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Jejunal mucosal recovery in coeliac disease in relation to the degree of adherence to a gluten-free diet.

Thirty-eight patients with a firm diagnosis of coeliac disease have been reassessed after being prescribed a gluten-free diet at least six months previously. The mean period between diagnosis with institution of the gluten-free diet and reassessment was 27.5 months.

Two dietitians co-operated in the study by making a careful dietary assessment of all the patients and classifying them into three dietary groups: those on a rigid gluten-free diet; those consuming small amounts of gluten; those consuming large amounts of gluten.

Various investigations were performed on these patients including a repeat jejunal biopsy for morphological study and for disaccharidase estimations. These investigations were performed without knowledge of how the individual patients had been classified by the dietitians, thus avoiding any conscious bias.

The patients judged to be on a strict gluten-free diet were all symptom-free and virtually all showed normal structural appearances in the jejunal biopsy specimen as judged by dissecting microscope appearances, by bight microscopy and by the surface: volume ratio. Likewise, all the disaccharidases had risen from very low levels at the time of diagnosis into the normal range.

The patients judged to be consuming small amounts of gluten showed some improvement in mucosal structure and in disaccharidase content, but appreciably less so than the patients on a rigid gluten-free diet.

The patients judged to be consuming large amounts of gluten showed little or no improvement in mucosal structure and disaccharidase content. Most of them were clinically improved but this can probably be accounted for by the fact that we took a daily intake of 0.5 g gluten as a large amount whereas the average consumption of gluten in the general population is 7.0 g/day. It is presumed that the patients were likely to be consuming average amounts of gluten before diagnosis whereas they were consuming much less at the time of reassessment even when they were failing to adhere to a gluten-free diet.

Previous work has suggested that young patients with coeliac disease show better mucosal recovery with a gluten-free diet than older patients. The present study shows that the degree of recovery is independent of age and is dependent upon the strictness with which the patient adheres to a gluten-free diet.