Mutatis mutandis: Are we diagnosing too many people with non-celiac gluten sensitivity? Multiple case report

Abstract

We report three patients presenting with gluten-related signs and symptoms. Since villous height/crypt depth ratio, intraepithelial lymphocyte count, and serum antibody tests were not diagnostic for celiac disease (CD), a diagnosis of non-celiac gluten sensitivity (NCGS) was suggested. On the other hand, antibodies suggestive for CD surprisingly showed positive results in the duodenal biopsy organ culture of all three cases. The reported cases suggest the precious potential role that organ culture systems may play in differentiating CD from NCGS. This method should be recommended when gluten-related disorders are suspected in order to reduce the inappropriate diagnosis of NCGS.

Systematic review: noncoeliac gluten sensitivity

“…The authors further admitted that these latter 30% of NCGS patients could actually suffer from coeliac disease . Finally, a recent case series from Italy showed three adult NCGS patients with gluten‐dependent symptoms, HLA DQ2/DQ8 and Marsh 1 lesions with negative or borderline coeliac disease serology, which showed complete remission on GFD . However, biopsy organ culture of the second part of the duodenum showed EMA IgA and anti‐tTG IgA antibody‐positive results and these patients were reclassified as coeliac patients.…”

“…Several diagnostic tools have been proposed in consensus recommendations (γδ + IELs, IgA anti‐TG2 deposits) for a final diagnosis of coeliac disease in these hard‐to‐diagnose patients . However, these techniques (characterisation of γδ + IELs, immunohistological detection of IgA anti‐TG2, duodenal aspirate or biopsy culture and HLA‐DQ2‐gliadin tetramer test) are complex and not always part of current clinical practice. Alternatively, both clinical and histological remission on a GFD could be taken as the features supporting a diagnosis of coeliac disease …”