Synopsis
Evaluate symptoms attributed to gluten without missing coeliac disease, wheat allergy, inflammatory disease or nutritional harm; distinguish gluten from fructan and expectation effects; and use a supervised restriction-and-rechallenge strategy only after appropriate exclusion.
- Non-coeliac gluten sensitivity describes reproducible intestinal or extra-intestinal symptoms related to wheat or gluten exposure after coeliac disease and wheat allergy are excluded; there is no validated diagnostic biomarker.
- Do coeliac serology while gluten is still eaten and complete any required biopsy pathway before restriction, because diet change can normalise both.
- Wheat contains fructans and other components, so improvement on a gluten-free diet does not prove gluten itself was the trigger.
Key red flags
Rapid urticaria, angioedema, throat symptoms, wheeze, vomiting, hypotension or exercise-associated reaction after wheat suggests IgE-mediated allergy and can be life-threatening.
Investigation priorities
Exclude coeliac disease while the person eats adequate gluten, using IgA tTG and assay-appropriate alternatives in IgA deficiency.
Management branches
A patient attributes recurrent gastrointestinal or systemic symptoms to wheat or gluten.
- Document symptom pattern, current gluten exposure, family and autoimmune risk, immediate allergy features and organic red flags.
- Perform coeliac testing while gluten is consumed and refer positive or high-risk discordant cases; use the allergy pathway for rapid IgE-type reactions.