of 381 adults with biopsy-proven celiac disease, 241 had both a diagnostic and follow-up biopsy.  Among these 241, the confirmed mucosal recovery at 2 years following diagnosis was 34% and at 5 years was 66%.  Most patients (82%) had some positive clinical response to the gluten-free diet, but it did not prove a reliable marker of intestinal recovery. 
     Poor compliance to the gluten-free diet, severe celiac disease as defined by diarrhea and weight loss, and total villous atrophy at diagnosis were strongly associated with persistent intestinal damage. 
    There was a trend toward an association between mucosal recovery and a reduced rate of all-causes of death, adjusted for gender and age. 
    The conclusions were that intestinal recovery was absent in a substantial portion of adults with celiac disease despite treatment with a gluten-free diet, and that there was an association between confirmed intestinal recovery (vs. persistent damage) and reduced mortality independent of age and gender. 
    So what can we learn from this?

    Eating gluten-free when you are sensitive will cause you to feel better.  Going on a gluten-free diet is not enough to ensure that your intestines will heal. Failing to heal your intestines puts you at increased risk for disease and death. Successfully healing your intestines reduces your incidence of death from disease.
    While you likely knew the first point, 2, 3, and 4 are perhaps less well known.  Where I see that we are failing the gluten intolerant population is in the narrow focus of eliminating gluten as the only needed treatment.  What the above research proves is that, unfortunately, for over 30% of those diagnosed simply eliminating gluten is insufficient to ensure intestinal healing. 
    If patients were educated that healing their intestine would make the difference between contracting disease or not and extending their life expectancy or not, I think they’d be more interested in ensuring that it occurs.
    I am not a researcher but my clinic sees hundreds of patients who align with the results of this study completely.  Patients come to see us who have been told that they shouldn’t consume gluten and for the most part they follow that recommendation.  They know that they feel better when they are gluten-free so that is an impetus to not cheat.  When they do cheat they know that they’ll “pay” for it but they still do so fairly regularly. 
    Why do they cheat?  Because they believe that the diarrhea, headache, bloating, etc is temporary and that when it goes away they are “fine” again.  Their thought process is not unreasonable, it’s just wrong!
    If each patient was educated that cheating created intestinal destruction that in turn put them on a fast track towards disease and early death, I believe that cheating would take on a whole new perspective.
    Patients need this education and they need it often.  Our book “The Gluten Effect” was written with this intention—our patients actually requested it.   They asked for a written reminder of why they should maintain their gluten-free lifestyle.  Later I began taping Youtube videos because other patients preferred a reminder in a video form. 
    I’m trying to say this in a few different ways because it is terribly upsetting to meet patients, as I so often do, who have been diagnosed celiac or gluten sensitive and do not follow their diet solely due to ignorance.
    After almost 25 years of clinical experience I also know that some people “hear what they want to hear” and doctors with the best of intentions cannot get through to everyone.  But I strongly believe that we could be doing a much better job at enlightenment.
    Further, we also need to educate patients about the secondary effects associated with gluten.  When the immune system of the intestine is suppressed, as is the case in the presence of gluten pathology, inhospitable and pathogenic organisms can gain entry into the intestine and remain there.  These organisms may be in the form of bacteria, parasites, amoebas or worms and if they are not identified and eradicated, complete healing of the intestines is all but impossible. 
    The good bacteria that are housed in the gut, known as the microbiome or probiotics, make up much of the intestinal immune system.  In gluten intolerant patients this important population of organisms is often insufficient due to the onslaught from gluten and pathogenic organisms.  If the population of these probiotics is not restored to a healthy, robust balance, any attempt to achieve a healthy intestine will be unsuccessful.
    Lastly, it is an interesting catch-22 that in order to digest our food we need enzymes and enzymes are made from the nutrients we digest.  This circular pattern is dramatically interrupted in the gluten intolerant patient.  Celiacs in particular suffer from very poor absorption.  It shouldn’t then come as a surprise that augmenting with proper enzymes may be critical for “priming the pump” until proper digestion of nutrients is restored.
    Unfortunately I find that few, if any, of these points are made clear to patients who are gluten intolerant.  Most believe they are doing all they need to do simply by maintaining a mostly gluten-free diet.  Nothing could be further from the truth.
    To review we need to do the following:

    Maintain a “perfect” avoidance  of gluten Test for the presence of pathogenic organisms Test for any imbalance of the probiotic organisms Evaluate the need for enzymes Evaluate for the presence of any other food sensitivities, e.g.  dairy Educate the patient until they have a full understanding of the above Test to ensure that the intestine is healed

    Jefferson Adams
    Four Big Differences Between Celiac Disease and Non-Celiac Gluten Sensitivity
    Celiac.com 05/08/2015 - While it's true that all people with celiac disease are intolerant to gluten, not all people who are intolerant to gluten have celiac disease.
    Several studies have confirmed the existence of non-celiac gluten sensitivity (NCGS), a hypersensitivity or form of gluten intolerance that causes numerous symptoms similar to those of celiac disease.
    There are several key differences between celiac disease and NCGS. NCGS is distinguished from celiac disease by the following factors:
    No Hereditary Link
    Unlike celiac disease, NCGS is not hereditary, and shows no genetic component.
      No Connection with Celiac-related Disorders
    Unlike celiac disease, NCGS is so far not associated with malabsorption, nutritional deficiencies, or a higher risk of autoimmune disorders or intestinal malignancies.
      No Immumological or Serological Markers
    Researchers have, as yet, identified no immunologic mechanisms or serologic markers for NCGS. That means that, unlike with celiac disease, there are no telltale screening tests that can point to NCGS.
      Absence of Celiac Disease or Wheat Allergy
    Doctors diagnose NCGS only by excluding both celiac disease, and an IgE-mediated allergy to wheat, and by the continued presence of adverse symptoms associated with gluten consumption. Diagnosing celiac disease can be challenging. Misdiagnosis is common, and final and accurate diagnosis can take years and visits to numerous doctors.
    Because of these key differences, non-celiac gluten sensitivity is often even more slippery and difficult to confirm than celiac disease, itself.
    How about you? Do you or someone you know have celiac disease or NCGS? Share your story in our comments section below.
    Source:
    US Pharmacist. 2014;39(12):44-48.

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    • Maureen and Cyclinglady, Of the foods you listed. . .. I would focus on the Chocolate. Chocolate has Tyramine in it and it could/can cause rashes that  might be confused for DH. Sometimes Tyramine get's confused for/in high sulfite foods as triggers. Here is a great overview article on this topic. http://www.chicagotribune.com/lifestyles/health/sc-red-wine-headache-health-0608-20160525-story.html you might also have trouble with headaches if it tyramine is causing you your trouble. People who have trouble Tyramine might also have trouble with consuming cheeses. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738414/ As for the Milk causing/triggering your DH don't rule Adult onset dairy allergy. While rare it does occur in the literature/research when you search it out. I am including the research here in the hopes it might help you or someone else entitled "Adult onset of cow's milk protein allergy with small‐intestinal mucosal IgE mast cells" https://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.1996.tb04640.x It is generally thought most of grow out of a Milk Allergy at approx. 3 years old. But for some lucky one (I guess) we never do apparently.  (I speak for my friend on this board JMG).  He found out he was having trouble with dairy as an adult better never realized until about 6 months ago. With delayed onset allergies it is often hard to tell if it (allergen) is effecting us because we might not associate it with our dairy consumption because it might happen a day or two latter. See this WHFoods article about food allergens/sensitivies.  It is very long/exhaustive but it is very helpful if you have time to study it in more detail. http://www.whfoods.com/genpage.php?pfriendly=1&tname=faq&dbid=30 I will quote some key points for your information. Symptoms of Food Allergies "The most common symptoms for food allergies include vomiting, diarrhea, blood in stools, eczema, hives, skin rashes, wheezing and a runny nose. Symptoms can vary depending upon a number of variables including age, the type of allergen (antigen), and the amount of food consumed. It may be difficult to associate the symptoms of an allergic reaction to a particular food because the response time can be highly variable. For example, an allergic response to eating fish will usually occur within minutes after consumption in the form of a rash, hives or asthma or a combination of these symptoms. However, the symptoms of an allergic reaction to cow's milk may be delayed for 24 to 48 hours after consuming the milk; these symptoms may also be low-grade and last for several days. If this does not make diagnosis difficult enough, reactions to foods made from cow's milk may also vary depending on how it was produced and the portion of the milk to which you are allergic. Delayed allergic reactions to foods are difficult to identify without eliminating the food from your diet for at least several weeks and slowly reintroducing it while taking note of any physical, emotional or mental changes as it is being reintroduced." Here is their information on Tyramine's. Tyramine "Reactions to tyramine (an amino acid-like molecule) or phenylalanine (another amino acid-like molecule) can result from eating the following foods: Fermented cheeses Fermented Sausage Chocolate Sour Cream Red wine Avocado Beer Raspberries Yeast Picked Herring Symptoms of tyramine intolerance can include urticaria (hives), angioedema (localized swelling due to fluid retention), migraines, wheezing, and even asthma. In fact, some researchers suggest that as many as 20 percent of migraines are caused by food intolerance or allergy, and tyramine intolerance is one of the most common of these toxic food responses." Here is an old thread on tyramine and especially how it can trigger headaches. https://www.celiac.com/forums/topic/95457-headache-culprit-is-tyramine/ I would also suggest your research a low histamine food diet.  Rashes/hives etc. can be triggered my disregulaton of histamine in the body. The other thing in chocolate that might be causing your problems is Sulfites. Here is a website dedicated to a Sulftie allergy. http://www.allergy-details.com/sulfites/foods-contain-sulfites/ Chocolate bars are on their list of sulfite contaning foods but probably most noted in dried fruits and red wine. Knitty Kitty on this board knows alot about a sulfite allergy. I want to go back to the possible dairy allergy for a second as a possible trigger. . .because it has been established as connected to DH . . .it is just not well known. Here is current research (as I said earlier) most dairy allergies are studied in children but it does occur in approx. 10 pct of the GP unless your of Asian descent where it is much more common. https://www.ncbi.nlm.nih.gov/pubmed/29555204 quoting the new research from this year on children. "When CMP (Cow's Milk Protein) was re-introduced, anti-tTG increased, and returned to normal after the CMP was withdrawn again." and if adults can also (though rarely) it seem develop "Adult onset of cow's milk protein allergy with small‐intestinal mucosal IgE mast cells" (see research linked above) as the research shows  you should at least trial removing dairy from your diet if you haven't already and see if your DH doesn't come back when you re-introduce it. It just takes 15 or 20 years for medical doctor' to incorporate new research/thinking into clinical practice.  And note the research on this happening in adults is 20+ years old and as far I know doctor's . . . are not aware of this.  I know I wasn't until recently and I research things alot of to help myself and my friends. But I know you can't do what you don't know about.  So this is why I am trying to share what I learned so that other might be helped and this research might not  lay hidden another 20 years before doctor's and their Celiac/DH patients become aware of it. And if it helps you come back on the board and let us know so it can help others too! If it helps you it will/can help someone else! if they know it helped you then they will/can have hope it might help them too and why I share and research these things for others'. . . who don't know or don't have time to research this for themselves. I hope this is helpful but it is not medical advice. Good luck on your continued journey. I know this is a lot of information to digest at one time but I hope at least some of if it helpful and you at least have a better idea of what in your chocolate could be causing your DH (idiopathic) as the doctor's say (of an unknown cause mild) DH symptom's. Or at least it is not commonly known yet that Milk can also cause trigger (DH) in children and adults who have a Milk allergy undiagnosed. . .because we don't don't typically think  or associate it with adults like maybe we should if we are not of Asian descent. Maureen if this doesn't help you you might want to start a thread in the DH section of the forum. As always  2 Timothy 2: 7   “Consider what I say; and the Lord give thee understanding in all things” this included. Posterboy by the grace of God,
    • I hooe you can get some answers with your new GI doc.
    • Many of us deal with doctor issues and diagnosis, you got a really bad draw indeed. Most doctors dismiss Celiac as their is no money in the cure for them IE a gluten free diet and not medications.

      Keep up updated on your new doctor and testing, good to see you finally found one that listens and can help, I got through on doc #5 I think it was.
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