Between celiac disease and irritable bowel syndrome: the "no man's land" of gluten sensitivity

Abstract

The repertoire of gastrointestinal (GI) symptoms is finite; however, the etiologies and mechanisms underlying symptom generation and perception are diverse and, in many cases, unknown. This review examines the clinical and experimental evidence exploring the putative relationship between gluten sensitivity (GS) and the generation of GI symptoms. It explores the hypothesis that, in a proportion of patients, GS causes functional bowel disorder (FBD)-like symptoms. We propose a model for investigating and understanding the induction of GI symptoms and dysfunction by gluten in FBD and organic disease. We hypothesize that, even in the absence of fully developed celiac disease, gluten can induce symptoms similar to FBD. We discuss the hypothesis that GS and post-infectious irritable bowel syndrome (IBS) provide two triggers that can explain at least part of the spectrum that constitutes IBS, further advancing an understanding of the role of mucosal responses to luminal factors in FBDs. We propose that the animal model of GS in human leukocyte antigen (HLA)- DQ8 mice allows investigation of mucosal pathophysiological changes that occur before the onset of full-blown inflammation in a GS host. A better understanding of how gluten can cause symptoms in sensitive individuals will illuminate the interaction between host genotype, diet, and intestinal microbiota in generating one of the most common GI conditions.

Figure 1

The spectrum of celiac disease includes subjects with genetic predisposition and sensitivity to gluten, celiac disease, and its complications. It is unknown whether a portion of gluten-sensitive subjects without celiac disease will ever progress in the severity of the spectrum or constitute a separate entity. Latent celiac disease is part of the spectrum, but differs from potential in that, with exposure to gluten, it will progress to celiac disease. GFD, gluten-free diet; Ttg Ab, tissue transglutaminase antibody.

Figure 2

Putative factors underlying the pathophysiology of gastrointestinal (GI) symptoms.

Figure 3

A clinical presentation of irritable bowel syndrome (IBS) does not constitute a specific diagnosis. Gluten sensitivity (GS) may be one of the underlying mechanisms for symptom generation and may not necessarily belong to the spectrum of celiac disease (CD).

Figure 4

Algorithm for the management of patients with IBS-like symptoms and minimal histological change. GFD, gluten-free diet; IBS, irritable bowel syndrome; Ttg Ab, tissue transglutaminase antibody.