Gluten and gluten-sensitive enteropathy have become hot topics among the lay public and in medical practices. We dermatologists have historically concerned ourselves with gluten only as it relates to dermatitis herpetiformis. This may be changing. John Zone, M.D., from the University of Utah, Salt Lake City, discusses how gluten sensitive enteropathy may impact many areas of our specialty.
Dr. Levine: Exactly what is gluten and what is a gluten-sensitive enteropathy?
A: John Zone, M.D.: Gluten is really a group of proteins that is in various grains: rye, barley and wheat. There are specific substances in them called prolamins that are responsible for the immune response. That group of proteins is not present in rice or oats; it is just present in rye, barley and wheat. These proteins are large enough to produce an immune response, and that’s what they do in celiac disease and possibly in other conditions.
Dr. Levine: So when we talk about gluten-sensitive enteropathy, what does that mean?
A: Gluten-sensitive enteropathy and celiac disease are synonymous. Gluten-sensitive enteropathy means that there is damage to the intestinal mucosa that is induced by gluten, and when gluten is withdrawn from the diet, the damaged mucosa heals over in a matter of months. So that’s gluten-sensitive enteropathy. There, of course, are other enteropathies that aren’t sensitive to gluten.
Dr. Levine: All of a sudden, it seems like people are talking about this and it seems like the incidence of this has become tremendously high. What happened?
A: The first thing that made celiac disease more common was better testing and identification of occult disease.
I started studying celiac disease and gluten sensitivity back in the 1970s, and it was deemed to be very rare. At that time, the only way that people could be diagnosed was with a small intestinal biopsy or with a skin biopsy if they had dermatitis herpetiformis.
We got better blood tests in the 1990s and a lot of work was done on establishing the reliability of various blood tests in predicting the intestinal abnormality. So with the availability of a blood test, it was first found in about 2000 that about one in 100 people in the United States had a positive blood test for celiac disease, and if you go ahead and biopsy their intestine, you will find out that indeed they have gluten-sensitive enteropathy or celiac disease of the intestine.
We used to think that people only had celiac disease if they had a lot of symptoms: crampy abdominal pain, diarrhea, etc. Now we know from our blood test that up to two-thirds of the people do not have abdominal symptoms, but they may have secondary complications such as malabsorption of iron and osteoporosis.
The question of whether or not the incidence of celiac disease is actually increasing with time is an interesting one. There is only one study that I know of that actually has dealt with that.
Joseph Murray, M.D., a researcher at Mayo Clinic, took serum that had been stored since the 1960s or ’50s, I am not sure, for military recruit and established their serum positivity. It was much lower than a comparable group today. It may well be that the incidence of celiac disease and gluten sensitivity is increasing for reasons other than better testing, we don’t know what those reasons might be (Murray JA, Van Dyke C, Plevak MF, et al. Clin Gastroenterol Hepatol. 2003;1(1):19-27).