SOURCE: Leonard MM, Sapone A, Catassi C, Fasano A. JAMA 2017;318:647-656.

The consequences of celiac disease include intestinal symptoms as well as diverse extraintestinal disorders such as anemia, osteoporosis, and increased risk of lymphoma. Gluten sensitivity has become sufficiently “popular” that an entire industry of “gluten-free” products has been created to satisfy the needs of a gluten-wary populace that too often views gluten as a toxin.

Patients with celiac disease possess specific human leukocyte antigen genotypes (DQ2 and DQ8) that allow an aberrant immunologic response to gluten-containing proteins, leading to the recognized signs and symptoms of celiac disease. Clinicians confirm the disease through intestinal biopsy. Consistently, this leads to not only symptom remission but also gluten antibody decline (anti-transglutaminase and antigliadin).

Anyone can experience a “food intolerance,” unpleasant symptoms ranging from dyspepsia to diarrhea and beyond in response to individual foods. Most patients who experience an adverse symptom in response to a particular food simply choose to avoid that food in the future and do not label it “broccoli sensitivity syndrome” or “lima bean sensitivity syndrome.” Because adverse abdominal symptomatology is commonplace in otherwise healthy individuals periodically, and there is high public awareness of gluten as a cause of abdominal pain in celiac disease, some simply remove gluten from their diet after which adverse abdominal symptoms (or sometimes other symptoms) disappear. Many of these individuals believe they suffer from celiac disease and never undergo appropriate diagnostic testing to affirm the diagnosis. As there is no diagnostic test to confirm any patient’s “non-gluten celiac sensitivity,” whether this clinical constellation should be considered a legitimate disorder remains a matter of controversy. However, there is no uncertainty about the necessity for long-term follow-up of patients with confirmed celiac disease.