Non-celiac gluten sensitivity (NCGS) is an intestinal tissue transglutaminase (TG2)- and IgE-independent form of GS. NCGS is approximately 6× more prevalent than the classical celiac disease (CD), and its incidence is on the rise. Because of its high relative prevalence and striking resemblance to other forms of GS, there is a greater need to develop new and accurate diagnostic assays to facilitate its definitive diagnosis. As the presence of serum anti-gliadin antibodies (AGA) in the absence of TG2 antibodies is suggestive of NCGS, several reports have recommended AGA immunoassays for differential diagnosis. Although AGA immunoassays are in general suitable for diagnostic purpose, to corroborate NCGS and to distinguish it from CD, a simultaneous use of CD-specific diagnostics, i.e., TG2 antibody-based assay, is also required. Due to lower accuracy of AGA assays than those of TG2-based ones, there will always be a chance (estimated to 5–10%) of misdiagnosing NCGS. Moreover, AGA-based diagnostics would not take into consideration the fact that NCGS is potentially triggered by not only gluten but also other molecules such as fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs). Therefore, a second generation of assays needs to be developed to differentiate NCGS from CD with high accuracy.
- tissue transglutaminase
- differential diagnosis
- gut microbiome
- chronic inflammation
- small intestine
- GI tract
1. Introduction: NCGS, CD, and irritable bowel syndrome
Similarities between non-celiac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS) were first noted in 1978 when it was reported that an adult female patient with IBS but not celiac disease (CD) showed dramatic relief of chronic diarrhea and abdominal pain symptoms after administration of gluten-free diet (GFD) [1–6]. More recent studies corroborated that some but not all IBS patients show significant onset of clinical diarrhea upon mucosal challenge with gluten [7, 8]. There is an emerging consensus that tissue transglutaminase (TG2) antibody-negative and anti-gliadin antibodies (AGA)-positive (TG2−AGA+) IBS patients with DQ2/8-negative haplotype qualify as NCGS candidates . Such an assumption can be confirmed by placing suspect NCGS patients on GFD with subsequent relief of clinical/immunological symptoms. Conversely, if AGA test is used alone, without other corroborative/exclusionary assays, its predictive value for NCGS is poor . Taken together, it appears that NCGS and IBS patients share several clinical and histopathological symptoms. NCGS should therefore be differentiated from IBS based on complete CD/NCGS serology, and diagnosis can be confirmed by performing a mucosal gluten challenge. To simplify and to expedite diagnostic steps, new molecular assays need to be developed to differentiate NCGS from IBS and CD.
2. Composition of host gut microbiome and NCGS/CD
Given the unprecedented rise of food allergies and autoimmune disorders in urban populations during recent decades, several studies have indicated that a potential causative association exists between some of these disorders and composition of the host’s gut microbiome [9, 10]. Since both CD and NCGS are inflammatory disorders of not only gastrointestinal (GI) tract but also other organs, including dysfunction of the gut-brain axis [11, 12], studies aimed at identification of specific hallmarks of gut dysbiosis of these disorders are the focus of current investigations.
It has been reported that bacteria involved in gluten metabolism predominantly belong to phylum
3. Host luminal shedding of fecal microRNAs
Recently, a novel concept concerning the capability of intestinal epithelial cells to release luminal regulatory microRNAs (miRNAs) was described . It was demonstrated that these fecal miRNAs could potentially enter bacterial cells and regulate their replication and growth. In this context, it is possible that inflammation-induced miRNAs could enter commensal bacteria and posttranscriptionally suppress or promote their growth by binding to specific sequences on bacterial genes . This in turn, depending on the outcome, may give pathogenic bacteria an opportunity to expand leading to dysbiosis. . These findings have therapeutic implications as oral supplementation of stable miRNA mimics capable of targeting specific dysbiotic or probiotic members of the gut microflora relevant to disease relapse and/or remission may be implemented. In our recently published studies, we hypothesized that GS disorders including CD and NCGS have their own unique signatures of dysbiosis. In addition, it is also likely that regulatory miRNAs secreted by host epithelial cells in response to dysbiotic events are also disease specific. Recently, we identified and reported several miRNAs (miR-203, miR-204, miR-23b, and miR-29b) with perfect complementarity between miRNA seed nucleotides (5′ prime nt position 2–7) and 16S rRNA sequence of dysbiotic bacterial species in the rhesus macaque model of CD (Figure 1) .
Dysbiotic bacterial species that could be potentially regulated in this fashion by inflammatory miRNAs included members of the
4. Dietary gluten and neurodevelopmental disease markers
The first report suggesting an association between increased occurrence of neurodevelopmental disorders and consumption of gluten-containing cereal grains dates back to 1966 . In the same year, it was reported that some but not all GS patients develop neurological dysfunctions referred to as gluten ataxia, gluten neuropathy, or gluten encephalopathy [18, 19]. Since then, several studies have suggested that symptoms of the autism spectrum disorders (ASD) could be improved upon changes in diet. One of these diets is GFD . Despite its widespread use, the efficacy of GFD for the treatment and prevention of ASD has not been conclusively proven. More recently, a case report involving NCGS patients with gluten psychosis was reported . The molecular mechanisms underlying ASD/psychosis vs. dietary gluten relationship are highly complex and understudied [22, 23]. Therefore, a transition from the “clinical phenomena” to “basic research” type of studies is needed. We propose that perturbation levels (measured by the extent of mRNA expression) of ASD predisposition genes need to be elucidated in preclinical, humanlike models first in the context of experimental introduction/withdrawal of dietary gluten.
For this and other purposes, we developed the rhesus macaque (
5. NCGS vs. CD microbial signatures
Based on the assumption that CD is caused by an autoimmune reaction to TG2, while NCGS is caused by chronic bacterial intestinal infections, a recent study by Columbia University researchers focused on the identification of differential, bacterial byproduct-specific diagnostic markers to distinguish the two conditions . Their findings suggested that enteropathy could occur in individuals who report GS in the absence of CD, while it is associated with increased serum antibodies recognizing bacterial lipopolysaccharide (LPS) and/or its CD14 ligand . Although several antibodies were evaluated for their potential to be used as differential diagnostic tools including anti-LPS, anti-flagellin, and anti-soluble CD14 (sCD14), the best predictive values were attributed to antibodies targeting LPS and sCD14. These results corroborated that NCGS and CD have common and differential features that can be further exploited for the development of more sensitive and accurate differential diagnostic assays.
Sestak K, Fortgang I: Celiac and non-celiac forms of gluten sensitivity: Shifting paradigms of an old disease. BMRJ. 2013; 3:585–589.
Husby S, Murray J: Non-celiac gluten hypersensitivity: What is all the fuss about? F1000 Prime Rep. 2015; 7:1–4.
Makharia A, Catassi C, Makharia GK: The overlap between irritable bowel syndrome and non-celiac gluten sensitivity: A clinical dilemma. Nutrients. 2015; 7:10417–10426.
Infantino M, Manfredi M, Meacci F, Grossi V, Severino M, et al.: Diagnostic accuracy of anti-gliadin antibodies in non-celiac gluten sensitivity (NCGS) patients. Clinica Chimica Acta. 2015; 451:135–141.
Biesiekierski JR, Peters SL, Newnham ED, Rosella O, Muir JG, et al.: No effects of gluten in patients with self-reported non-celiac gluten sensitivity after dietary reduction of fermentable, poorly absorbed, short-chain carbohydrates. Gastroenterology. 2013; 145:320–328.
Ellis A, Linaker BD: Non-celiac gluten sensitivity? Lancet. 1978; 1:1358–1359.
Vasquez-Roque MI, Camilleri M, Smyrk T, Murray JA, Marietta E, et al.: A controlled trial of gluten-free diet in patients with irritable bowel syndrome-diarrhea: Effects on bowel frequency and intestinal function. Gastroenterol. 2013; 144:903–911.
Biesiekierski JR, Newnham ED, Irving PM, Barrett JS, Haines M, et al.: FRACP1 gluten causes gastrointestinal symptoms in subjects without celiac disease: A double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011; 106:508–514.
Blaser MJ: Antibiotic use and its consequences for the normal microbiome. Science. 2016; 352:544–545.
Gensollen T, Iyer SS, Kasper DL, Blumberg RS: How colonization by microbiota in early life shapes the immune system. Science. 2016; 352:539–544.
Daulatzai MA: Non-celiac gluten sensitivity triggers gut dysbiosis, neuroinflammation, gut-brain axis dysfunction, and vulnerability for dementia. CNS Neur Disord. 2015; 14:110–131.
Aziz I, Hadjivassiliou M, Sanders DS: The spectrum of non-celiac gluten sensitivity. Nat Rev Gastroenterol Hepatol. 2015; 12:516–526.
Caminero A, Herran AR, Nistal E, Perez-Andres J, Vaquero L, et al.: Diversity of the cultivable human gut microbiome involved in gluten metabolism: Isolation of microorganisms with potential interest for coeliac disease. FEMS Microbiol Ecol 2014; 88:309–319.
Mohan M, Chow CET, Ryan CN, Chan LS, Dufour J, et al.: Dietary gluten-induced gut dysbiosis is accompanied by selective upregulation of microRNAs with intestinal tight junction and bacteria-binding motifs in rhesus macaque model of celiac disease. Nutrients. 2016; 8:1–18.
De Palma G, Nadal I, Collado MC, Sanz Y: Effects of a gluten-free diet on gut microbiota and immune function in healthy adult human subjects. Br J Nutr 2009; 102:1154–1160.
Liu S, Pires da Cunha A, Rezende RM, Cialic R, Wei Z, et al.: The host shapes the gut microbiota via fecal microRNA. Cell Host Microbe. 2016; 19:32–43.
Dohan FC: Wheat “consumption” and hospital admissions for schizophrenia during World War II. A preliminary report. Am J Clin Nutr. 1966; 18:7–10.
Cooke WT, Smith WT: Neurological disorders associated with adult coeliac disease. Brain. 1966; 89:683–722.
Hadjivassiliou M, Sanders DS, Grunewald RA, et al.: Gluten sensitivity: From gut to brain. Lancet Neurol. 2010; 9:318–330.
Catassi C, Bai JC, Bonaz B, Bouma G, Calabro A, et al.: Non-celiac gluten sensitivity: The new frontier of gluten-related disorders. Nutrients. 2013; 5:3839–3853.
Lionetti E, Leonardi S, Franzonello C, Mancardi M, Ruggieri M, Catassi C: Gluten psychosis: Confirmation of a new clinical entity. Nutrients. 2015; 7:5532–5539.
Genuis SJ, Lobo RA: Gluten sensitivity presenting as a neuropsychiatric disorder. Gastroenterol Res Pract. 2014. doi: 10.1155/2014/293206.
Mari-Bauset S, Zazpe I, Mari-Sanchis A, et al.: Evidence of the gluten-free and casein-free diet in autism spectrum disorders: A systematic review. J Child Neurol. 2014. doi: 101177/0883073814531330.
Bethune MT, Borda JT, Ribka E, Liu MX, Phillippi-Falkenstein K, Jandacek RJ, Doxiadis GG, Gray GM, Khosla C, Sestak K: A non-human primate model for gluten sensitivity. PLoS One. 2008; 3:e1614.
Bethune MT, Crespo-Bosque M, Bergseng E, Mazumdar K, Doyle L, Sestak K, Sollid LM, Khosla C: Noninflammatory gluten peptide analogs as biomarkers for celiac sprue. Chem Biol. 2009; 16:868–881.
Mazumdar K, Alvarez X, Borda JT, Dufour J, Martin E, Bethune MT, Khosla C, Sestak K: Visualization of transepithelial passage of the immunogenic 33-residue peptide from α-2 gliadin in gluten-sensitive macaques. PLoS One. 2010; 5:e10228.
Sestak K, Conroy L, Aye PP, Mehra S, Doxiadis GG, Kaushal D: Improved xenobiotic metabolism and reduced susceptibility to cancer in gluten-sensitive macaques upon introduction of a gluten-free diet. PLoS One. 2011; 6:e18648.
Sestak K, Mazumdar K, Midkiff CC, Dufour J, Borda JT, Alvarez X: Recognition of epidermal transglutaminase by IgA and tissue transglutaminase 2 antibodies in a rare case of rhesus dermatitis. JOVE. 2011; 58:e3154.
Sestak K, Thwin H, Dufour J, Liu DX, Alvarez X, et al.: Supplementation of reduced gluten barley diet with oral prolyl endopeptidase effectively abrogates enteropathy-associated changes in gluten-sensitive macaques. Nutrients. 2016; 8:1–13.
Xu H, Feely SL, Wang X, Liu DX, Borda JT, et al.: Gluten-sensitive enteropathy coincides with decreased capability of intestinal T cells to secrete IL-17 and IL-22 in a macaque model for celiac disease. Clin Immunol. 2013; 147:40–49.
Sadakata T, Washida M, Iwayama Y, et al.: Autistic-like phenotypes in Cadps2-knockout mice and aberrant CADPS2 splicing in autistic patients. J Clin Invest. 2007; 17:931–943.
Ogawa L, Vallender EJ: Evolutionary conservation in genes underlying human psychiatric disorders. Front Hum Neurosci. 2014; 8:1–10. doi: 10.3389/fnhum.2014.00283.
Dieterich W, Laag E, Schopper H, et al.: Autoantibodies to tissue transglutaminase as predictors of coeliac disease. Gastroenterol. 1998; 115:1317–1321.
Sulkanen S, Halttunen T, Laurila K, et al.: Tissue transglutaminase autoantibody enzyme-linked immunosorbent assay in detecting coeliac disease. Gastroenterol. 1998; 115:1322–1328.
Uhde M, Ajamian M, Caio G, et al.: Intestinal cell damage and systemic immune activation in individuals reporting sensitivity to wheat in the absence of coeliac disease. Gut. 2016; 0:1–8.