Third Gastroenterology and Nutrition Conference, Worcester, UK. September 12, 2014

This day-long conference was organised by Kamran Rostami and David Aldulaimi who pulled together an impressive line up of speakers. The first session was devoted to gluten related disorders and the gluten free diet. This is timely because the market for gluten free products in the USA alone is huge and out of all proportion to those who have coeliac disease. It is a multibillion dollar industry. Who is consuming all these gluten free products? Clearly many people think that they are gluten sensitive and on little or no objective evidence begin a gluten free diet. Dr Rostami summarised what is known about the three conditions that are now grouped under the heading gluten related disorders – wheat allergy, non-coeliac gluten sensitivity and coeliac disease. Wheat allergy is an uncommon adverse reaction to wheat proteins, the site of exposure determining the clinical manifestations e.g. in the skin, the gastrointestinal or respiratory tracts. IgE antibodies play a central role in the pathogenesis of these disorders. Non coeliac gluten sensitivity is defined as a reaction to gluten in which allergic and autoimmune mechanisms have been excluded. The morphology of the small intestinal mucosa is grossly normal. Symptoms should resolve on gluten free diet and reappear on gluten challenge. There are no specific tests and the diagnosis is one of exclusion. Recent research suggests that gluten itself may not be the only culprit and the role of FODMAPS which are short-chain indigestible carbohydrates that coexist with gluten in cereals, have been highlighted in provoking symptoms. Coeliac disease is by far the best known and researched of gluten related disorders and now recognised as a chronic immune mediated enteropathy triggered by exposure to dietary gluten in genetically susceptible subjects. Geoffrey Holmes discussed the epidemiology of coeliac disease and pointed out that figures from his large data base from Derby, UK, indicated in recent years a 15-fold increase in prevalence has occurred. This has been mainly due to better case finding with the advent of endoscopic biopsy and reliable screening tests but there is also evidence that coeliac disease is becoming more common. An increased intake of gluten containing foods or a reduction in infections might explain this. The increase in prevalence through the years has been found in many adult and paediatric coeliac centres. It is interesting that while coeliac disease is increasing in prevalence, dermatitis herpetiformis is decreasing. A possible explanation is that the earlier diagnosis and treatment of coeliac disease is preventing the skin lesions from appearing. The diagnosis of coeliac disease in Derby and elsewhere is increasingly being made in the elderly who improve on and are well able to manage a gluten free diet. A survey in Derby showed that coeliac disease is more common in Asians than in their white counterparts and this could be attributed to a significantly higher prevalence in Asian women ≥16 years and ˂60 years. Dietary factors may be responsible for these observations. Of concern coeliac disease was not being diagnosed in elderly Asian men so this group needs special attention. Strategies need to be developed to help this group adhere to a gluten free diet. Coeliac disease in India is potentially a huge problem with perhaps 10,000,000 undiagnosed patients.