Factors Influencing the Type, Timing and Severity of Symptomatic Responses to Dietary Gluten in Patients with Biopsy-proven Coeliac Disease

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Stephen M. Barratt1, John S. Leeds2, David S. Sanders1

1) Shefield Teaching Hospitals NHS Foundation Trust, Shefield;
2) Aberdeen Royal Infirmary, Aberdeen, UK


Background & Aim: There is a paucity of data reflecting the symptomatic responses to dietary gluten (SRDG) in patients with Coeliac Disease (CD). We aimed to determine the type, timing and severity of SRDG with reference to a range of disease-related factors.

: Postal survey of 224 biopsy-proven patients including gluten-free diet (GFD) adherence, symptom checklist, ROME II criteria and The Hospital Anxiety & Depression Scale.  Case-note review was also conducted.

: 26% of respondents were male. Full GFD adherence: n=159 (70%). Irritable bowel syndrome (IBS): n=50 (22%). Anxiety: n=30 (13%); Depression: n=33 (14%); Anxiety & Depression: n=72 (32%). Pruritus, fatigue and bloating were a more common SRDG in the partial/none GFD adherent group (p=ns). Co-existing IBS was associated with a greater prevalence of nausea and fatigue in response to gluten (p=<0.05). Fully GFD adherent patients are more likely to have SRDG <1hr than partial/none adherent (OR 4.8; p=0.004), as are a third of patients with co-existing IBS (OR 1.5; p=0.027) and those patients at risk of both anxiety and depression (OR 1.9; p=0.04). Inadvertent exposure to dietary gluten in the fully GFD adherent group is more likely to result in a severe SRDG in comparison to symptoms arising prior to consistent GFD adherence (OR 2.3; p=0.01). IBS sufferers are also more likely to rate their SRDG as severe in nature (OR 1.4; p=0.038).

: Patients with consistent GFD adherence experience a SRDG faster and more severe in comparison to prior gluten exposure possibly demonstrating an adept immunological response. Anxiety and depression also enhance the speed of symptom onset and co-existing visceral hypersensitivity is a risk factor for severe reactions to dietary gluten.

Key words: coeliac disease - symptoms - gluten-free diet - irritable bowel syndrome - gluten challenge - anxiety - depression - gluten.