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Immunology and allergology are in a phase of great evolution and many ideas that seemed well-established in the past years are now being questioned as new possibilities for interpretation and therapy are being developed.

Many things are changing about the approach to celiac disease due to recent studies on immune tolerance. Especially if we consider Sampson's definition of celiac disease as a mixed allergy made up of a component resulting from the immediate allergy that is independent from the quantity of substance (even a small amount of gluten can cause a disturbance) and a part that depends on the repeated ingestion of gluten for consecutive days. This description forces us to think of this pathology as an expression of an immune reaction that can travel at two different speeds. In relation to the dominance of one part or another, it will therefore be possible to use or eliminate gluten (meaning wheat, kamut, spelt, barley, etc.) from one's diet or not use it at all. The debate is becoming turbulent, as can be seen in several disputes that have come out on the website regarding this news.

In our clinical experience, for example, we continue to encounter at least three different situations, each one with its own precise frequency and well-defined way of manifesting itself:

1. Celiac disease in the classic form, serious, with an acute beginning in infancy; it is easily recognizable and its treatment involves the elimination of gluten for the rest of the subject's life.  In this case, at least at present, there are no other alternatives.
2. A transitory form of celiac disease that develops mostly in subjects with a predisposition for allergies, who eat wheat and gluten in an almost exclusive manner without varying their diet.  These forms usually begin in a more subtle way and an examination of food intolerances leads to an important possibility for controlling the disease.  In our experience, with the proper strict medical guidance, these people are often able to resume the use of flour and gluten once a week (sometimes they can even reach 2-3 days of free diet per week) but must observe a strictly regulated diet during the rest of the week. The work performed by Patriarca and Gasbarrini has recently demonstrated the possibility of bringing even patients with serious celiac disease back to a normal diet.
3. An initial form of celiac disease, most of all in adulthood, that almost always manifests itself in people who systematically use gluten in a disorderly manner. In reality, the diagnosis of these forms must be reconfirmed by way of a correct medical and allergological evaluation.  Sometimes these are phenomena in which a brief period of diet can restore the body's proper equilibrium.  Often these subjects are lacking a general stimulus for regaining immune tolerance, they don't eat fruit and vegetables and have little variety in their diet.

The subjects in the last two categories are often diagnosed with celiac disease when their state of health is good, but just because some have test results that are "fuzzy", and the intestinal biopsy, although far from being excessively altered, simply shows a "compatibility" with a form of gluten hypersensitivity without being absolutely representative.  In these cases the possibility of remission is extremely high

However, when dealing with celiac disease, one must not generate false hopes. In all of the cases that we treat, we start from concept that we must understand whether or not the body has exhausted its possibilities for regaining autonomy but we always assume that a person diagnosed with celiac disease falls into category 1) described above, until we are sure that it is otherwise.

Clearly, it would be cruel to imply the possibility of returning to a more varied diet to people who would probably have to then go back to a totally and permanently  gluten-free diet.  Usually though, this "trial" aspect is refuted by traditional gastroenterologists who stop at the generally accepted diagnosis and therapies without pondering upon the possibility of a reparable immunological disorder at the basis of the problem.   The constant and continuous examination into the field of possible immunological changes within persons who are thought to have celiac disease encourages us to continue in this direction out of respect for the human being and not out of fear of the disease.

Italian version of this article available