SSAT - NON-CELIAC GLUTEN SENSITIVITY (NCGS) � A NARRATIVE REVIEW

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NON-CELIAC GLUTEN SENSITIVITY (NCGS) � A NARRATIVE REVIEW
Muhammad Chaudhary^*¹, Fazeela Bibi², Muhammad Ibrahim³, Mian Zahid Jan Kakakhel⁴, Janmejay Kumar Singh⁵, Oluwagbenga Serrano¹
¹Internal Medicine, Indiana University School of Medicine, Indianapolis, IN; ²Jinnah Medical and Dental College, Karachi, Sindh, Pakistan; ³Bannu Medical College, Bannu, N.W.F.P, Pakistan; ⁴Rehman Medical College, Peshawar, N.W.F.P, Pakistan; ⁵Teerthanker mahaveer medical college, Moradabad, Moradabad, India

Introduction
Non Celiac Gluten Sensitivity (NCGS) is a syndrome with intestinal symptoms and extra intestinal symptoms (e.g., fatigue, headache, anxiety) triggered by gluten ingestion, despite negative tests for celiac disease (CD) and wheat allergy (WA). NCGS is challenging to diagnose due to the lack of reliable biomarkers. Diagnosis involves excluding CD and WA and observing symptom improvement on a gluten free diet, often guided by the Salerno criteria. Symptom overlap with irritable bowel syndrome (IBS), which also improves on a low FODMAP diet, complicates differentiation. Factors like placebo effects and fermentable carbohydrates obscure diagnosis.

Background and Rationale

Differentiating NCGS from IBS is difficult due to overlapping symptoms and the absence of specific biomarkers for NCGS. NCGS is diagnosed by excluding CD and WA, while IBS is diagnosed using the Rome criteria. This study investigates the overlap of symptoms between NCGS and IBS to improve diagnostic accuracy.
A systematic review of PubMed, Cochrane, and other databases was conducted using terms like "non-celiac gluten sensitivity," "irritable bowel syndrome," and "symptom overlap." Relevant studies on clinical presentation, pathophysiology, and diagnostics/treatment of NCGS and IBS were included.

Results

Evidence for NCGS

NCGS is a legitimate condition in individuals without CD or WA. Symptoms improve with gluten withdrawal, but diagnostic challenges remain due to subjective symptom reports and lack of standardized criteria. Randomized trials show symptom relief with gluten free diets, though placebo effects limit generalizability.

Role of Fructans vs. Gluten

Fructans, not gluten, may trigger symptoms in some NCGS cases. A study by Skodje et al. found fructans induced symptoms in many NCGS patients, highlighting overlap with IBS, where sensitivity to FODMAPs is common.

Mechanisms and Biomarkers

The mechanisms of NCGS remain unclear. Possible factors include mild intestinal inflammation, increased gut permeability, and immune activation, but findings are inconsistent. Altered gut microbiota and the gut-brain axis may also contribute, especially in those with psychological or functional disorders.

Conclusion

NCGS remains challenging to diagnose and is treated as a diagnosis of exclusion. Fructans may contribute to symptoms, making it hard to distinguish from IBS. The lack of biomarkers and clear mechanisms limits diagnostic accuracy. Gluten-free and low-FODMAP diets show promise, but standardized diagnostic and treatment guidelines are needed. Future research should clarify the mechanisms behind NCGS and IBS to improve patient outcomes.

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