Gluten intolerance acquired after gastroenteritis

Gluten intolerance can occur at any age due to a number of causes that contribute to loss of immune tolerance. The authors of a paper published recently in the journal Gastroenterology and Hepatology from Bed to Bench remind how a bout of viral or bacterial gastroenteritis can be the trigger. They state:

"The spectrum of irritable bowel syndrome (IBS) is narrowing and many conditions previously known/attributed to IBS seem to be related to unrecognised primary or acquired intolerances to nutrient components. Infection might act as triggering factor for inflammatory conditions in susceptible individuals...Inflammation of absorptive surface leading to various enzymatic defects, changing the microbiota and increasing intestinal permeability may result in symptoms previously known as post gastroenteritis IBS. It is time to recognise the possible pathophysiology of acquired gluten intolerance that has been miss-treated under the mask of IBS."

By way of  authors report on a case of IBS occurring only after gastroenteritis that resolved on a gluten-free and lactose-free diet.

GI infection damages the gut barrier promoting loss of immune tolerance

Clinicians doing case management of autoimmunity are well aware that infection can trigger latent loss of immune tolerance. One mechanism is through compromise of the barrier systems (gut, respiratory, blood-brain).

"Viral or bacterial gastroenteritis can cause structural changes to the small bowel mucosa, including locally reduced digestive enzymes activities secondary to the local inflammatory reaction. Peptidase deficiency resulting from infected small bowel can cause accumulation of partially digested gluten peptides and damage the intestinal mucosal cell. We speculate that damages and deficiencies might cause transitory or permanent intolerances to gluten and other nutrients...involvement of the small bowel and colon may cause IBS-like symptoms, whereas involvement of the stomach and duodenum may cause functional dyspepsia."

Gluten intolerance after gastroenteritis may be common

An earlier post reports on loss of immune tolerance to the normal commensal gut microbiota after food borne illness. Practitioners should be alert to complaints persisting after resolution of a GI infection.

"Transient or permanent post gastroenteritis gluten intolerance might be a common unrecognised clinical condition. Like secondary lactose intolerance, post gastroenteritis gluten intolerance could explain the prolonged symptoms that develop in a group of patients who have suffered from infective gastroenteritis. Patients may present with diarrhoea, bloating, pain, vomiting and dyspepsia."

Non-celiac gluten sensitivity

Gluten intolerance should be considered as a possibility under the same circumstances that would suggest lactose intolerance.

"Non-coeliac gluten sensitivity is an entity separate from coeliac disease with a much higher prevalence. The autoantibodies like anti-EMA and/or anti-tTG tests are negative although antigliadin antibodies may be present...We suggest there may be an important role for the reduction of gluten in the diet as a treatment for these patients, in a manner analogous to the reduction in lactose intake frequently advised by dieticians for symptoms attributed to transient post infectious lactose intolerance."

The authors conclude:

"We suspect that patients who develop lactose and gluten intolerances after an episode of gastroenteritis are labelled as having IBS and can be left untreated for years or given only symptomatic treatment for pain, diarrhoea and constipation rather than advised to reduce their dietary intake of lactose and gluten. By moving toward clear diagnosis and targeted treatment of diseases that are involved in the formation of symptoms, we proportionally are approaching the end of the era of non-specific and unhelpful diagnosis like IBS and post gastroenteritis IBS. Clinician and dietician considering the possibility of a post infectious gastroenteritis irritable bowel syndrome being, in part, due to gluten intolerance may encourage colleagues to consider introducing a trial of a lactose and gluten free diet in suitable candidates after exclusion of celiac disease."