<<Disclaimer:  Verify this information before applying it to your situation.>>

Having seen the on-going interest in laboratory screening tests for
celiac disease, particularly anti-gliadin antibodies, expressed by
members of this network, I feel it is important to share information
about an alternative approach to laboratory testing.  Testing for
"intestinal permeability" is a sensitive and accurate way to screen for
celiac disease, with fewer false positive and false negative results
than other commonly used screens. Intestinal permeability reflects the
ability of the intestinal lining to absorb nutrients while keeping
undesirable chemical substances out of the body. In patients with
celiac disease who are consuming gluten, even small amounts of damage
to the intestine will allow certain large chemical molecules to leak
into the bloodstream, from which they may be excreted by the kidneys
into the urine. The available permeability test requires that the
individual drink a solution which contains two sugars, neither of which
is metabolized or changed in the body. One sugar is usually mannitol,
which is readily absorbed from the intestine and excreted in the urine.
The other sugar is lactulose, which is hardly absorbed at all under
normal conditions. Any lactulose that is absorbed is excreted unchanged
in the urine within 5 to 6 hours. Both sugars are safe to be taken,
even by small children. When a person with celiac disease drinks the
lactulose/mannitol mixture, an excessive amount of lactulose will
appear in the urine, unless the person is on a strict gluten-free diet.
If the person has enough celiac disease to create malabsorption, then
the mannitol level in urine will be low. The ratio of lactulose to
mannitol in urine is the most sensitive index of active celiac disease.
An elevated lactulose to mannitol ratio in urine may be due to
conditions other than celiac disease, such as intestinal infection,
severe food allergy or Crohn's disease, but a normal ratio indicates
either that the person does not have celiac disease or is in complete
remission due to strict adherance to a gluten-free diet. Information
about this test can be obtained from the one laboratory that presently
offers it, Great Smokies Diagnostic Laboratory in Asheville, NC. Their
number is 1-800-522-4762. Some references related to intestinal
permeability and celiac disease are:

        Cobden I, Rothwell J and Axon, ATR. Intestinal permeability and
screening tests for coeliac disease. GUT 1980; vol 21, pp 512-518.

        Hamilton IH, Cobden I, Rothwell J, Axon JTR. Intestinal
permeability in celiac disease: the response to gluten withdrawal and
single-dose gluten challenge. GUT 1982; vol 23, pp 202-210.

        Ukabam SO and Cooper BT. Small intestinal permeability as an
indicator of jejunal mucosal recovery in patients with celiac sprue on
a gluten-free diet.  JOURNAL OF CLINICAL GASTROENTEROLOGY 1985; vol 7,
pp 232-236.

Leo Galland, M.D.