A 36-Year-Old Woman With Cramping and Diarrhea

Alexander Potashinsky, MD; John W. Birk, MD

Disclosures

March 20, 2018

Discussion

This patient with a medical history of autoimmune thyroid disease presented with chronic diarrhea and "foggy brain" that responded to a gluten-free diet. When she reintroduced gluten into her diet, her symptoms returned. Her blood work was unrevealing, including a normal TSH level and absence of anemia. Her celiac serology testing was normal, and she had unremarkable EGD findings, with biopsies showing only mildly increased intraepithelial lymphocytes. This is a typical presentation of nonceliac gluten sensitivity (NCGS).

Gluten is a primary structural protein of wheat and other grains, such as rye and barley. Over the past 50 years, large-scale farming and use of gluten in food additives and thickeners has led to a fourfold increase in the consumption of gluten.[1] These grains comprise a large proportion of the Western diet, with an average adult in the United States consuming at least 10-15 g/day.[2] Besides gluten, wheat also contains many other proteins, including proinflammatory alpha amylase and trypsin inhibitors (AITs). The exposure of partially digested gluten and AITs to the intestinal mucosa leads to the cascades of both celiac disease and NCGS.[1]

Celiac disease is a well-described autoimmune disease that triggers a body-wide reaction to gluten. First termed "Gee disease," it was first described in 1887 by the British physician Samuel Gee as a childhood condition related to diet. It was then linked to wheat ingestion by Dutch physician William Dicke, who noticed an increase in and abatement of symptoms during wheat shortages during World War II.[3]

Today, celiac disease is a hot topic of public discussion and a major contributor to various food fads. Despite a prevalence of only 1%-3%, the US food market has seen an explosion of gluten-free foods. A survey estimated that about one third of the US population is trying to cut down gluten in their diet.[4] The gluten-free food market is estimated to be over $12 billion dollars, and is growing at over 10% per year. NCGS has been increasingly recognized over the past decade as a medical condition. The prevalence of NCGS is much more difficult to pinpoint, with certain studies reporting a prevalence as high as 13%.[2]

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