What is gluten?
How can gluten be harmful?
What is gluten sensitivity?
What are the symptoms of gluten sensitivity?
How is gluten sensitivity diagnosed?
Can I have gluten sensitivity if screening blood tests for celiac sprue
are negative or indeterminate?
Why is a stool test a logical test for gluten or other food sensitivity?
Do I have to be eating gluten to be tested?
Can I be tested if I am already on a gluten-free diet?
What is the role of genetic testing?
How do I know if I have intestinal damage due to gluten?
What is the difference between celiac sprue and gluten sensitivity?
Can I have gluten sensitivity if small intestinal biopsies are normal
or only minimally abnormal?
Who should be screened for gluten sensitivity?
Why you should not wait for intestinal damage before going on a
What test should I order for diagnosis of gluten sensitivity?
How do I place orders for multiple family members?
First, it must be understood that the gluten-containing grains we eat today are
actually domesticated and now genetically hybridized versions of what originally
were wild grasses endemic to the Tigris-Euphrates river basin. Presumably, due to
pressures from shortages of other foods, or ingenuity of ancient peoples, these
grasses became a source of food and calories. Learning how to cultivate and farm
these and other plants alleviated the pressures of the hunting/gathering lifestyle,
paving the way for more abundant and readily available food, which in turn, paved
the way for the more stable and populated Agrarian societies that followed. It is
believed and seems sensible, that this shift to agriculture-based societies was
responsible for the flourishing (note the word flour in flourishing) civilizations
of Mesopotamia and Egypt that followed. Thus, wheat, barley, rye, and oats are genetic
derivatives of wild grass, and therefore pose the possibility that eating a wild
plant may possess some toxicity.
What is gluten?
Gluten is a protein contained in the grains wheat, barley, rye, and oats. It
is a unique protein based on its structure that lends a doughy/elastic consistency
to flours derived from these grains. This is why over the centuries, gluten-containing
grains have come to be used so extensively in breads and other baked goods.Top
The nature of the toxicity, although to some extent stems directly from the chemical
nature of gluten, is mostly due to a reaction that occurs by the immune system of
individuals in possession of certain genes that recognize gluten for the foreign
protein that it is and hence toxic. The immune system genes in control of this reaction
are actually not rare, and may be present in up to 60% of Americans (based on my
research). However, there are other, as of yet undetermined, genes that control
whether or not a toxic reaction will occur, and further, whether and how much the
reaction will result in damage to the intestine and other tissues. It is speculated
that the structure of gluten may be similar to an infectious agent (for example
a virus) and that is really why the gene is present in the immune system in the
first place. It is even possible that the gene controlling reactivity to gluten
is so common because millions of years ago it lent a survival advantage against
dying from infections to those possessing it. Thus, having an immune system that
recognizes gluten as a foreign, potentially toxic protein actually may be a sign
of an immune system that is particularly sensitive and protective. Although this
may portend protection against infections, the down side is that the same genes
lead to more severe, longer lasting immune responses to foods, environmental allergens,
and even the human body itself. The consequences of these reactions are food sensitivities
(of which gluten sensitivity is just one), allergies/asthma, and autoimmune disease,
Gluten sensitivity implies that there is an ongoing immune reaction to gluten in
the diet, usually detected as antibodies against a subprotein of gluten called gliadin.
Although recently these antibodies were looked for only in the blood and are found
in 12% of the general American public, my research has revealed that these antibodies
can be detected in the stool in as many as 35% of what are otherwise normal people
(U.S. and International patents pending). If high risk patient populations are tested,
or people with symptoms, the percentage usually exceeds 50%. It makes sense that
the antibodies are more easily detected in the intestine because the immune system
reaction to food is mainly a response occurring inside the intestinal tract. Thus,
the end product of intestinal transit, stool, is the most logical (albeit more messy)
place to look. This is the rationale of the new tests developed by EnteroLab to
serve the testing needs of celiac patients. Top
Although there may be no detectable symptoms of the immune response to gluten, the
typical symptoms people develop occur when the reaction begins to damage the intestines.
The symptoms, resulting from malabsorption or improper digestion of dietary nutrients,
include abdominal bloating or pain, diarrhea, constipation, gaseousness, or nausea
with or without vomiting. It appears that acid reflux in the esophagus, manifesting
as heartburn, may be a potential symptom as well. Other symptoms people experience
include fatigue, joint pains, mouth ulcers, bone pain, abnormal menses in women,
In recent years, testing for gluten sensitivity and celiac sprue usually is initiated
with blood tests for antibodies against gliadin, the toxic subfraction of wheat
gluten, or for an antiendomysial antibody that is produced against an enzyme present
in the intestine and elsewhere in the body called tissue transglutaminase. These
tests have revolutionized testing for celiac sprue because they allow for detection
of the syndrome before extensive irreparable damage to the intestine, bones, and
other tissues has occurred. Up until recently it was thought that nearly all patients
with clinically important gluten sensitivity had these antibodies detectable in
blood. However, recent studies, including my own, have shown that this is not true.
In the early phases of the reaction, or especially when the disease is of a more
mild variety, antigliadin and antiendomysial/antitissue transglutaminase antibodies
may be absent from blood. Knowing that the immune reaction to gluten and other foods
takes place inside the intestinal tract, we began testing the hypothesis that these
antibodies may be present in the intestinal tract in gluten sensitive individuals,
even if they are absent from blood. Extensive research has revealed that this hypothesis
is true, and has resulted in the development of new methods for detection of gluten
sensitivity, celiac sprue, and other food sensitivities (U.S. and International
patents issued). This test has shown to be 100% sensitive for picking up celiac
sprue in those so affected. This test is being offered at an affordable price by
The answer to this question is definitively yes. Originally screening tests for
gluten sensitivity/celiac sprue consisted of blood tests against the damaging protein
in gluten called gliadin (antigliadin antibodies). However, with heightened awareness
of the possibility of gluten sensitivity in family members of diagnosed celiacs,
or in people with syndromes associated with celiac sprue, it has become clear that
not all people suspected of being immunologically intolerant to gluten have positive
blood tests. This is problematic because these individuals are told outright that
they are not gluten intolerant based on negative blood tests. Many times patients
themselves are able to deduce that it is wheat that causes them to feel ill or have
intestinal symptoms, but when blood tests are negative they are diagnosed with irritable
bowel syndrome or sometimes "wheat allergy". It is not surprising to me that blood
tests in the early phase of gluten sensitivity are negative. This is because the
immunologic reaction to gluten begins and occurs inside the intestinal tract and
not in the blood per se. For this reason, I had an idea about a year ago that these
antibodies should be more frequently detected in the stool of gluten sensitive individuals
rather than in the blood. This turned out to be the case based on extensive analysis
of more than 500 normal people or people with various medical syndromes (including
bonafide celiacs, patients with microscopic colitis, a form of colitis genetically
and clinically related to gluten sensitivity, and patients with chronic diarrhea
of unknown origin). Based on this research and its importance, I have brought this
new test to the public directly via the internet from www.EnteroLab.com This new
stool test can detect antigliadin antibodies in stool whether a person has symptoms
or not. It is ideal for children who do not have to be stuck with a needle. Samples
can be mailed from your home without having to go to the hospital or a doctor's
office. Furthermore, you can decide if you want to be tested and do not have to
beg a doctor to test you for gluten sensitivity.
Thus, because the antibodies produced as the result of gluten sensitivity are mainly
secreted into the intestine rather than the blood, analyzing stool turns up many
more positive tests than blood tests. It is only when the immune reaction has been
present for long periods of time and/or the process is far advanced that antibodies
are produced in quantities sufficient to leak into the blood.Top
The immune cells present in the intestinal tract comprise the largest mass of tissue
in the body assigned the function of protecting against foreign invaders. These
invaders are present in the form of proteins called antigens. Although the intestine's
immune cells probably evolved originally to ward off infecting organisms, in fact,
their most frequent exposure to foreign antigens comes from food. One of the first
lines of defense against foreign antigens (food or infections) is the secretion
of a special antibody called secretory IgA into the intestinal lumen (i.e., the
hollow center of the intestine). Here, these antibodies bind the antigen by a sort
of lock and key recognition mechanism, in an attempt to neutralize the antigen so
that it cannot enter the body. Because these antibodies do not get reabsorbed after
entering the intestinal tract, they travel all the way through the intestine where
they can be recognized in the stool. This is the rationale for the new gluten and
other food sensitivity testing methodology invented and offered by EnteroLab (U.S.
and International patents issued)Top
Because production of antigliadin antibodies is under genetic control, your body
continues to make these antibodies for an extended period after gluten is removed
from the diet, albeit, in lesser quantities the longer gluten is removed from the
diet. Research has shown that these antibodies continue to be produced at lower
levels for months, even 1-2 years after gluten is removed from the diet. Stool tests
can continue to detect these low levels of antigliadin antibody produced in the
intestine over this 1-2 year period (and longer if there is still small amounts
of gluten in the diet, even hidden gluten); tests for antigliadin antibody in the
blood routinely become negative after 3-6 months on a gluten-free diet.
Although it has been stated that a person must be eating gluten to be able to detect
antibodies to gliadin in blood, we have found that this is not true for our stool
tests (and other researchers have found the same when sampling upper intestinal
contents with tubes). Because the stool tests (but not blood tests) can find low
levels of antigliadin antibody produced in the intestine, we actually recommend
that you be tested on your current diet, that is, gluten-containing or gluten-free.
The amount of antibody being produced at any given gluten intake will be more meaningful
if it reflects your normal condition rather than an artificially created condition
by reintroducing gluten (if you have been off of it for a time) or trying to eat
gluten in excess. Furthermore, even though a person removes obvious sources of gluten
from the diet, there continues to be the potential of hidden gluten in less obvious
food or drug sources (such as food additives, medicines, lotions, etc.), or when
eating outside the home. Thus, it is possible that the test still may turn up positive
for this reason.
Our recommendation then is simply to eat what you are currently eating, or whatever
you think is best for you right now. There is no need to introduce the food being
test for in any amount, and especially not in large amounts which could make you
ill. If you have been off gluten for short periods, the results will be very close
to those if you never had removed gluten from the diet. For people who have been
gluten-free for longer than 1-2 years, it is actually best to remain gluten-free
for the stool test, and to also rely on the gene test to aid in the diagnosis (see
Thus, it is better to test on the current diet before adding the unreliable variable
of a one to two week gluten challenge. It varies in different people how they or
their immune system will react to gluten, and how long it would be required to eat
gluten to make tests positive (as they once may have been before starting the diet).
There are no guarantees that a truly gluten sensitive person will have positive
tests after a short 1-2 week gluten challenge anyway, even if they get symptoms
Here are the potential scenarios of stool and gene test results if testing is performed
on a low gluten or gluten-free diet (rather than doing a gluten challenge).
Because the stool test is much more sensitive than the blood tests, and the antibody
can be produced for years after removal of gluten from the diet, the stool test
may well be positive despite being on a reduced or restricted gluten diet. The gene
test (which we recommended as a complementary test to the stool testing, especially
when someone has been off of gluten for long periods of time because the gene test
is never affected by the diet) likely will support the positive results.
The stool test is negative (because they have limited or stopped gluten for a long
period like many years) but the gene test is positive. This data is useful because
it tells you at least that antibody production to gluten has stopped on the gluten-free
diet. And the positive gene test or potential improvement you may have experienced
after beginning your gluten-free diet are supportive that you are gluten sensitive.
If the gene test is negative, it is still remotely possible to be gluten sensitive.
Alternatively, if you choose to do a gluten challenge at the outset (again which
we do not recommend) and the test is negative, it may be so because damage and antibody
production has not yet been initiated. And you do not get the benefit of a comparison
of what your antibody levels were when gluten was out of the diet. The comparison
itself before and after gluten can be helpful, and is definitely more meaningful
than testing after a short time on gluten after being gluten-free for an extended
Thus, I recommend testing in the stable gluten-free condition first then in the
variable gluten-challenge condition only if necessary.
One final note. Sometimes people experience dramatic improvement of symptoms and
feeling of well-being after beginning a gluten-free diet. If the improvement to
health was dramatic following removal of gluten from the diet, then this in and
of itself is a positive diagnostic test (and perhaps the ultimate test).Top
Currently, tests are available to detect the genes that control the immune system's
reaction to gluten. These genes are called human leukocyte antigens or HLA. There
are several types of HLA genes within each person. It is a particular type called
HLA-DQ that is most useful in the assessment of the probability that a person may
be gluten sensitive. The reason gene testing assesses probability rather than disease
itself is because some people have the genes for gluten sensitivity but have no
detectable evidence of the immune reaction to gluten or have no symptoms. In such
people, gluten sensitivity is still possible but the probability (or in other words
the chances or the odds) is lower than in a person who may be having symptoms attributable
to gluten or that has antibodies detected. HLA testing is most useful when there
is diagnostic confusion about whether or not a person is gluten sensitive. Such
confusion often stems from one of the following: atypical intestinal biopsy results,
the presence of associated diseases (such as microscopic colitis) that may mask
the expected improvement of symptoms when gluten is withdrawn from the diet, negative
tests for gluten antibodies in the midst of suggestive symptoms or signs of gluten
sensitivity or celiac sprue (see the paragraph below to understand the difference),
or when there are no symptoms at all and the person or the doctor can hardly believe
that gluten sensitivity is really present. Other situations that HLA testing is
useful is when a person is already on a gluten-free diet, and for testing family
members (particularly children) for the odds that they have or will develop gluten
If intestinal symptoms are present in the face of a positive antibody test to gliadin,
it is likely that some damage is present. Although traditionally, doctors have relied
on a biopsy of the upper small intestine to prove or disprove this, it is now known
from medical research (including studies I have conducted) that the damage may be
imperceptibly subtle, possibly to the extent of being invisible to the microscope.
Thus, tests assessing the function of the intestine rather than how it looks under
a microscope are playing a more important role in this field.
For more than 50 years, the primary method used to assess for the presence of small
intestinal damage and nutrient malabsorption in patients with celiac disease has
been a 72-hour quantitative stool collection. However, because this method requires
that patients accurately collect all the stools they pass for 3 days (missed stools
lead to falsely low results), the test is logistically difficult for medical centers
unaccustomed to the procedure, and the voluminous specimens usually are abhorred
by patients and laboratory technicians. It poses obvious problems for children who
cannot or will not collect all their stools, as well as for patients with chronic
diarrhea, who may have bowel movement frequencies reaching 15 or more per day and/or
fecal volumes as high as 2 or 3 liters per day. For these reasons, physicians evaluating
patients with suspected or proven gluten sensitivity often avoid tests for intestinal
Recently, EnteroLab researchers have developed a new method for quantitating fecal
fat excretion that requires collection of only a single stool specimen. Development
of this method was based on the fact that as more fat is malabsorbed, the fat globules
in stool become more numerous and larger. As reported in the April 2000 issue of
the American Journal of Clinical Pathology in an article entitled "A New Method
of Quantitative Fecal Fat Microscopy and its Correlation with Chemically Measured
Fecal Fat Output", I and Frederick Ogunji Ph.D. tested 180 patients and found a
highly statistically significant linear correlation between quantitative fecal fat
microscopy (the new method) and chemically measured fecal fat output (the old method).
We also showed that microscopic analysis of just one stool gives comparable results
to analysis of an entire 3-day collection. Thus, a dedicated quantitative analysis
of one stool under a microscope can detect the rise in fecal fat due to intestinal
malabsoprtion (or pancreatic maldigestion) as accurately as 3-day stool collections,
making these multi-day collections a thing of the past for most patients.
Patients with gluten sensitivity should be evaluated for nutrient malabsorption
because if present, this means there is small intestinal damage and institution
of a gluten-free diet is imperative to prevent osteoporosis and other nutrient deficiency
syndromes. Furthermore, a test at the time of diagnosis serves as a baseline to
be compared to later if needed.
This new stool test for intestinal malabsorption and other celiac-testing is available
for order online from EnteroLab.Top
Gluten sensitivity implies that a person's immune system is intolerant of gluten
in the diet and is forming antibodies or displaying some other evidence of an inflammatory
reaction. When these reactions cause small intestinal damage visible on a biopsy,
the syndrome has been called celiac sprue, celiac disease, or gluten sensitive enteropathy.
(Nontropical sprue and idiopathic steatorrhea are other terms that have been used
for this disorder in the past.) The clinical definition of celiac sprue also usually
requires that there is clinical and/or pathologic improvement following a gluten-free
In the past, celiac sprue could only be diagnosed after somebody developed certain
symptoms like diarrhea, weight loss, or growth failure in children. A biopsy would
be performed and if abnormal and typical of celiac sprue, and if a gluten free diet
brought resolution of diarrhea, weight gain, or growth, only then would a diagnosis
of celiac sprue be made. However, recent advances in diagnostic screening tests
and application of these tests to people at heightened risk or to general populations
have allowed detection of celiac sprue, sometimes even before damage to villi has
occurred. This latter scenario is often called gluten sensitivity. Top
Although by definition a normal small bowel biopsy rules out celiac sprue, it does
not rule out gluten sensitivity. Although asymptomatic people with gluten sensitivity
may have normal or near-normal biopsies, so too may people with symptomatic gluten
sensitivity. This has been reported in the medical literature (called "Gluten Sensitivity
with minimal Enteropathy" or "Gluten-Sensitive Diarrhea without Celiac Disease".
Furthermore, even though such people's intestines appear normal under the microscope,
up to one half already have nutrient malabsorption, a major contributor to osteoporosis
and malnutrition, attesting to the fact that microscopic analysis of intestinal
biopsies is an insensitive way of assessing function and immunologic food sensitivity.
However, because there is still a virtually universal reliance on small bowel biopsies
to diagnose gluten intolerance, most asymptomatic or symptomatic gluten sensitive
people (based on screening tests) will not be diagnosed correctly or be instructed
to follow a gluten-free diet even though symptoms may resolve completely.Top
Because research has shown that as many as 30% of all Americans may be gluten sensitive,
and that 1 in 225 have a severe form of this sensitivity causing the intestinal
disease called celiac sprue, a case can be made that everyone in America should be
screened for gluten sensitivity. However, there are people with various
risk factors or diseases that are at greater risk of developing gluten sensitivity
who should undoubtedly be tested. These include:
- Microscopic colitis
- Relatives of gluten-sensitive individuals
- Gluten-sensitive individuals 1 year after treatment
- Chronic diarrhea of unknown origin
- Irritable bowel syndrome
- Inflammatory bowel disease
- Gastroesophageal reflux disease
- Hepatitis C
- Autoimmune liver disease
- Other causes of chronic liver disease
- Dermatitis herpetiformis
- Diabetes mellitus, type 1
- Rheumatoid arthritis
- Sjogren's syndrome
- Autoimmune thyroid disease
- Any autoimmune syndrome
- Chronic Fatigue
- Iron deficiency
- Short stature in children
- Down's syndrome
- Mothers of kids with neural tube defects
- Female infertility
- Peripheral neuropathy
- Cerebellar ataxia
- Seizure disorders
- Psychiatric disorders
More widespread use of my new stool test (or at a minimum, blood tests) for gluten
sensitivity, particularly in those at heightened risk to develop gluten sensitivity
such as family members of celiacs or persons with diseases associated with celiac
sprue(see list above), will allow identification of clinically important gluten
sensitivity before they have developed significant intestinal damage. This is the
ideal scenario for a gluten sensitive person because by the time the small intestine
becomes damaged, malnutrition has been present for years often causing irreversible
osteoporosis. Moreover it is the extensive inflammation and damage in the small
intestine that is responsible for the risk of cancer and lymphoma of the small intestine.
Autoimmune syndromes occur more commonly the longer a gluten sensitive person eats
gluten. Therefore, as common as gluten sensitivity seems to be (35% of all "normal"
people tested with the stool test and 12% of normal volunteers tested with blood
tests), we all must begin thinking in a more preventive health way about gluten
sensitivity and should take strides to identify it and treat it before it becomes
full-fledged celiac sprue.
Finally, because it has been shown in published studies and in an as of yet unpublished
study of my own that people with gluten sensitivity who have normal or near-normal
appearing small intestinal biopsies can have malabsorption of nutrients and have
symptoms that resolve with a gluten-free diet, the practice of biopsying everyone
thought to be gluten intolerant or those with positive screening tests must come
to a halt. The tests are invasive, require sedation, have associated risks, and
are expensive. Furthermore for the same reasons, we cannot wait until the intestine
is so severely damaged to be visible under a microscope that a gluten-free diet
is prescribed. Life can be enjoyed on a gluten-free diet. I speak from personal
The stool test for gluten sensitivity alone can answer the question of whether or
not a person is gluten sensitive. However, combining this with the gluten sensitivity
gene test provides the most complete assessment of the condition. Adding a test
for assessment of fat malabsorption further assesses intestinal absorption function
relative to their gluten sensitivity status. The most economical way of getting
just these stool tests ordered is in our Gluten/Antigenic Food Sensitivity Stool
Panel Limited or Gluten Sensitivity Stool Panel for $279 (Panel A or E). However
to receive a gene analysis at a 33% discounted price, and having three other food
sensitivity stool tests added, the best value would be the (Gluten/Antigenic Food
Sensitivity Stool/Gene Panel) for $369, and adding the fat malabsorption
test at the discounted price of $89 (regular price $129). If you have already been
diagnosed as gluten sensitive or with celiac sprue, we recommend that you have a
follow up fat malabsorption test while staying on your gluten-free diet to be sure
that your intestine has resumed its normal absorptive function. This is especially
important after the first 1-2 years of diagnosis.
If you have not been diagnosed with gluten sensitivity but you have been gluten-
free for more than a few weeks, it is best to stay off gluten and be tested on a
gluten-free diet. Our tests can detect intestinal antigliadin antibody up to 2 or
more years despite a gluten-free diet under most normal conditions. We never recommend
a gluten-challenge, ever! It is not safe and many people get very ill from doing
so because of the increased sensitivity to gluten that may occur while being gluten-free.Top
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