Personal Experience and Narrative Review
A Carroccio, P Mansueto, A D’Alcamo, G Iacono
Am. J. Gastroenterol 2013 Oct 29;[EPub Ahead of Print]
TAKE-HOME MESSAGE
- What is the pathogenesis of non-celiac wheat sensitivity (NCWS)?
- A review was conducted of 276 diagnosed patients.
- Patients might be suffering from non–IgE mediated food allergy, but other pathogenic mechanisms need to be considered.
Commentary By: David Rakel, MD, FAAFP
Is Non-Celiac Wheat Sensitivity Real?
Is non-celiac wheat sensitivity (NCWS) real? With gluten-free diets being all the rage, it makes us wonder if the fad is more powerful than the facts.
Carroccio and colleagues have published two studies1,2 that make a strong argument that there is, in fact, a unique wheat sensitivity—NCWS. They showed that about one-third of 900 patients with irritable bowel syndrome (IBS) had a sensitivity to wheat, with significant improvement when it was eliminated from the diet. Unlike celiac disease, there is no villous atrophy and anti-endomysial antibodies are often negative. But the researchers documented that 50% to 60% of NCWS patients had positive anti-gliadin IgG antibodies and the majority had eosinophilic mucosal infiltration on biopsy.
You should suspect NCWS in patients with a history of atopy (eczema, asthma) and food allergy in infancy, as this history was more common in the patients studied. The majority (206 of 276 patients) of those with NCSW also had a reaction to cow’s milk, suggesting that there may be multiple food sensitivities that extend beyond wheat in some patients.
If you have a patient with IBS symptoms (diarrhea and constipation dominant) who test negative for celiac disease, it may be worth doing an elimination diet off wheat and dairy for 2 weeks to see if the symptoms improve. If they do, then add a food group back for 1 day and see if the symptoms recur over the next 3 days. Then repeat with other foods groups as needed.
At this point, there is no dependable test to adequately confirm NCWS. The gold standard is to do an elimination diet. But be careful about the risk of creating a fear of food as the mind can trigger symptoms that can lead to malnutrition.
References
Carroccio A, Mansueto P, Iacono G, et al. Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. Am J Gastroenterol. 2012;107(12):1898-1906.
Carroccio A, Mansueto P, D’Alcamo A, Iacono G. Non-Celiac Wheat Sensitivity as an Allergic Condition: Personal Experience and Narrative Review [published online ahead of printOctober 29, 2013]. Am J Gastroenterol. doi: 10.1038/ajg.2013.353.
ABSTRACT
Objectives: Non-celiac wheat sensitivity (NCWS) is a newly described clinical entity characterized by symptoms, which can involve the gastrointestinal tract, the nervous system, the skin, and other organs. There is little data on the pathogenesis of NCWS and it is probable that different pathogenic mechanisms are involved in the different clinical manifestations of the disease. The only common denominator of NCWS “syndrome” is wheat consumption: the symptoms disappear on exclusion of wheat from the diet, and reappear on wheat consumption. The objective of this study was to review our prior data regarding NCWS and to review relevant medical literature regarding NCWS, with particular attention to the hypothesis that NCWS patients could suffer from non-immunoglobulin E (IgE)-mediated wheat allergy.
Methods: We reviewed our data on 276 patients diagnosed with NCWS by means of double-blind placebo-controlled (DBPC) wheat challenge. The data indicating a possible wheat allergy diagnosis were examined and other data in the literature were reviewed; we review the role of serum immunoglobulin G antibodies and the basophil activation assay in food allergy, and the histology findings in the food allergy diagnosis.
Results: The comparison between patients suffering from NCWS and presenting with irritable bowel syndrome (IBS) and controls with IBS not due to NCWS showed that NCWS was characterized by: a personal history of food allergy in the pediatric age (0.01), coexistent atopic diseases (0.0001), positive serum anti-gliadin (0.0001) and anti-betalactoglobulin (0.001) antibodies, positive cytofluorimetric assay revealing in vitro basophil activation by food antigens (0.0001), and a presence of eosinophils in the intestinal mucosa biopsies (0.0001).
Conclusions: Patients with NCWS and multiple food sensitivity show several clinical, laboratory, and histological characteristics that suggest they might be suffering from non-IgE-mediated food allergy. However, other pathogenic mechanisms need to be considered.
Full Story: http://www.practiceupdate.com/journalscan/6594
PubMed Reference: http://www.ncbi.nlm.nih.gov/pubmed/?term=Non-Celiac+Wheat+Sensitivity+as+an+Allergic+Condition%3A+Personal+Experience+and+Narrative+Review