Low gluten diet in the treatment of adult coeliac disease: effect on jejunal morphology and serum anti-gluten antibodies.

Abstract

SUMMARY Treatment of patients with coeliac disease with a low gluten containing diet (LGD) remains controversial. We have studied jejunal morphology and antigluten (AG) antibody titres by ELISA in patients on a LGD of 2.5-5 g/day for three to 14 months (median six months) and compared results with patients on a strict gluten free diet (GFD) for six to 27 months (median 13 months). We found no significant difference in villous height or crypt depth (eight LGD v 10 GFD patients) or serum AG-IgA, -IgG, and -IgM titres (13 LGD v 12 GFD patients). There was however, a significant increase (p<005) in intra-epithelial lymphocytes in those patients on a LGD. We conclude that adult coeliac patients can tolerate a LGD without gross morphological change and without initiating significant AG antibody responses.After the discovery that gluten is involved in the pathogenesis of coeliac disease,' the medical profession has maintained that a life long strict gluten free diet is mandatory for the health of all patients.' Although there is no doubt that dietary gluten withdrawal results in improvement of clinical symptoms and jejunal morphology, the necessity for total dietary gluten exclusion has been challenged.4 Furthermore, despite physicians' recommendations, many patients are unable to maintain a restrictive GFD and continue to ingest small quantities of gluten.`5 A proportion of these patients remain asymptomatic with normal haematological and biochemical parameters.7 In view of these findings we believe that a low gluten containing diet (LGD) may be a more realistic treatment for coeliac disease in some patients. This concept, however, remains controversial. 9 The aim of the present study was to determine the effects of a LGD on jejunal morphology and serum antibody levels to gluten in a group of coeliac patients we have maintained on a controlled LGD.

IgA Antigliadin Antibodies and Persistence of Jejunal Lesions in Adult Coeliac Disease

“…assessment and this is supported by the ob servation that 7 poorly complying patients with improvement of jejunal lesions were IgA AGA-negative. These patients, however, admitted some lapses from their diet, and this is in keeping with the report that adult coeliac patients can tolerate small quantities of gluten without morphological change and without initiating a significant IgA AGA re sponse [17], Previous attempts by other workers [ 18] failed to predict the status of the jejunal mucosa using noninvasive laboratory crite ria and concluded that, although dietary as sessment correlated more accurately with je junal mucosal findings than any of the pa rameters they measured, intestinal biopsy re mained the best means of determining the positive effect of GFD. We do agree with this view but our data show that, in coeliacs being IgA AGA-positive when untreated, the persistence of these antibodies after GFD is always predictive of the persistence of severe jejunal lesions.…”

Scanning Electron Microscopy of the Small Intestine during gluten-Challenge in Celiac Disease.

“…At present, two methods have been widely used to achieve a conclusive diagnosis of persistent gluten intolerance: the dosage of serum levels of AGA (GRECO et al, 1987;MAYER et al, 1989;VALLETTA et al,1990;BURGIN-WOLFF et al, 1991), and the observation of small intestinal biopsies by conventional histology (JUTo et al, 1985;KHosoo et al, 1988;MONTGOMERY et al, 1988).…”

A prospective, double-blind, placebo-controlled trial to establish a safe gluten threshold for patients with celiac disease

“…We previously showed that a 4-wk challenge with 100 mg gliadin/d caused deterioration of the small-intestinal architecture and that the histologic changes were more pronounced in patients challenged with 500 mg gliadin/d (2). Finally, a higher gluten intake (1-5 g/d), still lower than the normal gluten intake for the non-CD population in Western countries (10 -20 g/d) (24), caused relapse of disease at a clinical, laboratory, and histologic level, both in children and in adults (25)(26)(27). On the basis of the evidence from the current study and the quoted literature, it appears that 50 mg gluten/d is the minimum dose required to produce measurable damage to the small-intestinal mucosa in CD patients.…”