The Overlap of IBS and Nonceliac Gluten Sensitivity

Abstract and Introduction

Abstract

Purpose of review: There has been significant interest in gluten over the last decade, with an increase in interest of gluten-related disorders outside coeliac disease. Particularly, there has been a focus on the role of gluten in noncoeliac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS). There is significant overlap between both of these conditions, with the aim of this review to explore their complex relationship.

Recent findings: Gluten has been demonstrated to generate symptoms in individuals with NCGS. However, there appears to be an increasing role for gluten in symptom generation in patients with IBS also. Other components of wheat, other than gluten, are now also thought to be contributing factors in symptom generation.

Summary: There appears to be significant overlap between IBS and NCGS. It is likely that a subset of patients presenting with IBS actually have NCGS. In addition, it is likely that individuals with IBS may also have symptoms triggered by gluten. With the pathophysiology of both conditions not fully understood, as well as increasing knowledge of wheat components in symptom generation, further research is required to help distinguish between both.

Introduction

There has been a significant increase in the interest in gluten over the last decade, with over $15 billion spent in the gluten-free industry in the United States alone in 2016.^[1] Many individuals report wheat sensitivity, having been reported as 10%.^[2] However, only 1% of individuals have coeliac disease.^[3] This has led to an interest in gluten-related disorders outside the diagnosis of coeliac disease, with a recent focus on noncoeliac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS).

NCGS is a condition first described in the late 1970s.^[4] It is characterized by the development of intestinal and extraintestinal symptoms following the ingestion of gluten, provided that coeliac disease and IgE-mediated wheat allergy have been excluded. IBS presents with symptoms similar to NCGS, including abdominal pain, bloating and change in bowel habit.^[5]

Whilst gluten has been noted to trigger symptoms in individuals with IBS and NCGS, it is now understood that other components in wheat may also trigger symptoms. These include amylase trypsin inhibitors (ATIs), wheat germ agglutenins (WGAs) and fermentable oligosaccharides, disaccharides , monosaccharides and polyols (FODMAPs).^[6] With a lack of biomarkers for NCGS and a similar presentation to IBS, this has made it challenging to distinguish between these two clinical entities. This aim of this review is to explore the overlap between both of these conditions.

Table 1. Summary of studies evaluating gluten in irritable bowel syndrome and noncoeliac gluten sensitivity
Study Year	Lead author	Location	Population studied	Study design	Study duration	Outcome
2001	Wahnschaffe [43]	Germany	IBS-D	Prospective study	6 months	Improvement in stool frequency on GFD
2011	Biesiekierski [44]	Australia	IBS symptomatically controlled on GFD	DBPC trial	6 weeks	Worsening of overall symptoms following gluten re-introduction
2012	Carroccio [16]	Italy	IBS patients with wheat sensitivity	Crossover DBPC trial	5 weeks	Increase in overall symptoms following introduction of wheat
2013	Vazquez-Roque [23]	USA	IBS-D	RCT	4 weeks	Increase in bowel movements per day on GCD
2013	Biesiekierski [45]	Australia	IBS and NCGS	Crossover DBPC trial	5 weeks	No effect of gluten on GI symptoms
2015	Di Sabatino [46]	Italy	NCGS	Crossover DBPC trial	5 weeks	Worsening of overall symptoms following intake of gluten
2015	Zanini [47]	Italy	NCGS	Crossover DBPC trial	4 weeks	34% patients noted symptom recurrence following gluten re-challenge
2015	Capannolo [48]	Italy	NCGS	Prospective study	2 years	27 out of 392 patients (6.9%) identified as responding to GFD with recurrence of symptoms following gluten re-introduction
2015	Shahbazkhani [49]	Iran	IBS on a GFD	DBPC trial	6 weeks	Worsening of overall symptoms following intake of gluten
2016	Aziz [39]	UK	IBS-D	Prospective study	6 weeks	Reduction in IBS-SSS on GFD
2016	Rosinach [50]	Spain	NCGS with HLA DQ2/8-positive, gluten-dependent lmphocytic enteritis	DBPC trial	6 months	Ninety-one percent of patients had clinical relapse during gluten challenge
2016	Zanwar [51]	India	IBS who responded to GFD	DBPC trial	4 weeks	Worsening of symptoms following intake of gluten
2016	Elli [37]	Italy	IBS	Crossover DBPC trial	5 weeks	Fourteen percent patients who responded to gluten, noted to have symptomatic relapse at rechallenge
2017	Barmeyer [52]	Germany	IBS-D/M	Prospective study	12 months	Thirty-four percent patients responded to GFD
2018	Francavilla [53]	Italy	Suspected NCGS in children	Crossover DBPC trial	9 weeks	Eleven out of 28 patients tested positive to gluten challenge
2018	Dale [54]	Norway	NCGS	DBPC trial	26 days	Four out of 20 patients tested positive to gluten challenge

Table 1. Summary of studies evaluating gluten in irritable bowel syndrome and noncoeliac gluten sensitivity

Study Year

Lead author

Location

Population studied

Study design

Study duration

Outcome

2001

Wahnschaffe [43]

Germany

IBS-D

Prospective study

6 months

Improvement in stool frequency on GFD

2011

Biesiekierski [44]

Australia

IBS symptomatically controlled on GFD

DBPC trial

6 weeks

Worsening of overall symptoms following gluten re-introduction

2012

Carroccio [16]

Italy

IBS patients with wheat sensitivity

Crossover DBPC trial

5 weeks

Increase in overall symptoms following introduction of wheat

2013

Vazquez-Roque [23]

USA

IBS-D

RCT

4 weeks

Increase in bowel movements per day on GCD

2013

Biesiekierski [45]

Australia

IBS and NCGS

Crossover DBPC trial

5 weeks

No effect of gluten on GI symptoms

2015

Di Sabatino [46]

Italy

NCGS

Crossover DBPC trial

5 weeks

Worsening of overall symptoms following intake of gluten

2015

Zanini [47]

Italy

NCGS

Crossover DBPC trial

4 weeks

34% patients noted symptom recurrence following gluten re-challenge

2015

Capannolo [48]

Italy

NCGS

Prospective study

2 years

27 out of 392 patients (6.9%) identified as responding to GFD with recurrence of symptoms following gluten re-introduction

2015

Shahbazkhani [49]

Iran

IBS on a GFD

DBPC trial

6 weeks

Worsening of overall symptoms following intake of gluten

2016

Aziz [39]

IBS-D

Prospective study

6 weeks

Reduction in IBS-SSS on GFD

2016

Rosinach [50]

Spain

NCGS with HLA DQ2/8-positive, gluten-dependent lmphocytic enteritis

DBPC trial

6 months

Ninety-one percent of patients had clinical relapse during gluten challenge

2016

Zanwar [51]

India

IBS who responded to GFD

DBPC trial

4 weeks

Worsening of symptoms following intake of gluten

2016

Elli [37]

Italy

IBS

Crossover DBPC trial

5 weeks

Fourteen percent patients who responded to gluten, noted to have symptomatic relapse at rechallenge

2017

Barmeyer [52]

Germany

IBS-D/M

Prospective study

12 months

Thirty-four percent patients responded to GFD

2018

Francavilla [53]

Italy

Suspected NCGS in children

Crossover DBPC trial

9 weeks

Eleven out of 28 patients tested positive to gluten challenge

2018

Dale [54]

Norway

NCGS

DBPC trial

26 days

Four out of 20 patients tested positive to gluten challenge

The Overlap of Irritable Bowel Syndrome and Noncoeliac Gluten Sensitivity

Abstract and Introduction

Abstract

Introduction

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