Non-celiac Gluten Sensitivity / 대한소화기학회지

Non-celiac gluten sensitivity (NCGS) is a term that is used to describe individuals who are not affected by celiac disease or wheat allergy, yet they have intestinal and/or extra-intestinal symptoms related to gluten ingestion with improvement of their symptoms upon withdrawing gluten from their diet. Gluten-related disorder groups are manifested by symptoms of gastrointestinal tract disorders, as well as hematological dermatological endocrinological, gynecological, rheumatological and nervous system symptoms. It is believed that NCGS represents heterogeneous groups with different subgroups characterized by different etiologies, clinical histories and clinical courses. There also appears to be an overlap between NCGS and irritable bowel syndrome (IBS). There is a need for establishing strict criteria for diagnosing NCGS. The absence of validated biomarkers remains a significant limitation for research studies on NCGS. New evidence shows that a gluten-free diet may be beneficial for some patients with gastrointestinal symptoms, such as those symptoms commonly found in patients with IBS. Further studies about NCGS are needed.

Sensibilidad al gluten no celíaca / Non-celiac Gluten sensitivity

Introducción: La sensibilidad al gluten no celíaca es una afección emergente descrita en la última década, mediada por mecanismos inmunes, sin reconocido marcador serológico. Objetivo: Actualizar los conocimientos sobre esta condición, patogenia, diagnóstico y tratamiento. Métodos: Se revisaron las publicaciones en español e inglés en bases de datos de Google académico, PubMed, Scielo y Latindex desde el 2014 hasta el 20 agosto 2018. Resultados: Se trata de una afección no alérgica ni autoinmune. Se analiza su repercusión en niños y adultos. La epidemiología no está establecida, su presencia varía entre 6-10 por ciento, con predominio femenino/masculino 3:1. Se revisaron los criterios sobre la patogenia relacionados con las prolaminas de cereales tóxicos, carbohidratos de cadena corta fermentable e inhibidores de amilasa y tripsina. Se evaluaron los síntomas clínicos (intestinales y extraintestinales) y analizaron los argumentos del diagnóstico definitivo y diferencial con otras enfermedades desencadenadas por gluten. La dieta sin gluten representa la única opción terapéutica. Los síntomas desaparecen con su supresión y reaparecen con su reintroducción. Consideraciones finales: La sensibilidad al gluten no celíaca es una entidad de nueva aparición con participación de procesos inmunes y patogenia sustentada por distintos mecanismos con síntomas intestinales y extraintestinales relacionados con consumo de gluten. El diagnóstico no debe ser por exclusión del gluten, sino evaluación clínica, pues no existe diagnóstico serológico. Hay otras afecciones con similares manifestaciones como enfermedad celíaca, alergia al gluten, síndrome intestino irritable y enteritis linfocítica, con las que se debe hacer diagnóstico diferencial(AU)

Introduction: Non-celiac gluten sensitivity (SGNC, by its acronyms in Spanish) is an emerging condition of the last decade, which is mediated by immune mechanisms without a recognized serological marker. Objective: To update knowledge on SGNC, its pathogenesis, diagnostic and treatment. Methods: Publications in Spanish and English were reviewed in Google scholar, PubMed, SciELO and Latindex databases from 2014 to August 20, 2018. Results: Information about the description of SGNC as a non-allergic or autoimmune condition and impact on children and adults is updated. Epidemiology is not established, although recent studies report that it varies between 6 to 10 percent, with predominance of female / male 3:1. The criteria for the pathogenesis related to the prolamines of toxic cereals, fermentable short chain carbohydrates (FODMAPs) and amylase and trypsin inhibitors are reviewed. The clinical symptoms (intestinal and extraintestinal) were evaluated and it was analyzed the argument established for the diagnosis of certainty and differential with other diseases triggered by gluten, especially celiac disease. The gluten-free diet represents the only treatment option. The symptoms disappear with gluten suppression and reappear when re-introducing it. Final Considerations: SGNC is a new entity mediated by an immune mechanism with pathogenesis supported by different mechanisms with intestinal and extra intestinal symptoms related to gluten consumption. The diagnosis should not be by exclusion of foods that contain gluten, but by clinical evaluation since there is not serological diagnosis. To know better on it is of interest due to other conditions, such as celiac disease, gluten allergy, irritable bowel syndrome and lymphocytic enteritis, which should be made by differential diagnosis(AU)

Trastornos relacionados con el gluten: panorama actual / Gluten-related disorders: Current state

Resumen: El trigo representa uno de los cereales que más se producen y consumen en todo el mundo debido a su sencillez para ser cultivado en diversas condiciones climáticas, su valor nutricional y sus características organolépticas. El trigo, al igual que la cebada y el centeno, contienen gluten, molécula que potencialmente puede resultar tóxica para algunos individuos. Los trastornos relacionados con el gluten representan un reto diagnóstico-terapéutico en la actualidad porque incluyen enfermedades que pueden tener complicaciones y efectos nocivos para la salud, como la enfermedad celiaca, hasta situaciones puramente sintomáticas, como la sensibilidad al gluten no celiaca. Se necesita una alta sospecha clínica y el conocimiento e interpretación de las pruebas diagnósticas (serología, biopsias y pruebas genéticas) para tener un abordaje apropiado. En México se estima que 1% de la población padece enfermedad celiaca, 0.7% alergia al trigo y la sensibilidad al gluten no celiaca varía de 1 hasta 25% en poblaciones especiales (intestino irritable, dispepsia). En la actualidad los pacientes con enfermedad celiaca comprobada deben someterse a una estricta dieta sin gluten por el riesgo potencial de complicaciones. Asimismo, si bien se recomienda este tipo de dieta a los pacientes con sensibilidad al gluten no celiaca, la falta de apego sólo condicionará recaídas sintomáticas. Por otra parte, aunque existe gran disponibilidad de dietas que excluyen el gluten, éstas no se recomiendan para la población general o en casos en los que no esté establecido propiamente el diagnóstico de algunos de los trastornos relacionados con el gluten.

Abstract: Wheat is one of the most produced and consumed cereals worldwide because of its simplicity to be cultivated in different climatic conditions, its nutritional value and its organoleptic characteristics. Wheat, as barley and rye, contains a molecule which can potentially be toxic to some individuals, the gluten. Today gluten-related disorders represent a diagnostic and therapeutic challenge as they include diseases that can have complications and deleterious health effects such as celiac disease, to purely symptomatic situations such as non-celiac gluten sensitivity (NGCS). A high clinical suspicion, as well as knowledge in the interpretation of diagnostic tests (serology, biopsy and genetic testing) are required to have an appropriate approach. In Mexico it is estimated that 1% of the population suffers celiac disease, 0.7% wheat allergy and NGCS can vary from 1% to 25% in special populations (irritable bowel syndrome, dyspepsia). At present proven celiac disease patients must undergo a strict gluten-free diet for the potential risk of complications. On the other hand in patients with NGCS, although this type of diet is recommended, lack of adherence will only lead to symptomatic relapse. Moreover, although there is a great availability of gluten free diets and products, these are not recommended for the general population or in cases in who the diagnosis of some of the gluten-related disorders is not properly established.

Enfermedad celíaca, sensibilidad no celíaca al gluten y alergia al trigo: comparación de patologías diferentes gatilladas por un mismo alimento / Celiac disease, non celiac gluten sensitivity and wheat allergy: comparison of 3 different diseases triggered by the same food

El gluten y otras proteínas relacionadas del trigo, centeno y cebada, tienen propiedades antigénicas que pueden desencadenar reacciones adversas en individuos susceptibles. La enfermedad celíaca fue la primera patología en que se estableció relación causal con estas proteínas alimentarias. Recientemente se han descrito la alergia al trigo y la sensibilidad no celíaca al gluten. Si bien sus formas de presentación clínica y su relación con la ingesta pueden ser similares, sus mecanismos patogénicos, forma de diagnóstico y tratamiento difieren. Dado que su prevalencia en conjunto es relativamente alta, resulta necesario que los médicos de atención primaria y pediatras se familiaricen con estas patologías, sepan cómo diferenciarlas y enfrentarlas. El objetivo de esta revisión es comparar los principales aspectos de epidemiología, fisiopatología, diagnóstico y tratamiento de estas 3 condiciones.

Gluten and other related proteins of the wheat, rye and barley, have antigenic properties that may trigger adverse reactions in susceptible individuals. Celiac disease was the first pathology with clear causal association related to the intake of these proteins. Recently, wheat allergy and non celiac gluten sensitivity have been described. Although, clinical presentation and its relation with protein ingestion may be similar and elicit confusion, their pathogenic mechanism, diagnosis and treatment are quite different. Since the prevalence of these diseases is relatively high as a whole, it is essential that these become familiar to primary care doctors and general pediatricians, thus they will know how to differentiate and face them. The aim of this review is to compare the main aspects of epidemiology, pathofisiology, diagnosis and treatment of these 3 conditions.

Nutritional status variation and intestinal and extra intestinal symptomatology in patients with celiac disease and non-celiac gluten sensitivity given specialized dietary advice / Evolução do estado nutricional e sintomatologia intestinal e extra intestinal em pacientes com doença celíaca e sensibilidade ao glúten não celíaca submetidos à orientação dietética especializada

ABSTRACT Objective: To investigate the nutritional status variation and symptomatology of patients with celiac disease and non-celiac gluten sensitivity after specialized dietary advice Methods: This prospective study included 80 patients with celiac disease and non-celiac gluten sensitivity. Clinical, metabolic, and nutritional variables were collected from medical records, and the symptomatology was investigated by the Metabolic Screening Questionnaire. The variables were assessed on two occasions (T1 - before dietary advice and T2 - after dietary advice) with an interval of three months between T1 and T2 Results: The median age was 42 years. The prevalences of celiac disease and non-celiac gluten sensitivity were 66.2% and 33.8%, respectively. Normal weight prevailed at T1 (58.8%) and T2 (56.3%), but 30.0% of the patients at T1 and 34.9% of the patients at T2 had excess weight. The two conditions had similar symptomatology. The most frequent signs and symptoms on both occasions involved the gastrointestinal tract, followed by energy/activity and emotions. All symptoms decreased significantly after the introduction of a proper diet Conclusion: The patients were normal weight on both study occasions (T1 and T2), and the symptoms improved after dietary advice. Thus, we reinforce the importance of proper dietary management in both clinical conditions to make dietary adjustments that improve these individuals' symptomatology.

RESUMO Objetivo: Investigar a evolução do estado nutricional e a sintomatologia de pacientes com doença celíaca e sensibilidade ao glúten não celíaca após orientação dietética especializada Métodos: O estudo prospectivo foi realizado com 80 pacientes portadores da doença celíaca e de sensibilidade ao glúten não celíaca. A coleta das variáveis clínicas, metabólicas e nutricionais foi feita por análise dos prontuários, enquanto a sintomatologia foi investigada por meio de Questionário de Rastreamento Metabólico. As variáveis foram avaliadas em dois momentos (T1 - antes da orientação dietética e T2 - após orientação dietética), com intervalo de 3 meses entre T1 e T2 Resultados: A mediana de idade foi de 42 anos. A prevalência de doença celíaca e de sensibilidade ao glúten não celíaca foi de 66,2% e 33,8%, respectivamente. A eutrofia prevaleceu como estado nutricional de T1 (58,8%) e T2 (56,3%), porém 30,0% dos pacientes em T1 e 34,9% em T2 apresentaram excesso de peso. A sintomatologia foi similar entre as duas enfermidades. Os sinais e sintomas mais frequentes nos dois tempos foram os do trato digestório, seguido pelos relacionados à energia/atividade e às emoções. Todos os sintomas diminuíram significativamente após a introdução da dieta Conclusão: Os pacientes apresentaram estado nutricional de eutrofia nos dois momentos avaliados (T1 e T2) e houve redução dos sintomas após as orientações nutricionais. Dessa forma, reitera-se a importância do manejo dietético adequado para ambas as enfermidades clínicas a fim de adequar a dieta que favoreça a melhora da sintomatologia apresentada por esses indivíduos.

Brazilian Society for Food and Nutrition position statement: gluten-free diet

Position statement: The Brazilian Society for Food and Nutrition (SBAN) bases the following position statement on a critical analysis of the literature on the indications of a gluten-free (GF) diet. (1) There is insufficient evidence to assume that healthy individuals would experience any benefits from the consumption of a GF diet. (2) Recent studies suggest that gluten sensitivity may be confounded by sensitivity to low-fermentable, poorly absorbed, short-chain carbohydrates known as fermentable oligo-, di-, and mono-saccharides and polyols (FODMAPs). (3) Epidemiological data supports that evenover weight celiac disease (CD) individuals fail to achieve weight loss under a GF diet. (4) Recent experimental data showed possible deleterious effects of GF feeding on the intestinal microbiota of healthy individuals. (5) GF diets can be healthy for the general population, as long as GF-processed foods are avoided, and the ingestion of other whole grains, and low-energy-density vegetables is assured. This position statement has been externally reviewed and approved by the board of the Brazilian Society for Food and Nutrition, and has not gone through the journal' s standard peer review process.

Symptomatic improvement with gluten restriction in irritable bowel syndrome: a prospective, randomized, double blinded placebo controlled trial

BACKGROUND/AIMS: The existence of non-celiac gluten sensitivity has been debated. Indeed, the intestinal and extra-intestinal symptoms of many patients with irritable bowel syndrome (IBS) but without celiac disease or wheat allergy have been shown to improve on a gluten-free diet. Therefore, this study set out to evaluate the effects of gluten on IBS symptoms. METHODS: We performed a double-blind randomized placebo-controlled rechallenge trial in a tertiary care hospital with IBS patients who fulfilled the Rome III criteria. Patients with celiac disease and wheat allergy were appropriately excluded. The participants were administered a gluten-free diet for 4 weeks and were asked to complete a symptom-based questionnaire to assess their overall symptoms, abdominal pain, bloating, wind, and tiredness on the visual analog scale (0-100) at the baseline and every week thereafter. The participants who showed improvement were randomly assigned to one of two groups to receive either a placebo (gluten-free breads) or gluten (whole cereal breads) as a rechallenge for the next 4 weeks. RESULTS: In line with the protocol analysis, 60 patients completed the study. The overall symptom score on the visual analog scale was significantly different between the two groups (P<0.05). Moreover, the patients in the gluten intervention group scored significantly higher in terms of abdominal pain, bloating, and tiredness (P<0.05), and their symptoms worsened within 1 week of the rechallenge. CONCLUSIONS: A gluten diet may worsen the symptoms of IBS patients. Therefore, some form of gluten sensitivity other than celiac disease exists in some of them, and patients with IBS may benefit from gluten restrictions.

Symptomatic improvement with gluten restriction in irritable bowel syndrome: a prospective, randomized, double blinded placebo controlled trial

BACKGROUND/AIMS: The existence of non-celiac gluten sensitivity has been debated. Indeed, the intestinal and extra-intestinal symptoms of many patients with irritable bowel syndrome (IBS) but without celiac disease or wheat allergy have been shown to improve on a gluten-free diet. Therefore, this study set out to evaluate the effects of gluten on IBS symptoms. METHODS: We performed a double-blind randomized placebo-controlled rechallenge trial in a tertiary care hospital with IBS patients who fulfilled the Rome III criteria. Patients with celiac disease and wheat allergy were appropriately excluded. The participants were administered a gluten-free diet for 4 weeks and were asked to complete a symptom-based questionnaire to assess their overall symptoms, abdominal pain, bloating, wind, and tiredness on the visual analog scale (0-100) at the baseline and every week thereafter. The participants who showed improvement were randomly assigned to one of two groups to receive either a placebo (gluten-free breads) or gluten (whole cereal breads) as a rechallenge for the next 4 weeks. RESULTS: In line with the protocol analysis, 60 patients completed the study. The overall symptom score on the visual analog scale was significantly different between the two groups (P<0.05). Moreover, the patients in the gluten intervention group scored significantly higher in terms of abdominal pain, bloating, and tiredness (P<0.05), and their symptoms worsened within 1 week of the rechallenge. CONCLUSIONS: A gluten diet may worsen the symptoms of IBS patients. Therefore, some form of gluten sensitivity other than celiac disease exists in some of them, and patients with IBS may benefit from gluten restrictions.

Anti-gliadin Antibodies and Gluten Neuropathies: A Borderline Link.

The aim of this research was to estimate the prevalence of gluten sensitivity in neurologic diseases of unknown etiology and to determine their clinical and biological characteristics in a Moroccan population. Patients and Methods: A prospective case-control study was performed on 60 patients and 57 controls. Patients and controls underwent a screening for IgG and IgA anti-gliadin antibodies (ELISA anti-Gliadin, Orgentec, threshold: 12 IU/ml), and IgA anti-tissue transglutaminase antibodies (ELISA IgA-tGTA, DRG, threshold: 10 IU/m). Results: The median age of patients was 43±13.91 years (ranges: 13-67), versus 39.4±9.12 (ranges: 19-58) for controls. Male to female sexe-ratio was 0.7 for patients vs 2.1 for controls. IgG and/or IgA anti-gliadin antibodies (AGA) were positive in 26.7% of cases (n=16) vs 15.8% (n=9) in controls (p=0.15), while IgA-tTGA was negative in all patients, but positive in 1 control. Positive AGA cases corresponded to peripheral neuropathy (n=4), ataxia (n=3), ischemic stroke (n=3), myopathy (n=2), and 1 case for each of the following conditions: multiple sclerosis, epilepsy, cerebral thrombophlebitis and myelopathy. Among the positive AGA cases, IgA isotype was more prevalent, but IgG AGA titers were higher and clinically more relevant. Conclusion: Gluten Sensitivity is a potential cause of unknown etiological neurologic diseases in young adults, particularly peripheral neuropathy, ataxia and ischemic stroke. AGA testing especially IgG isotype might be a suitable marker to screen for gluten neuropathies.

Sensibilidad no celíaca al gluten: Una patología más que responde al gluten / Non-celiac gluten sensitivity: Another condition that responds to gluten

Remission of gastrointestinal and general symptoms after gluten withdrawal has been described in some non-celiac individuals for nearly 30 years. Only recently, efforts have been made to define this entity, now referred to as "non- celiac gluten sensitivity". It includes patients that clinically respond to gluten free diet without exhibiting allergic or autoimmune features to explain such response. Wheat allergy, celiac disease, irritable bowel syndrome and symptoms induced by high FODMAPs (Fermentable, Oligo-, Di-, Mono-saccharides And Polyols) consumption are the main differential diagnoses. The relationship with neuropsychiatric disorders such as schizophrenia and autism has not been demonstrated, but currently it gives ground to great hope in families with affected children. Epidemiology of non-celiac gluten sensitivity is not clear. It is described as more common among women and less common in children. Genetic and immune factors, changes in intestinal microbiota and non-gluten components present in wheat grains are main factors postulated in the pathogenesis of this condition. To date, there are no specific biomarkers for non-celiac gluten sensitivity and diagnosis is reached by excluding other causes of disease. A trial with gluten-free diet and subsequent gluten challenge is the methodology most frequently used to confirm diagnosis.

Sensibilidad al gluten: presentación de tres casos / Gluten sensitivity: presentation of three cases

En los últimos años, ha cobrado mayor interés la existencia de un cuadro clínico muy similar al de la enfermedad celíaca, que no se ajusta a los cánones tradicionales de diagnóstico. Se trata de pacientes con una alta sospecha diagnóstica de enfermedad celíaca, que presentan serología y biopsia de intestino delgado normal. La literatura relata, desde la década del 80, la existencia de un síndrome que relaciona el gluten de la dieta con un efecto tóxico generador de síntomas gastrointestinales en presencia de una mucosa normal. A esta entidad se la denominó síndrome de Cooper-Cook. En los últimos años, ha habido numerosas publicaciones que hacen referencia a esta entidad, pero ahora bajo la denominación de sensibilidad al gluten. En el siguiente artículo, se presentan tres casos clínicos que hacen referencia a esta enfermedad.

In the last few years, the existence of a clinical profile similar to celiac disease has become important; this disease does not adapt to the traditional diagnosis canons. It is related to a number of patients who are diagnosed as having the celiac disease but present normal serology and small bowel's biopsy. Since the 80's, medical literature reports the existence of a syndrome that connects gluten diet with a toxic effect that produces gastrointestinal symptoms even though the mucosa remains normal. This disease is called the Cooper-Cook syndrome. Over the last few years, there have been lots of publications about this disease under the name "gluten sensitivity". In the following article, three clinical cases that refer to this condition are presented.

Clinical analysis of gluten-related disease / 中华内科杂志

Objective To explore the diagnosis and treatment of gluten-related disorders (GRD).Methods Anti-gliadin antibodies (AGA),anti-tissue transglutaminase (tTG) antibody,deamidated gliadin peptides(DGP) antibody and serum specific IgG antibodies of 14 kinds of intolerable food were tested in people who developed chronic diarrhea after the intake of gluten diet.HLA-DQ2,HLA-DQ8 and intestinal endoscopic multiple biopsies would be performed further in patients with positive coeliac disease (CD)-specific serology.Gluten free diet was given to patients with positive CD-specific serology.One patient received prednisone (30 mg/d and diminished 5 rmg/w).Results Nine patients were confirmed with celiac disease(CD) and four cases were suspected non-coeliac gluten sensitivity (NCGS) in 13 patients with positive serologic tests.Twelve cases received effective therapy.In CD group,6 cases were accompanied with comorbidities mainly autoimmune diseases and osteoporosis.The positive rates of AGA and tTG antibody were 9/9 and 2/9 respectively in the CD group,while tTG antibody in the NCGS group were both negative.Endoscopic intestinal biopsy was performed in all 13 cases.Plasma cell proliferation and lymphocyte infiltration in the lamina propria without villus atrophy were identified in 4 cases,representing chronic inflammation of the small intestine.Villus atrophy was detected in 9 cases.Two patients with NCGS ingested gluten after 4 and 6 months of gluten-free diet respectively,and the number of bowel movements increased 1-2 times per day.Conclusions The diagnosis of CD is mainly based on serologic tests and characteristic of histological features.CD may be companied by other autoimmune diseases or metabolic disease of bone.Lifelong adherence to a gluten free diet is the most basic and effective therapy.

Celiac disease serology in dermatitis herpetiformis: which is the best option for detecting gluten sensitivity? / Serología de enfermedad celíaca en dermatitis herpetiforme. ¿Cuál es la mejor opción para detectar sensibilidad al gluten?

Background: Dermatitis herpetiformis (DH), a wellestablished gluten-sensitive skin disorder presenting variable degrees of enteropathy, constitutes a very useful model in order to assess the utility of the celiac disease (CD)-related serology in patients with mild intestinal damage. Objective: Our aim was to explore comparatively the performance of a panel of CD-related serologic tests in patients with DH. Methods: We assessed a series of 18 consecutive patients with skin biopsy proven DH presenting the overall spectrum of intestinal damage ranging from normal mucosa (n=6) to total villous atrophy (TVA) (n=6) through partial villous atrophy (PVA) (n=6). Sera were obtained from all patients while consuming a gluten containing diet. Serologic tests were antiendomysial, anti-tissue transglutaminase and antigliadin antibodies, and newly developed tests detecting both antibody isotypes (IgA and IgG) against deamidated synthetic gliadin-derivedpeptides (a-GDP). Results: Serologic tests had a variable behaviour depending on the degree of enteropathy. While the majority of tests detected patients with TVA, only 50% of those with normal histology had positive assays. Patients with PVA had discordant results. Classical CD-specific tests were positive in only some patients with mild damage while all of them were identified by a single assay detecting both isotypes of a-GDP. Conclusion: The detection of a-GDP antibodies was the most reliable tool in order to identify gluten sensitivity in DH patients presenting a wide range of intestinal damage. Further studies should explore if these findings can be extrapolated to patients with CDhaving mild enteropathy.

Introducción: la dermatitis herpetiformis (DH), una lesión dermatológica consecuencia de sensibilidad al gluten y asociada a grados variables de enteropatía, constituye un modelo muy útil con el objeto de evaluar la eficacia de la serología de la enfermedad celíaca(EC) en pacientes con daño intestinal leve. Objetivo: explorar comparativamente la utilidad de una serie de anticuerpos empleados en EC en pacientes con DH. Métodos: analizamos una serie de 18 pacientes consecutivos con diagnóstico de DH por biopsia de piel que presentaban el más amplio espectro de daño intestinal variando desde una mucosa normal (n=6) a la atrofia vellosa total (AVT) (n=6) y pasando por atrofia vellosaparcial (AVP) (n=6). Se obtuvo plasma de todos los pacientes mientras consumían gluten. Las pruebas serológicas empleadas fueron anticuerpos antiendomisio, anti-transglutaminasa y atigliadina, y unas pruebas recientemente desarrolladas que detectan anticuerpos IgA e IgG dirigidos contra péptidos sintéticos deamidados derivados de la gliadina (a-GDP). Resultados: las diferentes pruebas tuvieron un comportamiento variable dependiendo del grado de lesión intestinal. Mientras que la mayoría de las pruebas detectaron a todos los pacientes con AVT, sólo el 50% de aquellos con histologíanormal tuvieron resultados positivos. Los pacientes con AVP tuvieron resultados discordantes. Así las pruebas clásicas fueron positivas en sólo algunos pacientescon daño leve, mientras que todos ellos fueron positivos a una prueba para detectar ambos isotipos del a-GDP. Conclusión: la determinación de anticuerpos a-GDP fue la herramienta más confiable con el objeto de identificar serológicamente la sensibilidad al gluten en pacientes con DH que presentan variables grados de daño intestinal. Otros estudios deberían explorar si estos hallazgos podrían ser extrapolados a pacientes conEC con enteropatía de grado leve.