Coeliac Disease: Gluten Free Diet and… What Else?

Coeliac Disease (CD) is a permanent gluten intolerance, whose pathogenesis involves multiple factors including genetics and environment. CD has different representations and non-specific symptoms such as diarrhea, bloating, pain, flatulence and constipation may sometimes be misleading. Once diagnosed of CD, patients must adhere to Gluten Free Diet, which consists in the lifelong avoidance of gluten containing foods and of those naturally gluten free but at risk of contamination. This dietary approach is considered the only therapy in order to avoid symptoms exacerbation and to reduce the digestive mucosa inflammation, which has been related to higher risks of lymphoproliferative malignancy and other immunological disorders. However, being on a Gluten Free Diet is not as resolving as it may seem since it has several criticalities. First of all, excluding gluten means limiting food variety so that coeliac patients may have unbalanced intake of several nutrients and develop clinical or subclinical deficiencies. This can be due to scarce attention to qualitative and quantitative composition of diets and poor information about gluten-containing foods, which only patient-tailored dietetic protocol and long-term follow-up can achieve. Secondly, Gluten Free Diet may not result in complete remission of mucosal damage or in resolution of symptoms. Unintentional contamination of gluten or poor adherence to diet are the main culprits of the incomplete mucosal healing but other triggers may be involved. Recent research has focused on the role of FODMAPs in changing gut microbiota and on the improvement of Irritable Bowel Syndrome (IBS) symptoms after their dietary avoidance or reduction. Since CD and IBS may share many clinical presentations, further studies are needed to evaluate if a subgroup of CD patients whose symptoms are not improved by Gluten Free Diet could benefit from a new therapeutic approach consisting in both gluten/wheat and FODMAPs avoidance.