A rare presentation of gastric phytobezoar: Simultaneous bleeding and perforation. combined laparoscopic and endoscopic approach. Report of a case.

INTRODUCTION: Bezoars are intraluminal conglomerates of indigestible foreign materials that accumulate in the gastrointestinal tract. We describe our experience with a patient with gastric perforation and concomitant gastric haemorrhage with severe anaemia, in whom we successfully extracted a giant gastric phytobezoar by cooperative laparoscopic and endoscopic surgery. CASE PRESENTATION: A 68-year-old man was admitted with melena and septic shock. CT scan revealed a gastric perforation. We performed a combined laparoscopic and endoscopic approach with gastrotomy, removal of the phytobezoar and laparoscopic gastric suture. The suture was examined for leakage with the endoscopic hydropneumatic test to obtain direct vision of the suture and no evidence of leakage by insufflation of the area. DISCUSSION: Gastric bezoars can be managed conservatively, endoscopically or surgically. Endoscopic removal, if effective, would be an attractive alternative for bezoar treatment. Usually endoscopic attempts are unsuccessful because of the large size of the bezoar and the difficulty in fragmentation. The laparoscopic approach for bezoar seems to have better postoperative outcomes. The main criticisms of the technique are abdominal spillage with risk of contamination as well as longer operative times. CONCLUSION: In our case we simultaneously performed laparoscopic surgery and endoscopic operative procedure in accordance with the principles of laparoscopic and endoscopic cooperative surgery to treat the gastric bezoar in order to overcome the limits of a single technique.

Altered Gut Microbic Flora and Haemorrhoids: Could They Have a Possible Relationship?

To date, the exact pathophysiology of haemorrhoids is poorly understood. The different philosophies on haemorrhoids aetiology may lead to different approaches of treatment. A pathogenic theory involving a correlation between altered anal canal microflora, local inflammation, and muscular dyssynergia is proposed through an extensive review of the literature. Since the middle of the twentieth century, three main theories exist: (1) the varicose vein theory, (2) the vascular hyperplasia theory, and (3) the concept of a sliding anal lining. These phenomena determine changes in the connective tissue (linked to inflammation), including loss of organization, muscular hypertrophy, fragmentation of the anal subepithelial muscle and the elastin component, and vascular changes, including abnormal venous dilatation and vascular thrombosis. Recent studies have reported a possible involvement of gut microbiota in gut motility alteration. Furthermore, dysbiosis seems to represent the leading cause of bowel mucosa inflammation in any intestinal district. The alteration of the gut microbioma in the anorectal district could be responsible for haemorrhoids and other anorectal disorders. A deeper knowledge of the gut microbiota in anorectal disorders lays the basis for unveiling the roles of these various gut microbiota components in anorectal disorder pathogenesis and being conductive to instructing future therapeutics. The therapeutic strategy of antibiotics, prebiotics, probiotics, and fecal microbiota transplantation will benefit the effective application of precision microbiome manipulation in anorectal disorders.

Colorectal infiltrating deep endometriosis: Laparoscopic treatment. A case report.

Endometriosis is a disease affecting approximately 10% of women of fertile age. A particular presentation is deep infiltrating endometriosis of the rectosigmoid colon with symptoms that can mimic an intestinal obstruction or neoplasm. We report the case of a 39-year-old woman with pelvic pain during the menstrual cycle and significant anemia who presented an ectopic endometrial tissue in correspondence of the rectum. Because of the thickness of the lesion the patient underwent a segmental laparoscopic colorectal resection with end-to-end anastomosis.

Uterine Involvement in Klippel-Trenaunay Syndrome: A Rare But Relevant Event. Review of the Literature.

Introduction: Klippel-Trenaunay syndrome (KTS) is a rare vascular congenital disorder characterized by the classical triad of port-wine stains, abnormal growth of soft tissues and bones, and vascular malformations. The involvement of the genitourinary tract and of the uterus in particular is extremely infrequent but relevant for possible consequences. Methods: We performed an extensive review of the literature using the Pubmed, Scopus and ISI web of knowledge database to identify all cases of KTS with uterine involvement. The search was done using the MeSH term "Klippel-Trenaunay syndrome" AND "uterine" OR "uterus." We considered publications only in the English language with no limits of time. We selected a total of 11 records of KTS with uterine involvement, including those affecting pregnant women. Results: Klippel-Trenaunay syndrome was described for the first time in the year 1900 in two patients with hemangiomatous lesions of the skin associated with varicose veins and asymmetric soft tissue and bone hypertrophy. Uterine involvement is a rare condition and can cause severe menorrhagia. Diagnosis is based on physical signs and symptoms. CT scans and MRI are first-choice test procedures to evaluate both the extension of the lesion and the infiltration of deeper tissues before treatment. The management of Klippel-Trenaunay syndrome should be personalized using careful diagnosis, prevention and treatment of complications. Conclusion: Klippel-Trenaunay syndrome is a rare vascular malformation with a wide variability of manifestations. There are no univocal and clear guidelines that suggest the most adequate monitoring of the possible complications of the disease. Treatment is generally conservative, but in case of recurrent bleeding, surgery may be needed.

Development of Histologically Verified Thyroid Diseases in Women Operated for Breast Cancer: A Review of the Literature and a Case Series.

BACKGROUND: The possible relationships between breast and thyroid diseases have been reported in the literature. The purpose of our study was to evaluate the occurrence of histologically verified thyroid pathologies in women who were diagnosed with breast cancer and, after mastectomy/quadrantectomy complemented by oncological treatment, were thyroidectomized based on their periodic thyroid evaluation. PATIENTS AND METHODS: Our series consist of 31 women with a mean age of 62.9 ± 10.9 years (range, 45-81) treated for breast cancer (18 right-sided, 11 left-sided, and 2 bilateral), of whom 29 were thyroidectomized, since two women who developed Graves' disease refused thyroidectomy. These 31 women belong to a cohort of 889 women who referred to the Breast Surgery Unit of our university hospital during the period January 2010 through December 2020. RESULTS: The mean time interval between breast cancer and thyroid pathologies was 48.1 ± 23.4 months (range, 12-95). The final diagnosis at histopathology was infiltrating ductal breast carcinoma in 26 women (with 2/26 patients having bilateral carcinoma) and infiltrating lobular breast carcinoma in the other 5 women. Ten of the twenty-nine thyroidectomized women (34.5%) had a thyroid malignancy on histology: five papillary carcinomas, three papillary micro-carcinomas and two follicular carcinomas. Two of the five women with papillary carcinoma also had histological evidence of chronic lymphocytic thyroiditis/Hashimoto's thyroiditis, which was also detected in another five women with benign thyroid diseases. CONCLUSIONS: We suggest that breast cancer survivors should be made aware of the possible increased risk of thyroid pathologies (including thyroid malignancy) so that they can undergo screening and follow-up.

Botulinum toxin associated with fissurectomy and anoplasty for hypertonic chronic anal fissure: A case-control study.

BACKGROUND: Lateral internal sphincterotomy is still the approach of choice for the treatment of chronic anal fissure (CAF) with internal anal sphincter (IAS) hypertonia, but it is burdened by high-risk postoperative faecal incontinence (FI). Sphincter saving procedures have recently been reconsidered as treatments to overcome this risk. The most employed procedure is fissurectomy with anoplasty, eventually associated with pharmacological sphincterotomy. AIM: To evaluate whether fissurectomy and anoplasty with botulinum toxin injection improves the results of fissurectomy and anoplasty alone. METHODS: We conducted a case-control study involving 30 male patients affected by CAF with hypertonic IAS who underwent fissurectomy and anoplasty with V-Y cutaneous flap advancement. The patients were divided into two groups: Those in group I underwent surgery alone, and those in group II underwent surgery and a botulinum toxin injection directly into the IAS. They were followed up for at least 2 years. The goals were to achieve complete healing of the patient and to assess the FI and recurrence rate along with manometry parameters. RESULTS: The intensity and duration of post-defecatory pain decreased significantly in both groups of patients starting with the first defecation, and this reduction was higher in group II. Forty days after surgery, we achieved complete wound healing in all the patients in group II but only in 80% of the patients in group I (P < 0.032). We recorded 2 cases of recurrence, one in each group, and both healed with conservative therapy. We recorded one temporary and low-grade postoperative case of "de novo" FI. Manometry parameters reverted to the normal range earlier for group II patients. CONCLUSION: The injection of botulinum toxin A in association with fissurectomy and anoplasty with a V-Y advancement flap improves the results of surgery alone in patients affected by CAF with IAS hypertonia.

Early diagnosis of primary melanoma of caecum. Case report and review of the literature.

Malignant gastrointestinal melanoma is usually a metastatic lesion. We report the case of a 79-year-old female asymptomatic patient. Colonoscopy revealed one plane 15 mm pigmented lesion in the caecum. Neither CT scan of the abdomen nor right hemicolectomy revealed no metastatic disease. Histopathological examination of the surgical specimen was indicative of malignant melanoma.A set of additional enquires such as laboratory and imaging tests did not point out any suspicious lesions in the skin, eye, leptomeninges or other sites. Therefore, we made the diagnosis of primary colonic melanoma.The diagnosis of this disease is still a challange and often demanding for a multidisciplinary approach, involving the surgeon, onclogist and even immunotherapy or radiotherapy.

Fissurectomy and anoplasty in posterior normotensive chronic anal fissure.

PURPOSE: Anal Fissure (AF) is the second most frequent proctological disease in Italy. Chronic AF (CAF) most common located at the posterior anal commissure (CAPF). CAPF are thought to be associated with hypertonic internal anal sphincter (IAS) but manometric findings showed that a normotonic IAS is present in the 20-40%. Sphincterotomy is often recommended as treatment of choice for CAF independently from IAS tone; nevertheless, this approach appears less logical for CAF with normotonic IAS, as in those cases there's a higher risk of post-operative anal incontinence. The aim of this study is to evaluate the results of fissurectomy and anoplasty with V-Y cutaneous advancement flap, as treatment for patients suffering from CAPF without hypertonic IAS. METHODS: We enrolled 30 patients affected by CAPF without IAS hypertonia. All patients were followed up for 2 years after the surgical procedure, with evaluation of anal continence, recurrence rate and maximum resting pressure, maximum squeeze pressure, ultraslow wave activity. RESULTS: All patients healed within 40 days after surgery. We didn't observe any "de novo" post-operative anal incontinence cases. We reported 2 cases of recurrences, within 18 months from surgery, all healed after conservative therapy. We didn't record statistically significant differences in pre- and post-operative manometry findings. CONCLUSION: At 2 years after the surgical procedure we achieved good results, these evidences shows that sphincter preserving procedures are more suitable for CAPF without hypertonic IAS.

Safety and effectiveness of saving sphincter procedure in the treatment of chronic anal fissure in female patients.

INTRODUCTION: Lateral internal sphincterotomy (LIS) is still the approach of choice for the treatment of chronic anal fissure (CAF) regardless to the internal anal sphincter tone but it is burdened by high risk post-operative faecal incontinence (FI). In female patient there are some anatomical and functional differences of the sphinteric system which make them more at risk of FI and vaginal birth could cause sphinteric lesions affecting the anal continence function. The aim of our study is to evaluate the results of saving sphincter procedure as treatment for female patients affected by CAF. METHODS: We studied 110 female patients affected by CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement associating pharmacological sphincterotomy in patients with hypertonic IAS. The follow up was at least for 2 years. The goals were patient's complete healing, the evaluation of FI, recurrence rate and manometry parameters. RESULTS: All wounds healed within 40 days after surgery. We recorded 8 cases of recurrences 6 healed with medical therapy and 2 with dilatation. We recorded 2 "de novo" temporary and low grade post-operative cases of FI. Post-operative value of MRP were unmodified in patient with normotonic IAS but significantly lower at 12 months follow up as compared with the pre-operative ones in patients with hypertonic IAS; after 24 months from surgery MRP values were within the normal range. CONCLUSION: The fissurectomy and anoplasty with V-Y cutaneous flap alone or in association with a pharmacological sphincterotomy in patients with hypertonic IAS may represent an effective approach for the treatment of CAF in female patients.

Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation.

Chronic anal fissure's (CAF) etiopathogenesis remain unclear. CAF of the posterior commissure (CAPF) are often characterized by internal anal sphincter (IAS) hypertonia. The treatment of this disease aimed to reduce IAS hypertonia. Due to the high rate of anal incontinence after LIS, the employment of sphincter preserving surgical techniques associated to pharmacological sphincterotomy appears more sensible. The aim of our study is to evaluate the long-term results of fissurectomy and anoplasty with V-Y cutaneous flap advancement associated to 30 UI of botulinum toxin injection for CAPF with IAS hypertonia. We enrolled 45 patients undergone to fissurectomy and anoplasty with V-Y cutaneous flap advancement and 30 UI botulinum toxin injection. All patients were followed up for at least 5 years after the surgical procedure, with evaluation of anal continence, recurrence rate and MRP (Maximum resting pressure), MSP (Maximum restricting pressure), USWA (Ultrasound wave activity). All patients healed within 40 days after surgery. We observed 3 "de novo" post-operative anal incontinence cases, temporary and minor; the pre-operative ones have only temporary worsened after surgery. We reported 3 cases of recurrences, within 2 years from surgery, all healed after conservative medical therapy. At 5 year follow-up post-operative manometric findings were similar to those of healthy subjects. At 5 years after the surgical procedure, we achieved good results, and these evidences show that surgical section of the IAS is not at all necessary for the healing process of the CAPF.

Lateral Internal sphincterotomy is still crucial to heal hypertonic chronic anal fissure and normalize the internal anal sphincter tone? Is V-en Y plastic a valuable alternative?

INTRODUCTION: The role of augmented internal anal sphincter (IAS) tone in the genesis of chronic anal fissure (CAF) is still unclear. Lateral internal sphincterotomy (LIS) is the most employed surgical procedure, aiming to reduce the IAS tone leaving a permanent anatomical alteration and it is burdened by high risk post-operative anal incontinence (AI). The aim of this work was to evaluate if the pre-operative manometric alterations of CAFs with hypertonic IAS would normalize after sphincter preserving surgical procedure. METHODS: We enrolled 108 consecutive patients affected by idiopathic and non-recurrent CAF undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement and pharmacological sphincterotomy, matched with 54 healthy subject in a 1 to 2 ratio, and followed up for at least for 2 years. The goals were patient's complete healing, the evaluation of AI, recurrence rate and manometry parameters. RESULTS: All wounds healed within 40 days after surgery. We recorded 7 cases of recurrences healed with medical therapy. We recorded 3 "de novo" post-operative cases of AI all temporary and low grade. Pre-operative values of maximum resting pressure (MRP) and detection of ultraslow wave activity (USWA) were significantly higher than in the healthy control group, but both come back to be similar to those recorded in healthy subject after 24 months from the surgery. CONCLUSION: The high healing rate without post-operative "de novo" AI cases with the normalization of manometric parameters suggest that fissurectomy and anoplasty with V-Y cutaneous advancement flap and pharmacological sphincterotomy is an adequate procedure for the treatment of CAF with IAS hypertonia. KEY WORDS: Anal fissure, Anoplasty, Fissurectomy, Proctology, Sphincterotomy.

Autoimmunity Features in Patients With Non-Celiac Wheat Sensitivity.

INTRODUCTION: Nonceliac wheat sensitivity (NCWS) is characterized by intestinal and extraintestinal manifestations consequent to wheat ingestion in subjects without celiac disease and wheat allergy. Few studies investigated the relationship between NCWS and autoimmunity. The aim of this study is to evaluate the frequency of autoimmune diseases (ADs) and autoantibodies in patients with NCWS. METHODS: Ninety-one patients (13 men and 78 women; mean age of 40.9 years) with NCWS, recruited in a single center, were included. Seventy-six healthy blood donors (HBD) and 55 patients with a diagnosis of irritable bowel syndrome (IBS) unrelated to NCWS served as controls. Autoantibodies levels were measured. Human leukocyte antigen haplotypes were determined, and duodenal histology performed in all patients carrying the DQ2/DQ8 haplotypes. Participants completed a questionnaire, and their medical records were reviewed to identify those with ADs. RESULTS: Twenty-three patients with NCWS (25.3%) presented with ADs; autoimmune thyroiditis (16 patients, 17.6%) was the most frequent. The frequency of ADs was higher in patients with NCWS than in HBD (P = 0.002) and in patients with IBS (P = 0.05). In the NCWS group, antinuclear antibodies tested positive in 71.4% vs HBD 19.7%, and vs patients with IBS 21.8% (P < 0.0001 for both). The frequency of extractable nuclear antigen antibody (ENA) positivity was significantly higher in patients with NCWS (21.9%) than in HBD (0%) and patients with IBS (3.6%) (P = 0.0001 and P = 0.004, respectively). Among the patients with NCWS, 9.9% tested positive for antithyroglobulin, 16.5% for antithyroid peroxidase, and 14.3% for antiparietal cell antibodies; frequencies were not statistically different from controls. The presence of ADs was related to older age at NCWS diagnosis, female sex, duodenal lymphocytosis, and eosinophil infiltration. DISCUSSION: One in 4 patients with NCWS suffered from AD, and serum antinuclear antibodies were positive in a very high percentage of cases. These data led us to consider NCWS to be associated to ADs.

Effect of Fibrin Sealant on Seroma Formation Post-Incisional Hernia Repair.

Background: Development of seroma after incisional hernia repair is a common complication. Our study aims to compare the outcomes of sublay incisional hernia repairs with or without spray instillation of fibrin glue. Methods: We enrolled fifty patients undergoing incisional hernia repair. In all patients a suction drain was placed in the subcutaneous space. In one group (FG) 4 ml fibrin glue was instilled in the subcutaneous space. In the control group (C) patients did not receive any prevention measure. Wounds fluids were collected on post-operative day 1 (POD) and once daily until drain removal. All patients were followed up by ultrasound on POD 15, 20, 40, 60. Results: Drain fluid production, even if in significantly greater amount in the C group (p 0.01) as compared with the FG group, decreased after POD 1 in both groups. Drain was removed on POD-5 in 80% of FG patients and in 36% of C patients (p 0.01). No infective or bleeding complications were detected. In group FG average hospital stay was of 5.5 ÃÂ+- 2 days versus 7.1 +- 1.5 days in group C (p 0.01). At ultrasounds examination, seroma development was similar among two groups. Conclusions: Spray instillation of fibrin glue during the surgical repair reduces amount of drained fluid and hospital stay without increasing surgical complications. However, seroma occurrence was not significantly reduced.

Recurrent sacrococcygeal pilonidal disease: the efficacy of minimal subcutaneous excision of the sinus and unroofing of pseudocystic cavity.

Patients undergoing surgery for recurrent pilonidal disease are at high risk of developing re-recurrence. The present prospective analysis was performed to evaluate the outcome for recurrent pilonidal disease treatment with a technique that provides a minimal subcutaneous excision of fistula and of the skin above the cyst, with secondary healing of wounds. METHODS: 48 consecutive patients with previous surgical excision and recurrent pilonidal disease underwent surgery from January 2009 to December 2016, under local anaesthesia. The age of the patients (42 males and 6 females) at the time of our observation was 28.5 ± 10.2 years, the BMI of 26.3 ± 6.8. The average number of interventions prior to our was 2.02 ± 1.14. RESULTS: The mean operative time was 18.2 ± 5.5 minutes. All patients were discharged 2 to 4 hours after surgery, with an average healing time of 22.8 ± 15.3 days. We recorded, in the follow-up period, only 4 relapses (8.32%), all retreated with the same surgical procedure and brought to complete healing. The results of the cosmetic questionnaire, which assessed patient satisfaction and contentment, showed that 96% of patients were completely satisfied and all patients recommended surgery to others. Kaplan-Meier analysis showed that in 7 years of follow-up, 85% of patients healed without recurrence. CONCLUSIONS: Our simple procedure appears to be safe and easily reproducible, allowing a high surgical success in the treatment of recurrent pilonidal disease. KEY EORDS: Excision, Healing, Recurrent sacrococcygeal pilonidal disease.

Surgical Sphincter Saving Approach and Topical Nifedipine for Chronic Anal Fissure with Hypertonic Internal Anal Sphincter.

PURPOSE: The role of augmented internal anal sphincter (IAS) tone in the genesis of posterior chronic anal fissure (CAPF) is still unknown. Lateral internal sphincterotomy is the most employed surgical procedure, nevertheless it is burdened by high risk post-operative anal incontinence. The aim of our study is to evaluate results of sphincter saving procedure with post-operative pharmacological sphincterotomy for patients affected by CAPF with IAS hypertonia. Methods: We enrolled 30 patients, undergone fissurectomy and anoplasty with V-Y cutaneous flap advancement; all patients received topical administration of nifedipine 0.3% and lidocaine 1.5% ointment-based therapy before and for 15 days after surgery. The primary goal was patient's complete healing and the evaluation of incontinence and recurrence rate; the secondary goal included the evaluation of manometry parameters, symptom relief and complications related to nifedipine and lidocaine administration. Results: All wounds healed within 40 days after surgery. We didn't observe any de novo postoperative anal incontinence case. We reported 2 cases of recurrences, healed after conservative therapy. We didn't report any local complications related to the administration of the ointment therapy; with whom all patients reported a good compliance. Conclusions: Fissurectomy and anoplasty with V-Y cutaneous advancement flap and topical administration of nifedipine and lidocaine, is an effective treatment for CAPF with IAS hypertonia.

Conservative Treatment of Splenic Haematoma After Colonoscopy: A Case Report.

Colonoscopy is a routine procedure performed worldwide, nevertheless, a small risk of splenic injury, often under-estimated, is still present. As a matter of fact, the diagnosis may be delayed, leading to a rising risk of morbidity and mortality. This paper describes a case of conservative treatment of colonoscopy-associated splenic injury. A 57-year-old woman presented with worsening pain in the upper left abdominal quadrant; she had radiation therapy to the ipsilateral subscapular region, and a diagnostic colonoscopy 18 hours earlier. The computed tomography (CT) scan revealed splenic laceration without signs of hemoperitoneum. Because of the hemodynamic stability of the patient, successful conservative treatment and serial controls of the blood and hemodynamic parameters were adopted. Even if rare splenic injury during colonoscopy is associated with significant morbidity and mortality. A high degree of clinical suspicion is essential to achieve a prompt diagnosis as well as an early surgical evaluation. The nonoperative approach is usually taken in patients with no intraperitoneal bleeding, a closed subcapsular haematoma and a stable hemodynamic status.

Gallbladder Agenesis: Report of a Preoperative Diagnosis With Magnetic Resonance Cholangiopancreatography.

Agenesis of the gallbladder is an extremely rare congenital entity with shaded clinical and radiologic features, which make the preoperative diagnosis really challenging. Here, we report a case of a 52-year-old symptomatic female with biliary symptoms and contracted gallbladder at ultrasound (US). The final diagnosis was made with magnetic resonance cholangiopancreatography (MRCP) and the treatment was conservative. However, diagnosing this condition preoperatively is still challenging. However, with innovations in terms of biliary tract imaging technique, and with better knowledge of this entity, many unnecessary surgical procedures might be avoided.

TNF-α, IL-17, and IL-22 production in the rectal mucosa of nonceliac wheat sensitivity patients: role of adaptive immunity.

In recent years, a new gluten- or wheat-related disease has emerged, a condition labeled "nonceliac gluten sensitivity" (NCGS) or "nonceliac wheat sensitivity" (NCWS). NCWS pathogenesis is still uncertain and attributed to very different mechanisms. We aimed to study the different T-lymphocyte subsets in the rectal mucosa of NCWS patients to demonstrate the possible contribution of adaptative immune response. Twelve patients (11 women, 1 man, age range 23-61 yr, median 32 yr) with a definitive diagnosis of NCWS were recruited at random for the present study. They underwent rectal endoscopy with multiple mucosal biopsies at the end of a double-blind placebo-controlled (DBPC) wheat challenge when they reported the reappearance of the symptoms. As controls we included 11 "healthy patients", sex- and age-matched with the patients who underwent colonoscopy evaluation for rectal bleeding due to hemorrhoids. Cells freshly obtained from rectal tissue were stained to detect anti-CD45, anti-CD3, anti-CD4, and anti-CD8. Furthermore, intracellular staining was performed with anti-tumor necrosis factor (TNF)-α, anti-interleukin (IL)-17, and anti-IL-22. Production of TNF-α by CD45+, CD3+, CD4+, and CD8+ cells, as well as of IL-17 by CD4+ cells, was higher in the rectal tissue of NCWS patients than in controls. On the contrary, IL-22 production by CD8+ cells was lower in NCWS patients than in the controls. In NCWS patients diagnosed by DBPC wheat challenge, there is a complex immunological activation, with a significant role for the adaptive response.NEW & NOTEWORTHY Nonceliac wheat sensitivity (NCWS) is a syndrome characterized by symptoms triggered by gluten intake. The pathogenesis is still uncertain. Studies have shown a role for innate immunity. We demonstrated that production of TNF-α by CD45+, CD3+, CD4+, and CD8+ cells and of IL-17 by CD4+ cells is higher in the rectal tissue of NCWS patients than in controls. We clearly demonstrated that in patients with NCWS there is a significant role for the adaptive response.