Diagnostic Dilemma, Possible Non-celiac Gluten Sensitivity: Consideration in Approach and Management

Non-celiac gluten sensitivity (NCGS) is clinically identified as a condition where a percentage of the population reports intestinal and/or extraintestinal symptoms caused by gluten and/or wheat ingestion, and they are tested negative for celiac disease (CD) on the basis of specific serology and histopathology. NCGS should be labelled after the exclusion of CD and wheat allergy. This population reports improved symptoms on a gluten-free diet. Despite great interest and work on NCGS, much remains unknown about its pathogenesis. A positive and improved response to a gluten-free diet for a limited period of time (e.g., six to eight weeks), followed by retrieval of symptoms in case of gluten intake, is presently considered to be the best strategy for confirmation of diagnosis. A middle-aged lady came for medical attention with concerns of weight loss, lethargy and abdominal discomfort. On investigations, her serum transglutaminase IgA was found to be largely raised. The patient was switched to a gluten-free diet with suspicion of CD. Upper GI endoscopy was done one week after being on a gluten-free diet. Both endoscopy with histopathology was negative for villous atrophy and increased intraepithelial lymphocytes. Later human leukocyte antigen (HLA) testing was found to be negative for CD, leading to a diagnostic conundrum. On the basis of remarkable symptom improvement on a gluten-free diet, drop in transglutaminase levels, negative biopsy and HLA testing, the diagnosis was made as possible NCGS. Considering gluten-related disorders are rising and not much is known about NCGS, we aimed to present this case to create awareness and raise questions regarding diagnosis, need for specific monitoring and implications on the management.