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Irritable Bowel Syndrome and Gluten Sensitivity Without Celiac Disease: Notes from the Front Lines 05/14/2012 - Should gluten sensitivity be thought of as “celiac light,” as just one of the milder manifestations within the wider spectrum of celiac disease? Some doctors and researchers think so.

Photo: CC--Joe MabelOver the past several years, there has been increasing discussion concerning gluten sensitivity as a possible cause of irritable bowel syndrome (IBS) symptoms in patients for whom celiac disease has been excluded. 

This is undoubtedly because gluten sensitivity, like IBS, is a symptom-based condition of diverse pathogenesis. As discussed, some have argued that gluten sensitivity might be best thought of as “celiac light,” representing the milder domains of the celiac disease spectrum.

However, there are some data to suggest that a subset of patients with gluten sensitivity may actually belong to the spectrum of celiac disease.

In a recent letter to the editors of the American Journal of Gastroenterology, doctors Courtney C. Ferch and William D. Chey of the Division of Gastroenterology at the University of Michigan Health System in Ann Arbor, Michigan, comment at length on the latest findings regarding Irritable Bowel Syndrome and gluten sensitivity without celiac disease.

Ferch and Chey note that gluten sensitivity is one of the most rapidly growing sectors in the food industry, with gluten-free products accounting for $1.31 billion in U.S. sales alone in 2011. Those sales are expected to exceed $1.6 billion by 2015.

Major food manufacturers such as General Mills and Betty Crocker, along with popular restaurant chains like PF Chang's and Subway are busy introducing new gluten-free options, or retooling original products into gluten-free versions.

People with gluten sensitivity typically show symptoms after eating gluten, but show no evidence of celiac disease or food allergy.

Unlike celiac disease, there are no accepted biomarkers for gluten-sensitivity. Doctors diagnose the condition mainly by looking at the connection between eating gluten and the presence adverse symptoms.

Numerous studies on gluten sensitivity suffer have included small sample size, a lack of adequate controls, a lack of blinding, and the use of non-validated outcome measures. Even with these limitations, Ferch and Chey say there are several studies worthy of further consideration.

One of the studies discussed in the Ferch and Chey was a double-blind, placebo-controlled, dietary re-challenge trial performed by Biesiekierski et al. The study sought to better understand the role of gluten ingestion in the development of gastrointestinal (GI) and non-GI symptoms in patients diagnosed with IBS.

The Biesiekierski study included a sample of 34 patients diagnosed with IBS by the Rome III criteria who had experienced symptom improvement with a gluten-free diet for 6 weeks before study enrollment. Celiac disease had been excluded in all study participants by either a negative HLADQ2/HLA-DQ8 haplotype or a normal duodenal biopsy. The study excluded patients with conditions such as cirrhosis, inflammatory bowel disease, non-steroidal anti-inflammatory drug ingestion, or excessive alcohol.

Over a six week double-blind randomization phase, study participants followed either a gluten-free or gluten-containing diet that was assigned at random. Nineteen of the 34 patients ate food containing 16 g of gluten per day. The other 15 patients ate gluten-free bread and muffins. Gluten used in the study was free of fermentable oligo-, di-, monosaccharides and polyols, and its protein distribution included 2.3% nongluten, 45.7% glutenin, and 52% gliadin.

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The primary outcome of the study was the proportion of patients answering “no” on over half of the occasions at the end of each week to this question: “Over the past week, were your symptoms adequately controlled?”

The study team also assessed secondary outcomes including bloating, abdominal pain, satisfaction with stool consistency, nausea, and tiredness using a 100-mm visual analog scale.

Once the study period ended, the results showed that many more patients in the gluten group compared with the gluten-free group answered “no” to the primary outcome question (68% vs 40%; P  .001).

Compared with the gluten-ingesting group, those who remained gluten-free also reported significant improvements in pain (P  .016), bloating (P  .031), satisfaction with stool consistency (P  .024), and tiredness (P  .001), although they showed similar levels of wind (P  .053) or nausea (P  .69).

The results of celiac antibodies at baseline and after the dietary intervention were
similar.  The team also found that diet had no effect on intestinal permeability as measured by urine lactuloseto-rhamnose ratio. Additionally, they found detectable fecal lactoferrin levels in just one patient during the treatment period.

Meanwhile, high-sensitivity C-reactive protein levels remained normal before and after the dietary intervention.

There was no difference in the level of symptoms experienced by those with and without HLA-DQ2 and HLA-DQ8 alleles. The authors felt that these data support the existence of non–celiac-associated gluten sensitivity. They concluded that gluten is in fact tied to overall IBS symptoms, bloating, dissatisfaction with stool consistency, abdominal pain, and fatigue in some patients.

In their letter, Ferch and Chey also comment on several side issues.

First, they note that a recent global meta-analyses of studies showed that patients with IBS symptoms had significantly higher rates of celiac disease than controls. As such, they point out that the American College of Gastroenterology Task Force now recommends routine celiac blood screens for patients with diarrhea-predominant IBS and IBS with a mixed bowel pattern (grade 1B recommendation).

Secondly, they note that there has been much recent discussion around the potential role of food in IBS symptoms that has focused on celiac disease. However, they point out that much has been made over the possible role of food, and possibly celiac disease, in IBS symptoms. However, they note that data from US studies show no higher risk for celiac disease among patients with IBS symptoms and no warning signs.

Although these results are certainly intriguing and hypothesis generating, they require validation in larger, randomized, controlled trials in other parts of the world.

What is clear and important for providers to understand is that gluten sensitivity is here to stay and significantly more likely for them to encounter in day-to-day practice than celiac disease.

Read the full letter by Ferch and Chey at the website for the  American Journal of Gastroenterology.

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15 Responses:

Bettye Whitten
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said this on
14 May 2012 7:35:42 AM PST
I found this article to be very informative. As one who suffers from irritable bowel syndrome, I am always looking for any helpful hints. Thanks

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said this on
16 May 2012 6:03:28 AM PST
They gave them gluten-free bread and muffins, but did not restrict the rest of their diet? How about pasta, soy sauce, gravy, etc.? To really make a difference, the study needs to be completely gluten-free.

Cindy Chong
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said this on
20 May 2012 7:16:48 AM PST
You are absolutely correct. But then again, there is the possibility that the tests were to identify or screen out, the patients who were "a-symptomatic" through suggestion?

C. Ray
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said this on
16 May 2012 6:16:20 AM PST
Good article. I was diagnosed with irritable bowel syndrome about 8 years before I was diagnosed with celiac disease. When I began eating glutenfree because of the celiac disease diagnosis, my "IBS" symptoms went away. I suspect in the years to come there will be more information on the link between gluten, irritable bowel syndrome, gluten sensitivity, and celiac disease.

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said this on
16 May 2012 6:32:11 AM PST
As a matter of fact, about 4 years ago I thought perhaps trying a gluten-free diet would help my irritable bowel syndrome. So for at least three months I switched to totally gluten-free. The results? For me anyway - absolutely no change. I guess in my case, irritable bowel syndrome is not affected at all by gluten.

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said this on
16 May 2012 8:11:42 AM PST
Very helpful. I am going to pay more attention to this. I have found more issues when eating gluten alone than when I eat it with other foods. Example: sandwich is ok, plain bread is bad.

Robert E Hadwick
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said this on
16 May 2012 8:19:05 AM PST
Just trying to read all I can after being diagnosed with celiac spew. Very good article.

Lois Parker
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said this on
16 May 2012 8:40:07 AM PST
This is helpful but now I wish someone would approach the connection between "near-celiac" or irritable bowel syndrome with gluten sensitivity and sensitivity to dairy and soy sensitivity! It is easy enough to research one of the three but it seems many people have this same additional problem, and it bears research as well.

Mary M. Cushnie-Mansour
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said this on
19 May 2012 4:05:55 AM PST
I have had irregular bowels all of my life, so decided to finally go to a naturalpath. Celiac disease runs in my family - two of my children have it, and two or three cousins (that I know of). While experimenting with foods, in and out of the diet, several interesting results were discovered - it is surprising what one learns about the effects of food on our system. Great article here, to prove that one does not have to be a full blown celiac to have the gluten sensitivity, and what this possibly tells me is that if there is a sensitivity there in the first place, it is only a matter of time before you become full blown. Why not take the action from now and just eat gluten-free - I am!

Anne Marie
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said this on
21 May 2012 8:21:48 PM PST
I have been following all possible links to irritable bowel syndrome and gluten-free/non-celiac research information for the last 6 years as I have severe irritable bowel syndrome but not celiac disease (endoscopy tested twice). Now with the additional diagnosis of Gerd and Barretts's esophogus I am really trying to uncover the cause of these gastrointestinal issues. I have explored the fructose malabsorption diagnosis and am amazed at the relief I have received eliminating the FODMAPS. Gluten is one of the foods to eliminate not because of the 'gluten proteins' but because of the fructan component. I wish I had learned about this sooner and wonder why this 'fructan' component of gluten is not discussed more frequently. Gluten-free is wonderful but often not enough to bring total relief of gut sensitivities.

Jenny W
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said this on
11 Jun 2012 6:54:54 PM PST
My grandson has been diagnosed with celiac disease and also has irritable bowel syndrome, or a bowel problem that has not cleared up after 2 years on a gluten-free diet. At 13, he is not quite in control of his life yet, and I am trying to help. I have just discovered FODMAPS and wonder if you can elaborate on the connection between gluten and fructan. Maybe that is the key to making his life more bearable! I hope so!

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said this on
22 May 2012 3:18:29 AM PST
I was diagnosed with irritable bowel syndrome first and celiac disease many years later. This is an excellent article/letter. Now if the gastrointestinal community will get on board...

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said this on
22 May 2012 4:34:18 AM PST
Whilst searching for info about my recent irritable bowel syndrome symptoms I found out that Hashimoto's thyroiditis sufferers are recommended to go gluten-free. I decided then and there to try it out. After only two days, my irritable bowel syndrome symptoms had almost dissappeared. Also, my aching arms and constant lack of energy are now a thing of the past. I feel so much better, so gluten-free will now be permanent for me. By the way, I am lactose intolerant and as I also have Graves' disease I can't eat soy products either.

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said this on
21 May 2013 11:11:31 AM PST
I went on the Ideal Protein diet for 3 months and along with weight loss, I was amazed and pleased with the peace in my gut. The diet eliminates ALL carbs. Now I am maintaining my weight but the constipation and pain is back. I'm going to try eliminating gluten and see if that peaceful gut returns.

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said this on
25 Sep 2013 8:56:56 AM PST
I was diagnosed with IBS in 1992. I have not found symptom relief until recently. I have been gluten free for one month and noticed a tremendous improvement in my IBS symptoms. I plan to speak to my doctor soon to see if I should have endoscopy to rule out celiac disease. I don't know anyone in my family with celiac, but I do have a family history significant for digestive disorders such as Colitis/Crohn's (which I know I do not have).

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