Gluten challenge in borderline gluten-sensitive enteropathy

OBJECTIVES: In patients with signs and symptoms of malabsorption, suggestiv e of gluten-sensitive enteropathy, small intestinal biopsies sometimes only reveal infiltration of lymphocytes into the mucosal epithelium. This infil trative lesion (Marsh I) is not a definite proof for gluten-sensitive enter opathy. However, in the present study, we aimed to show that a subgroup of these patients could ultimately be identified as being gluten sensitive. METHODS: A total of 38 patients with a Marsh I lesion were subjected to a g luten challenge comprising 30 g of gluten added daily to a normal gluten-co ntaining diet for 8 wk. Before and after the challenge, small intestinal bi opsies were taken, and symptoms and signs of malabsorption were scored. RESULTS:In 12 patients we demonstrated a significant change in mucosal hist opathology, i.e., subtotal villous atrophy (Marsh IIIB, n = 1), partial vil lous atrophy (Marsh 3A, n = 6) or infiltrative-crypthyperplastic lesions (M arsh II, n = 5). In the other 26 patients, the small intestinal mucosa rema ined unchanged. After initiation of a gluten-free diet, follow-up small int estinal biopsies in 12 patients who initially had progressive mucosal patho logy after gluten challenge showed normalization of mucosal pathology in se ven cases, regression to a Marsh I lesion in four, and to a Marsh n lesion in one. Symptom relief was seen in all 12 patients. Ten of 26 patients with out histological response to the gluten challenge were motivated to adhere to a gluten-free diet. Follow-up biopsies revealed unchanged Marsh I lesion s in eight patients and normalization (Marsh 0) in two patients. Three pati ents had follow-up biopsies while on a normal diet. All had unchanged Marsh I lesions. CONCLUSIONS: In the present study we demonstrated that a gluten challenge m ight be useful in identifying patients as being sensitive to gluten if init ial small intestinal biopsies reveal only minor abnormalities. (C) 2001 by Am. Cell. of Gastroenterology.