Glutenfreie Ernährungstherapie
In der S3-Leitlinie wird auch eine glutenfreie Diät (GFD) bei erwachsenen IBS-Patienten empfohlen, bei denen eine Zöliakie ausgeschlossen wurde. Gluten, ein Bestandteil in verschiedenen Getreiden, ist bei Zöliakie der Auslöser für unspezifische gastrointestinale Beschwerden, wie sie auch beim IBS vorliegen.
Die Erkenntnisse zeigen, dass sich bei einer Vielzahl der IBS-Patienten die Symptome unter einer glutenarmen bzw. glutenfreien Ernährung besserten, obwohl bei ihnen im Vorfeld eine Zöliakie ausgeschlossen wurde. Ebenso geeignet ist die GFD auch bei der Behandlung der Gluten-/Weizensensitivität, die durchaus bei einigen IBS-Patienten auftritt. Der Verzehr glutenfreier Produkte verbesserte signifikant das Auftreten von Schmerzen, Blähungen und Müdigkeit sowie die Stuhlkonsistenz. Zu betonen gilt es außerdem, dass Patienten mit den genetischen Markern HLA-DQ2 bzw. HLA-DQ8 und dem serologischen Marker IgG-Antikörper besser auf eine GFD ansprechen. Diese Patienten sollten weiterhin beobachtet und in regelmäßigen Abständen untersucht werden, um frühzeitig eine potenzielle Zöliakie zu identifizieren. Studien zeigen umgekehrt, dass rund 40 Prozent der Zöliakiepatienten unter Symptomen wie beim IBS leiden. Die Beschwerden bessern sich zwar in der Regel unter Einhaltung einer GFD, dennoch gibt es auch Fälle, bei denen sich die Symptome nicht bessern. [1]
Die Rolle von Gluten bei IBS
| STUDY CHARACTERISTICS AND MAIN OUTCOMES | |||||||
| First author, pub year (nation) |
Study Design | Participants | Total sample size (drop out) | Intervention (N of participants | Source of gluten/placebo | Duration of intervention (washout) | Main Outcomes |
| Carroccio, 2011 (IT) | Elimination diet and double-blind, placebo-controlled challenge | IBS Patients | 920 | 4 weeks of elimination diet (exclusion of wheat, cow ’ s milk and derivatives, eggs, tomato, and chocolate) double-blind placebo-controlled (DBPC) wheat challenge |
Capsules of wheat or xylose | 4 week elimination 2 week challenge 1 weel washout |
70 patients wheat sensitive and 206 multiple food sensitivities including WS |
| Vazquez-Roque, 2013 (USA) | single-center, parallel-group trial | Patients with IBS-D | 45 (1) | GCD (22) vs. GFD (23) |
Foods provided by study dietitians | 4 wk | Reduction in stool frequency in patients on GFD (P= 0.04) |
| Fritscher-Ravens , 2014 (Germany) | Challenge, long term exclusion diet | Patients with IBS and suspected food intolerance | 36 | P1: Food provocation → antigens administered to the duodenal mucosa through the endoscope P2: CLE+ (22) → exclusion diet : milk (9), wheat (13), yeast (6), soy (4) |
Antigen mixtures → cow´s milk; wheat [2g]; yeast [1g] ; soy [2g] / 18 ml sterile water + 2 ml simethicone |
25-30 min FU : 1 y |
36 % showed mucosal responses to wheat-antigen in CLE (= food sensitive IBS). All patients improved after on the GFD for 1 year. |
| Peters, 2014 (Australia) |
Challenge, double-blind, crossover trial | Patients with IBS on GFD (≥ 6wk) | 22 | P1: GFD + low FODMAP P2: diet treatment
|
whole-wheat gluten/whey protein or no additional protein | P1: 3d P2: 3d (3d-2wk) |
Gluten ingestion was associated with higher STPI state depression scores compared to placebo [M=2.03, 95 % CI (0.55-3.51)] |
| Aziz, 2015 (UK) | Prospective trial | Patients with IBS-D | 40 | GFD (single dietetic clinic appointment) vs. GCD | - | 6 wk FU: 1.5 y |
A 6 week GFD reduced IBS Symptom Severity Score statistically significant in 71% of patients with IBS-D (mean score before diet: 286 ; after diet: 131 points). 72% of the responders planned to continue the GFD long term. |
| Di Sabatino, 2015 (Italy) | Randomized, double-blind, placebo-controlled, cross-over trial |
Patients with self-reported NCGS | 59 | W0: GFD W1: gluten [4,4 g/d] or pl W2: washout W3: crossover W4: washout |
Gastrosoluble capsules/rice starch | P1: 1 wk 2 wk (2 wk) |
Intake of 4,375 g gluten/d for 7 days increased intestinal symptoms (abdominal bloating and pain) and extra-intestinal symptoms (foggy mind, depression, aphthous stomatitis) compared with placebo (P=0.034) |
| Shabazkhani 2015 (Iran) | double-blind, placebo-controlled trial | Patients with IBS, no CD, GCD, | 102 (30) | P1: GFD (102) P2: intervention (72) → Gl-group (35) vs pl- group (37) |
packets (100g) containing a gl meal (free of FODMAP, 52% gluten or gliadin) / packets (100g) containing powder of gluten-free foods | P1: 6wk P2: 6 wk |
The symptomatic improvement was different in the gluten-group (25, 7 %) vs. placebo-group (83, 8 %) (P=< 0.001). 26/35 patients in the gluten-group became symptomatic on gluten-challenge. |
| Zanini, 2015 (Italy) | Challenge, double-blind, placebo-controlled, crossover-trial | NCGWS on GFD | 35 | Gluten Challenge
|
Gluten-free/gluten-containing flours dispensed in sealed sachets labelled A and B. 1 sachet per day containing 10g flour, consumed with pasta or soup | 20d (2wk) | 34% of the patients were symptomatic with gluten-containing flour, 49% of the patients were symptomatic with gluten-free flour, 17% didn´t respond. |
| Zanwar, 2016 (India) | Rechallenge double-blind, placebo- controlled trial (prospective) |
Patients with IBS | 65 (5) | P1: GFD (65)→ if responsive, begin with P2: rechallenge (60)
|
Two slices of bread containing gl each morning/ two slices of gl-free bread each morning | P1: 4wk P2: 4 wk |
The patients in the gluten-group presented higher symptoms (abdominal pain, bloating and tiredness) (P=0.05). Significant reduction in VAS after 4 weeks GFD. |
| Elli, 2016 (Italy) – GLUTOX trial | Challenge, double-blind placebo-controlled (crossover) | Patients with functional gastroenterological symptoms | 134 (7) | P1: GFD(130) → if responsive begin P2: Gluten Challenge (98)
|
7 gastrosoluble capsules per day (4 at lunch and 3 at dinner) / capsules with rice starch | P1: 3 wk 2 wk (1wk) |
Improvement of global well-being in 75.3 % of patients following GFD for 3 weeks. Compared to placebo greater deterioration of wellb-eing during gluten-administration → 14% of patients had a symptomatic response to gluten on rechallenge. |
| Barmeyer, 2017 (Germany) GIBS-Study | Double-blind, phase 3 diagnostic study, prospective | Patients with IBS type D and M | 35 | GFD: 2 dietary consultations in 2 wk | - | 4 mo FU: 1 y |
34% of patients responded to a GFD (relief of IBS symptoms on at least 75% of weeks in 4 month) and continued GFD. |
| Carroccio 2017 | Patients with NCGS | 200 participants from a previous study of NCWS | - | 148 of these individuals were still on a strict wheat-free diet. In total, 175 patients (88%) improved (had fewer symptoms) after a diagnosis of NCWS; 145 of 148 patients who adhered strictly to a gluten-free diet (98%) had reduced symptoms, compared with 30 of 52 patients who did not adhere to a gluten-free diet (58% | |||
Abbreviations: min, minutes, d, days, wk, week, y, year, mo, month, CD, celiac disease, IBS-D, Irritable Bowel Syndrome-Diarrhea, NR, non-reported, t-TG, anti-tissue-transglutaminase, anti-EMA Ab, anti-endomysial antibodies, GCD, gluten-containing diet, GFD, gluten-free diet, gl, gluten, pl, placebo P, Phase, VAS, visual analog scale, VASF, visual analog fatigue scale, NCGWS, non-celiac-gluten-wheat-sensitivity, GSRS score, Gastrointestinal Symptoms Rating Scale, IBS-QoL, Quality of Life, IBS-SSS, Symptom Severity Scale, HADS, Hospital Anxiety and Depression Scale, FIS, Fatigue Impact Scale, SF-36, Short Form 36, EQ-5D, European Quality of Life-5 Dimensions, SGA, Subject’s Global Assessment, CLE, confocal laser endomicroscopy, FU. Follow up, CLE+, patients who reacted to the food challenge with mucosal responses, STPI, State Trait Personality Inventory, GI, gastrointestinal
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1. Wahnschaffe et al., 2007
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