Introduction

Non-coeliac gluten/wheat sensitivity (NCGWS) is characterized by gastrointestinal and extra-intestinal symptoms triggered by gluten/wheat ingestion in patients without coeliac disease (CD) or wheat allergy. There are controversies on the mechanism leading to this phenomenon, including media influence and the presence of a nocebo effect. Moreover, after the COVID-19 pandemic, a decrease in the rates of NCGWS diagnosis has been noted. The only treatment available for the management of NCGWS is a gluten/wheat-free diet (GFD), yet long-term outcomes are poorly understood. This study aimed to evaluate post-pandemic trends in NCGWS and the long-term GFD adherence in patients with NCGWS. The secondary goals are the assessment of the perceived efficacy of GFD and the need of further medical support.

Aims & Methods

We retrieved data from gluten-free products vendors up to September 2024 (top 6 retailer in the UK) and gluten free products customers up to July 2021, using a questionnaire. Subsequently, patients with self-reported NCGWS referred to a tertiary center clinic from 2006 to 2018 completed a questionnaire regarding their dietary habits and further need of medical advice for symptoms related to their diagnosis. The Biagi score was used to assess their adherence to a GFD. We compared the dietary adherence scores to age and sex matched controls cohort of patients with CD to validate the results.

Results

The marked data analysis showed a persistent rise in the sales of gluten free products, from £200B in 2014 vs £600B in 2024. Moreover, NCGWS patients account for 9.7% of the total number of buyers and for 26% of the spent for GF products.
In our cohort, out of 186 patients with NCGWS, 111 answered the questionnaire (response rate 59.7%, female 82.0%, average age 54 ± 13 years). Of these 111, 58 are not currently following a GFD. Out of the 53/111 patients following a GFD, only 27/53 (50,9%) are adhering strictly (Biagi score 3-4), 2/53 had a Biagi score of 2 (3,8%) indicating poor adherence to a gluten free diet, and 24/53 (45,2%) voluntarily ate gluten (Biagi 1-0). Only two patients report that gluten/wheat is not causing them any symptoms if eaten. The average time patients remained on a gluten free diet was 141±58 months. Compared to patients with CD those with NCGWS on a GFD showed a significantly lower adherence to a GFD (Biagi score of 0-1 NCGS: 73.9% vs CD: 8.1%, p<0.05; Biagi score 3-4, NCGWS: 24.3% vs CD: 90.1%, p<0.05). After being discharged, 40 patients (36.0%) sought medical advice again, but no significant correlation was found between the adherence to a GFD and need for further medical intervention.

Conclusion

Self-reported NCGWS is still consistently present among general population. Unlike CD, the vast majority of patients with self-reported NCGWS do not continue a GFD or significantly reduce their level of adherence. Still, NCGWS patients account for a vast part of the expenses in the gluten-free market. However, over a third of NCGWS sought further medical advice to manage their symptoms. These findings underline the need of a better understanding of this condition and the challenges in the management of these patients.

References

1. Ciacci C, Valitutti F. Where are the non-celiac gluten-sensitive patients gone? The COVID-19 effect. Dig Liver Dis. 2023 May;55(5):690-691. doi: 10.1016/j.dld.2023.02.004. Epub 2023 Mar 3. PMID: 36872202; PMCID: PMC9983782.
2. Barbaro MR, Cremon C, Wrona D, Fuschi D, Marasco G, Stanghellini V, et al. Non-Celiac Gluten Sensitivity in the Context of Functional Gastrointestinal Disorders. Nutrients. 2020 Dec 4;12(12):3735.
3. de Graaf MCG, Lawton CL, Croden F, Smolinska A, Winkens B, Hesselink MAM, et al. The effect of expectancy versus actual gluten intake on gastrointestinal and extra-intestinal symptoms in non-coeliac gluten sensitivity: a randomised, double-blind, placebo-controlled, international, multicentre study. Lancet Gastroenterol Hepatol. 2024 Feb;9(2):110–23.

Introduction

This study aimed to compare the efficacy of combined intravenous and oral proton pump inhibitor (PPI) versus oral vonoprazan (VPZ) alone therapy in preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) in a consecutive and large case series.

Aims & Methods

A retrospective study at Chiba University Hospital included consecutive patients who underwent gastric ESD between January 2017 and July 2023. Before 2019, patients received intravenous omeprazole 20 mg in the morning and evening on the day of ESD and the day after. Thereafter, esomeprazole 20 mg was administered orally once daily, which was continued for generally 28 days (defined as the PPI group). From 2020 onward, patients received oral VPZ 20 mg once daily starting on the day of ESD, also typically continued for 28 days (defined as the VPZ group). Propensity score generation and 1:1 matching of patients between the PPI and VPZ groups were performed to minimize selection bias in treatment assignment. Matching was based on nine covariates associated with DB rates for gastric ESD, including whether patients were taking warfarin, directly acting oral anticoagulant (DOAC), P2Y12 receptor antagonist, aspirin, or cilostazol; whether it was CKD with haemodialysis, a tumour size >30 mm, lower-third in tumour location and presence of multiple tumours.

Results

There were 720 cases (856 tumors) of gastric ESD during the study period, of which 352 (409 tumors) were in the PPI group and 368 (447 tumors) in the VPZ group. Propensity score matching for 9 covariates related to DB rates for gastric ESD ultimately produced 334 best matches. There was no significant difference in DB rates between the two groups (3.6% vs 3.6%. p = 1.000).

Conclusion

Though further prospective studies are needed to draw definitive conclusions, it was suggested that the easily administered oral VPZ can be an important option for acid suppression after gastric ESD.