Original Contribution

Colon/Small Bowel

Gluten Causes Gastrointestinal Symptoms in Subjects Without Celiac Disease: A Double-Blind Randomized Placebo-Controlled Trial

  • The American Journal of Gastroenterology 106, 508514 (2011)
  • doi:10.1038/ajg.2010.487
  • Download Citation
Received:
Accepted:
Published online:

Abstract

OBJECTIVES:

Despite increased prescription of a gluten-free diet for gastrointestinal symptoms in individuals who do not have celiac disease, there is minimal evidence that suggests that gluten is a trigger. The aims of this study were to determine whether gluten ingestion can induce symptoms in non-celiac individuals and to examine the mechanism.

METHODS:

A double-blind, randomized, placebo-controlled rechallenge trial was undertaken in patients with irritable bowel syndrome in whom celiac disease was excluded and who were symptomatically controlled on a gluten-free diet. Participants received either gluten or placebo in the form of two bread slices plus one muffin per day with a gluten-free diet for up to 6 weeks. Symptoms were evaluated using a visual analog scale and markers of intestinal inflammation, injury, and immune activation were monitored.

RESULTS:

A total of 34 patients (aged 29–59 years, 4 men) completed the study as per protocol. Overall, 56% had human leukocyte antigen (HLA)-DQ2 and/or HLA-DQ8. Adherence to diet and supplements was very high. Of 19 patients (68%) in the gluten group, 13 reported that symptoms were not adequately controlled compared with 6 of 15 (40%) on placebo (P=0.0001; generalized estimating equation). On a visual analog scale, patients were significantly worse with gluten within 1 week for overall symptoms (P=0.047), pain (P=0.016), bloating (P=0.031), satisfaction with stool consistency (P=0.024), and tiredness (P=0.001). Anti-gliadin antibodies were not induced. There were no significant changes in fecal lactoferrin, levels of celiac antibodies, highly sensitive C-reactive protein, or intestinal permeability. There were no differences in any end point in individuals with or without DQ2/DQ8.

CONCLUSIONS:

“Non-celiac gluten intolerance” may exist, but no clues to the mechanism were elucidated.

  • Subscribe to The American Journal of Gastroenterology for full access:

    $870

    Subscribe

Additional access options:

Already a subscriber?  Log in  now or  Register  for online access.

References

  1. 1.

    , , et al. Intestinal antibodies against gliadin, tissue-transglutaminase, beta-lactoglobulin, and ovalbumin in patients with irritable bowel syndrome. Ann NY Acad Sci 1998;859:280–284.

  2. 2.

    , . Review article: small intestinal bacterial overgrowth, bile acid malabsorption and gluten intolerance as possible causes of chronic watery diarrhoea. Aliment Pharmacol Ther 2009;29:1069–1077.

  3. 3.

    , , et al. Predictors of clinical response to gluten-free diet in patients diagnosed with diarrhea-predominant irritable bowel syndrome. Clin Gastroenterol Hepatol 2007;5:844–850.

  4. 4.

    , , et al. Food intolerance: a major factor in the pathogenesis of irritable bowel syndrome. Lancet 1982;2:1115–1117.

  5. 5.

    , . Fructans of chicory: intestinal transport and fermentation of different chain lengths and relation to fructose and sorbitol malabsorption. Am J Clin Nutr 1998;68:357–364.

  6. 6.

    , , et al. Dietary triggers of abdominal symptoms in patients with irritable bowel syndrome: randomized placebo-controlled evidence. Clin Gastroenterol Hepatol 2008;6:765–771.

  7. 7.

    , , et al. In vivo antigen challenge in celiac disease identifies a single transglutaminase-modified peptide as the dominant A-gliadin T-cell epitope. Nat Med 2000;6:337–342.

  8. 8.

    , , et al. A structural and immunological basis for the role of human leukocyte antigen DQ8 in celiac disease. Immunity 2007;27:23–34.

  9. 9.

    , , et al. Evidence for a primary association of celiac disease to a particular HLA-DQ alpha/beta heterodimer. J Exp Med 1989;169:345–350.

  10. 10.

    . Gluten, major histocompatibility complex, and the small intestine. A molecular and immunobiologic approach to the spectrum of gluten sensitivity (“celiac sprue”). Gastroenterology 1992;102:330–354.

  11. 11.

    , , . Intestinal permeability and screening tests for coeliac disease. Gut 1980;21:512–518.

  12. 12.

    , . Coeliac disease. Lancet 2003;362:383–391.

  13. 13.

    , , . Gliadin cytotoxicity and in vitro cell cultures. Toxicol Lett 2003;146:1–8.

  14. 14.

    , , et al. Induction of apoptosis in caco-2 cells by wheat gliadin peptides. Toxicology 2000;145:63–71.

  15. 15.

    , , . In vitro cytotoxic effect of wheat gliadin-derived peptides on the Caco-2 intestinal cell line is associated with intracellular oxidative imbalance: implications for coeliac disease. Biochim Biophys Acta 1999;1453:152–160.

  16. 16.

    , , et al. Rapid disruption of intestinal barrier function by gliadin involves altered expression of apical junctional proteins. FEBS Lett 2005;579:4851–4855.

  17. 17.

    , , et al. Wheat gliadin induces apoptosis of intestinal cells via an autocrine mechanism involving Fas-Fas ligand pathway. FEBS Lett 2003;540:117–124.

  18. 18.

    , , et al. Rapid and simultaneous quantification of rhamnose, mannitol, and lactulose in urine by HPLC for estimating intestinal permeability in pediatric practice. Clin Chem 1996;42:71–75.

  19. 19.

    , , et al. Measurement of short-chain carbohydrates in common Australian vegetables and fruits by high-performance liquid chromatography (HPLC). J Agric Food Chem 2009;57:554–565.

  20. 20.

    , , . Between celiac disease and irritable bowel syndrome: the no man's land of gluten sensitivity. Am J Gastroenterol 2009;104:1587–1594.

  21. 21.

    , , et al. Fatigue in irritable bowel syndrome: characterization and putative role of leptin. Eur J Gastroenterol Hepatol 2007;19:237–243.

  22. 22.

    , , . Patchy villous atrophy in adult patients with suspected gluten-sensitive enteropathy: is a multiple duodenal biopsy strategy appropriate? Endoscopy 2008;40:219–224.

  23. 23.

    , , et al. Immune activation in patients with irritable bowel syndrome. Gastroenterology 2007;132:913–920.

  24. 24.

    , , et al. Immune dysfunction in patients with functional gastrointestinal disorders. Neurogastroenterol Motil 2009;21:389–398.

  25. 25.

    , , et al. Review article: faecal markers in the assessment of activity in inflammatory bowel disease. Aliment Pharmacol Ther 2002;16:675–681.

  26. 26.

    , . Evidence-based dietary management of functional gastrointestinal disorders. The FODMAP approach. J Gastroenterol Hepatol 2010;25:252–258.

  27. 27.

    , , et al. Interactions between commensal bacteria and gut sensorimotor function in health and disease. Am J Gastroenterol 2005;100:2560–2568.

  28. 28.

    , , et al. Gliadin-dependent neuromuscular and epithelial secretory responses in gluten-sensitive HLA-DQ8 transgenic mice. Am J Physiol Gastrointest Liver Physiol 2008;294:G217–G225.

  29. 29.

    , , et al. In vitro basophil activation assay for the diagnosis of food hypersensitivity in patients with irritable bowel syndrome. Clin Gastroenterol Hepatol 2010;8:254–260.

  30. 30.

    , , . The immunology of gluten sensitivity: beyond the gut. Trends Immunol 2004;25:578–582.

Download references

Acknowledgements

We acknowledge the sponsorship of Well and Good P/L Classic Bread Mix and Muffin Mix by Sam Barak (Noble Park, VIC, Australia); Gemtec Wheat Gluten by Manildra Group Milling (Manildra, NSW, Australia); Evan Perrett (Bakers Delight Centre of Excellence, Box Hill Institute of TAFE, Box Hill, VIC, Australia), and Lynette McCarthy (Gluten Free Gourmet, Mornington, VIC, Australia).

Author information

Affiliations

  1. Monash University Department of Medicine and Gastroenterology, Box Hill Hospital, Box Hill, Victoria, Australia

    • Jessica R Biesiekierski
    • , Evan D Newnham
    • , Peter M Irving
    • , Jacqueline S Barrett
    • , Melissa Haines
    • , Susan J Shepherd
    • , Jane G Muir
    •  & Peter R Gibson
  2. CSIRO Preventative Health Flagship, CSIRO Mathematics and Information Sciences, Brisbane, Australia

    • James D Doecke

Authors

  1. Search for Jessica R Biesiekierski in:

  2. Search for Evan D Newnham in:

  3. Search for Peter M Irving in:

  4. Search for Jacqueline S Barrett in:

  5. Search for Melissa Haines in:

  6. Search for James D Doecke in:

  7. Search for Susan J Shepherd in:

  8. Search for Jane G Muir in:

  9. Search for Peter R Gibson in:

Competing interests

Guarantor of the article: Peter R. Gibson, MD, FRACP.

Specific author contributions: Enrolment of patients and assessment of recruited patients: Jessica R. Biesiekierski, Evan D. Newnham, Peter M. Irving, Jacqueline S. Barrett, and Melissa Haines; analysis of data: Jessica R. Biesiekierski, Evan D. Newnham, and Peter M. Irving; writing of paper: Jessica R. Biesiekierski, Evan D. Newnham, Peter M. Irving, Jacqueline S. Barrett, Melissa Haines, James D. Doecke, Susan J. Shepherd, and Jane G. Muir; approval of the final draft: all authors; design of study: Peter M. Irving, Susan J. Shepherd, and Peter R. Gibson; statistical analysis: James D. Doecke; recruitment of patients: Susan J. Shepherd; supervision of J.R.B.: Jane G. Muir; oversight of study: Jane G. Muir and Peter R. Gibson; mentoring and writing of study: Peter R. Gibson.

Financial support: This study was supported by the Helen Macpherson Smith Trust, the National Health and Medical Research Council (NHMRC) of Australia, and the Vera and Les Erdi Foundation. Susan J. Shepherd was supported by a Dora Lush Scholarship from the NHMRC of Australia. Jacqueline S. Barrett was supported by Sir Robert Menzies Memorial Research Scholarship. Evan D. Newnham was supported by a scholarship from the Gastroenterological Society of Australia. Jessica R. Biesiekierski was supported by a scholarship from the Eastern Health Clinical School, Box Hill Hospital, the Faculty of Medicine, Nursing and Health Sciences, Monash University.

Potential competing interests: Susan J. Shepherd has published cookbooks directed toward issues of dietary fructan restrictions, fructose malabsorption, and celiac disease. She has also published shopping guides for low FODMAPs and low fructose and fructan foods.

Corresponding author

Correspondence to Peter R Gibson.