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    What is a Gluten Challenge and How Long Must it Last?

    Scott Adams
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    Reviewed and edited by a celiac disease expert.

      A Three Month Gluten Challenge May be Necessary, and the Length Can Differ Between Kids and Adults.


    A gluten challenge can be daunting to those with symptoms. Image: CC BY 2.0--2017 Canada Summer Games
    Caption: A gluten challenge can be daunting to those with symptoms. Image: CC BY 2.0--2017 Canada Summer Games

    Celiac.com 06/04/2020 - Currently, in order to properly diagnose celiac disease based on serology and duodenal histology, doctors need patients to be on gluten-containing diets, even if they are causing symptoms, and this is called a "gluten challenge." This is a problem for many people, especially those who have already given up gluten, and see benefits from the gluten-free diet. For those people, going back on gluten for several weeks can be demoralizing. For many, it's a deal breaker. This can present challenges for doctors attempting to diagnose celiac disease.

    According to the University of Chicago Celiac Disease Center, a gluten challenge should be done as follows:

    • Prior to celiac disease blood tests: 1/2 slice of wheat bread or 1 wheat cracker should be eaten each day for at least 12 weeks;
    • Prior to endoscopic biopsy procedure: 1/2 slice of wheat bread or 1 wheat cracker should be eaten each day for at least 2 weeks;

    A Three Month Gluten Challenge May be Necessary, and the Length Can Differ Between Kids and Adults



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    In a 2013 study by Maaike J. Bruins, of the DSM Biotechnology Center, The Netherlands, found that:

    Quote

    The onset of symptoms upon gluten intake varied largely from days to months and did not parallel serum antibody or histological changes. Within 3 months of gluten challenge, 70%–100% of pediatric CD patients became positive for AGA-IgA and EMA-IgA antibodies and 50%–70% for AGA-IgG. A limited number of trials suggest that no more than half of adult patients developed positive AGA-IgA, EMA-IgA, tTG-IgA or DGP-IgA/IgG titers. Approximately 50%–100% of pediatric and adult patients experienced mucosal relapse of gluten provocation within 3 months, which was preceded by increased mucosal intra-epithelial lymphocytes within several days of challenge. A 3-month high-dose gluten challenge should be suitable to diagnose the majority of CD patients. In some cases prolonged challenge may be needed to verify diagnosis. Combination testing for antibodies and mucosal histology may fasten the diagnosis.

    Future Tests May Spot Celiac Disease Without Prolonged Gluten Consumption

    Research on systemic cytokine release that occurs after gluten sensitive individuals ingest gluten may lead to new tests that can spot celiac disease without gluten consumption, however, until further research is done, and such tests are developed and made available, a gluten challenge will be necessary to make a formal celiac disease diagnosis.

     

    Edited by Scott Adams

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    Accurate but confusing information. My "executive" summary:

    Eating 1 to maximum 2 slices of bread per day, minimum 2 weeks can give enough gluten to render a proper serologic (blood) test. Other factors apply, therefore read full article for important considerations.

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    This was helpful but if I'm having an upper GI and a biopsy, can I eat less gluten to show positive (over the blood test)? I've been off of gluten for a year and not sure it's helping anything but I'm so afraid to go back, however, I don't want to undergo the biopsy and upper GI if it's pointless.

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    My 5 year old daughter's symptoms point to celiac. After 6 months of symptoms the doctors are finally willing to entertain that there is a problem, blood work came back positive. The G.I. specialist isn't available for 2 months to meet and schedule a test, another (2 months??). We can't feasibly continue to poison this poor girl waiting for the test as symptoms of distended stomach and malnutrition are apparent already. Knowing that the diet must have gluten to present proper results, we don't feel comfortable continuing behaviour that is damaging.

     

    Question is; does it make sense to stop the gluten diet now, wait for improvement and not preform the test?

    Should we resume eating gluten just prior to the testing? Will this still give correct and accurate results?

    Continue feeding her gluten and wait for the doctors to become available?

     

    Bear in mind that we have been on a Miralax dose twice the recommended for an adult and still suffer constipation and distended stomach.

     

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    Is there any other disease or illness for which the "confirmed" diagnosis requires that the patient subject themselves to bodily harm, possibly irreversible?  Is there any other disease or illness that requires the patient to submit themselves to conditions that could be called torture in order to arrive at a "confirmed" diagnosis?  If you have positive blood tests, and have been helped by eliminating gluten, why should you have to endure this extra challenge to your entire body (not just your digestive system)?  I didn't and won't submit myself to these extraordinary requirements, just so my doctor can be satisfied with a "gold standard" diagnosis.  If you, yourself want that gold standard diagnosis, and don't mind the extra harm that will be inflicted on your body, then you should have the test.  In the meantime, I'm going to wait until a test is developed that doesn't require that I torture and damage my body by ingesting gluten.

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    Yes, and many people can't go this route after going gluten-free and seeing relief. On the downside you may not get all the follow up care you should have that comes with a diagnosis, but on the upside you also won't have to pay higher private health or life insurance rates, which I've been dealing with.

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    22 hours ago, Scott Adams said:

    Yes, and many people can't go this route after going gluten-free and seeing relief. On the downside you may not get all the follow up care you should have that comes with a diagnosis, but on the upside you also won't have to pay higher private health or life insurance rates, which I've been dealing with.

    "...you may not get all the follow up care you should have that comes with a diagnosis..."   Follow-up care?  Most patients are given a sheet of information about celiac disease, and shown the door.  How many studies and surveys have we seen documenting the poor after-care for newly diagnosed celiac disease patients?

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    True, and I can attest to the fact that  my insurer, Kaiser, has done little to nothing to follow up my CD diagnosis, unless I ask them to do something like a follow up test. In general their doctors agree and run those, but if I didn’t have a diagnosis they’d likely deny those tests.

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    On 12/24/2015 at 6:58 AM, Guest james said:

    My 5 year old daughter's symptoms point to celiac. After 6 months of symptoms the doctors are finally willing to entertain that there is a problem, blood work came back positive. The G.I. specialist isn't available for 2 months to meet and schedule a test, another (2 months??). We can't feasibly continue to poison this poor girl waiting for the test as symptoms of distended stomach and malnutrition are apparent already. Knowing that the diet must have gluten to present proper results, we don't feel comfortable continuing behaviour that is damaging.

     

    Question is; does it make sense to stop the gluten diet now, wait for improvement and not preform the test?

    Should we resume eating gluten just prior to the testing? Will this still give correct and accurate results?

    Continue feeding her gluten and wait for the doctors to become available?

     

    Bear in mind that we have been on a Miralax dose twice the recommended for an adult and still suffer constipation and distended stomach.

     

    I can only give you a non medical answer based on experience. I am sorry you see your child struggling. It must be hard. It is not unusual to have a 2 month space between appointment, testing, and endo scopy.

    My timeline was in 2016. My first Dr allergist/immunologist in March 2016 had to rule out allergies environmental/food IgE allergies, she then sent me to a another immunologist/specialist with a team including gi. I didn't get in until May for my initial appt. In June I went to rheumatologist to check for AI's. My scopes were scheduled in October. I had to eat gluten two weeks prior. 

    I had been gluten-free for a few years before as I suspected I had gluten intolerance , but was diagnosed IBS (symptoms only) since my early 20s. I know your daughter is a child, and she may have a different timeline, but I wanted to let you know many of us have 2 months plus before scopes. 

    I do know having been off gluten it was really difficult to go back on gluten. My husband and children said later they knew from watching me that a gluten-free household was coming before the results were in.

    It is hard to see your child in pain and struggling. I am glad to hear that they are moving forward to determine if your child is celiac. I wish you all luck.

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  • About Me

    Scott Adams was diagnosed with celiac disease in 1994, and, due to the nearly total lack of information available at that time, was forced to become an expert on the disease in order to recover. In 1995 he launched the site that later became Celiac.com to help as many people as possible with celiac disease get diagnosed so they can begin to live happy, healthy gluten-free lives.  He is co-author of the book Cereal Killers, and founder and publisher of the (formerly paper) newsletter Journal of Gluten Sensitivity. In 1998 he founded The Gluten-Free Mall which he sold in 2014. Celiac.com does not sell any products, and is 100% advertiser supported.


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