The 4 differences between celiac disease and gluten sensitivity (explained)

Celiac disease (CD) is an immune-based systemic disorder, caused by the ingestion of gluten in those people who have a genetic predisposition. The fact that it is a systemic disease means that it not only affects the digestive system, but also any function of the body. In this way, the characteristic symptoms can be digestive (diarrhea and / or constipation, gas, nausea, vomiting, gurgling, heartburn, etc.), but also extra-digestive (tiredness, migraines, dizziness, skin problems, infertility ...).

Gluten, celiac disease and sensitivity: who is who?

CD has been a great unknown until very recently, since it was considered that this could only be manifested in a single way. Traditionally, it was only diagnosed in those cases of children in which there was chronic diarrhea, abdominal bloating and growth problems. Thanks to research, another side of the disease has been discovered.

In addition to children, it can also appear in adults, and it does not always appear in the form of digestive symptoms. Many people with seemingly inexplicable symptoms and ailments actually suffer from this disease. Although more and more is known about CD, it is still an underdiagnosed disease. Many people with celiac disease are unaware that they are, despite their symptoms, which prevents them from taking the appropriate treatment to end them, which is a strict gluten-free diet for life.

The decisive test to diagnose celiac disease is a duodenal biopsy.. This allows to determine if there is a lesion in the villi of the small intestine and, if there is, what is its degree of severity. However, digestive medicine is finding many patients who, without showing visible lesions when performing this biopsy, see their symptoms reduced by removing gluten from the diet.

Thus, since the late 1970s, a concept known as non-celiac gluten sensitivity has been proposed. Although at that time it aroused great controversy, it is now beginning to be recognized and studied in depth. Although much remains to be known regarding non-celiac gluten sensitivity and there is no decisive test to diagnose it, it can be determined based on certain premises:

• The patient shows digestive and / or extra-digestive symptoms consistent with celiac disease.
• The patient is NOT celiac.
• The patient is NOT allergic to gluten or wheat.
• The patient shows improvement when on a gluten-free diet.
• The patient shows worsening when consuming foods with gluten.

Due to the gaps that still exist in reference to this table, it is not known with certainty how many people may be affected by non-celiac gluten sensitivity, with estimates ranging between 0.6% and 10% of the population. Some authors consider that people considered sensitive are actually celiacs who have not been correctly diagnosed.

Both tables are very difficult to discriminate, although some points can serve as a guide to differentiate them. In this article we are going to learn about the differences between celiac disease and gluten sensitivity.

How are celiac disease and gluten sensitivity different?

As we have been discussing, there are some differences that can help us differentiate celiac disease from non-celiac gluten sensitivity. Let's get to know them.

1. Diagnostic markers

People with celiac disease often show specific indicators that suggest the presence of this condition. Some, not all, show positive antibodies in the blood, as well as compatible genetic markers and characteristic histological changes of the disease. As we have already commented, the decisive test to diagnose CD is the duodenal biopsy, since this allows to determine if there is damage to the intestinal villi and of what intensity.

It should be noted that in celiac children older than 2 years, adolescents and adults, antibody serology is usually negative or only slightly elevated. In addition, the biopsy does not always show deep lesions, since only lymphocytic enteritis can be detected. In the case of non-celiac gluten sensitivity, patients resemble celiac patients with lymphocytic enteritis (without damage to their villi), although in their case the increase in intraepithelial lymphocytes is generally less than 25%. Furthermore, unlike genuine celiacs, those sensitive to gluten do not have genetic markers for CD and show normal serology.

As we can see, there are infinite nuances that make differentiating the two conditions especially complex. In addition to the markers that we have mentioned, the healthcare professional should always make a careful evaluation of the medical history, keeping in mind the personal history of the patient in his childhood.

Especially important is the search for possible diseases and existing autoimmune processes, as well as diseases typically associated with celiac disease, such as bronchial asthma or recurrent chronic rhinitis. It is also essential to review the family history of celiac disease. However, as it is a disease with a genetic basis, it is common for there to be several celiacs in the same family nucleus, although often the lack of diagnosis can make the patient believe that they are the only celiac at home when this is not the case at all.

2. Diagnostic protocol

In line with the previous point, it must be taken into account that the diagnostic process of both entities is quite different. In the case of CD, there is a very clear and standardized diagnostic protocol, endorsed in the case of Spain by the Ministry of Health, Social Services and Equality.

The clinical history is always evaluated in conjunction with the markers already mentioned, being the joint balance of all the information that determines whether or not the patient is celiac. Conversely, reaching a diagnosis of non-celiac gluten sensitivity is a much more chaotic and disorganized process, fruit of the ignorance that still exists regarding this issue.

The problem with this condition is that, unlike CD, it does not have specific markers. Therefore, there is no other option than to be guided by pure exclusion criteria. It should be ruled out that the person is celiac or allergic to wheat, that there are no other digestive diseases, etc. In other words, the sensitivity diagnosis is never the first option to assess, but the last when there are no other possible explanations.

3. Celiac disease is an autoimmune disease; sensitivity, an intolerance

It is essential to understand that CD and gluten sensitivity are two entities of a different nature. On the one hand, celiac disease is an autoimmune disease, in which the ingestion of gluten triggers a reaction of the immune system. It is not an allergy or an intolerance.

On the other hand, non-celiac gluten sensitivity is a symptomatic intolerance. When someone who is sensitive to gluten ingests this protein, some digestive and extra-digestive symptoms are triggered in their body. The most recent studies are trying to understand if what causes the symptoms in sensitive people is really gluten (as in celiacs) or other components of wheat, such as fructooligosaccharides.

4. Symptoms

Celiac disease can manifest itself with digestive symptoms (diarrhea, gas, constipation, fatty stools ...) and extra-digestive symptoms (anemia, osteoporosis, fatigue, infertility, dermatitis herpetiformis, etc.). However, what is not always known is that celiac disease can also be asymptomatic and have no visible clinical manifestations. For this reason, when someone is diagnosed as celiac, screening tests are usually performed on first-degree relatives, in order to assess whether there are more celiac patients in the family.

In the case of non-celiac gluten sensitivity, it always manifests itself with obvious symptoms, are these digestives or not. The most common are abdominal pain, skin rashes, fatigue, migraines, anemia, constipation, etc.

Conclusions.

In this article we have talked about two related health problems with gluten: celiac disease and non-celiac gluten sensitivity. Even if in both cases, patients must follow a strict gluten-free diet To alleviate its symptoms, these are two problems with several essential differences.

Celiac disease is a disease of an autoimmune nature, where gluten acts as an agent that triggers a harmful response in the body. In contrast, non-celiac gluten sensitivity is an intolerance in which there is no involvement of the immune system.

On the other hand, celiac disease is a well-known condition for which specific markers are known. This has allowed the establishment of a well-defined and standardized protocol to reach its diagnosis. On the contrary, gluten sensitivity is not yet well understood and is a diagnosis that is reached through exclusion criteria, ruling out other conditions such as wheat allergy and celiac disease.

Regarding the symptoms, Celiac and sensitive patients usually show similar symptoms, both digestive and extra-digestive. However, in the case of the former, the possibility of asymptomatic celiac disease is also viable. For this reason and because CD is a disease with known genetic markers, family screening is usually performed to identify possible celiac disease in the patient's family unit.

Although everything that refers to pathologies related to gluten has advanced intensely in recent years, there are still many unknowns to solve. At the moment, gluten sensitivity is a diagnosis in which there are certain gaps and where the exact causes that trigger its appearance have not been discovered, although it has been shown that a gluten-free diet alleviates the symptoms of both celiac and gluten-sensitive.