Indications and Use of the Gluten Contamination Elimination Diet for Patients with Non-Responsive Celiac Disease

Abstract

For the majority of patients diagnosed with celiac disease, once a gluten-free diet is initiated, symptoms improve within weeks and may completely resolve in months. However, up to 30% of patients may show signs, symptoms or persistent small intestinal damage after one year on a gluten-free diet. These patients require evaluation for other common GI etiologies and assessment of their celiac disease status in order to make a diagnosis and suggest treatment. Here, we propose an approach to evaluating patients with celiac disease with persistent symptoms, persistently elevated serology, and or persistent villous atrophy despite a gluten-free diet. We detail how to diagnose and distinguish between non-responsive and refractory celiac disease. Finally, we introduce the indications for use of the gluten contamination elimination diet and provide information for practitioners to implement the diet when necessary in their practice.

Keywords: celiac; celiac disease; gluten; gluten contamination elimination; gluten-free diet; non-responsive; refractory.

Figure 1

Evaluation of a patient with celiac disease and persistent symptoms, elevated serology, and/or persistent enteropathy. Abbreviations: VA: villous atrophy, ESPGHAN: European Society for Pediatric Gastroenterology Hepatology and Nutrition, GCED: gluten contamination elimination diet, GFD: gluten-free diet, HLA: human leukocyte antigen, CD: celiac disease, EGD: esophagogastroduodenoscopy, Sx: symptoms. * Gluten challenge: Current recommendations suggest a patient to eat approximately 3 g of gluten, which is equivalent to 1–2 slices of gluten-containing bread, daily for 2 to 6 weeks. Clinicians should consider a patient’s length of time on the GFD and symptomatic response to the challenge when determining the ultimate time course of the challenge [24].