Other possible causes of enteritis as listed in the~

New England Journal Of Medicine Review Article on Celiac Sprue : N Engl J Med, Vol. 346, No. 3 · January 17, 2002

Intolerance of cow’s-milk protein
Eosinophilic gastroenteritis
Bowel ischemia
Severe malnutrition
Diffuse lymphoma of the
small intestine
Autoimmune enteropathy
Peptic duodenitis (including
Zollinger–Ellison syndrome)
Soy-protein intolerance
Crohn’s disease
Bacterial overgrowth
of the small intestine
Tropical sprue
Alpha chain disease
Refractory sprue
Collagenous sprue


"Food-induced enteropathy: Cow's milk proteins and soy proteins can cause an uncommon syndrome of chronic diarrhea, weight loss, and failure to thrive, similar to that appearing in celiac disease. Vomiting is present in up to two thirds of patients. Small bowel biopsy shows an enteropathy of variable degrees with villous hypotrophy. Total mucosal atrophy, histologically indistinguishable from celiac disease, is a frequent finding."
eMedicine: Protein Intolerance


"Up to 20% of celiacs will continue to experience loose or watery stools even after going on a GF diet. Sometimes this is due to inadvertent gluten in the diet, but a recent study at Dr. Fine's medical center showed that in these cases other diseases epidemiologically associated with celiac disease are present.[7] These include microscopic colitis, exocrine pancreatic insufficiency, lactose intolerance, selective IgA deficiency, hypo- or hyperthyroidism, and Type I diabetes mellitus. When diarrhea continues after beginning a GF diet, a search for these associated diseases or others should be undertaken and treated if found." From Celiac.com

Dr. Nelson - see Other tests to consider if not Celiac Disease

Parasitic and bacterial infections in individuals with gastrointestinal symptoms
 From Nutritional Healing 

WebMD on Habba Syndrome

PubMed Abstracts:

RESULTS:Of the 2,390 patients with IBS-like symptoms, 848 (35%) were symptomatic lactose malabsorbers and 1,531 (64%) sympto-matic fructose malabsorbers. A combined symptomatic carbohydrate malabsorption was found in 587 (25%) patients. Severe fructose malabsorbers (pathologic 25 g fructose test) exhaled significantly higher H2 concentrations in the 50 g test than patients with negative 25 g fructose test (P < 0.001). Out of 460/659 patients with early significant H2 increase in the lactose and fructose test who underwent a glucose breath test, 88 patients had positive results indicative of SIBO and they were sig-nificantly older than patients with negative test result (P < 0.01). Celiac disease was found in 1/161 patients by upper endoscopy.
Unclear abdominal discomfort: pivotal role of carbohydrate malabsorption.

PMID:24840375 April 2014

CONCLUSIONS:Although the available evidence is limited, the olmesartan-associated sprue-like enteropathy may be considered as a distinct clinical entity, and should be included in the differential diagnosis when serological testing for coeliac disease is negative.
Systematic review: sprue-like enteropathy associated with olmesartan.
PMID: 24805127  May 2014

To report the response to discontinuation of olmesartan, an angiotensin II receptor antagonist commonly prescribed for treatment of hypertension, in patients with unexplained severe spruelike enteropathy.
Olmesartan may be associated with a severe form of spruelike enteropathy. Clinical response and histologic recovery are expected after suspension of the drug.
Severe Spruelike Enteropathy Associated With Olmesartan.

PMID: 22728033  June 2012

Giardia lamblia is the most common human parasite with a worldwide distribution and fecal-oral way of transmission. Diagnostic procedures include stool examination and gastroduodenoscopy with biopsy or secret aspiration. In most cases histology reveals a dense accumulation of the parasites on the surface of the duodenal mucosa with no or only slight inflammation. In rare cases, a dense inflammatory infiltrate with severe mucosal atrophy and increased count of intraepithelial lymphocytes may be seen. If in such cases the amount of parasites is low, the histological picture may mimic celiac disease. The two presented cases demonstrate the close morphological relationship and show the importance of considering giardiasis in the differential diagnosis in patients with suspected celiac disease.
Lambliasis as Differential Diagnosis of MARSH Type 3b.
PMID: 20687019  Aug 2010

[Duodenal villous atrophy associated with Mycophenolate mofetil: Report of one case.]  
PMID: 20668815  May 2010

RESULTS: A total of 786 sets of biopsies from 262 consecutive patients (200 females and 62 males, mean age 46 years; range: 15-82), were analyzed. Microscopic damage was observed in 212 of 262 patients (81%) with normal mucosa. Mild to moderate and severe duodenitis or villi atrophy was histologically confirmed in 65%, 26% and 8% of 212 patients respectively. The negative predictive value of a normal appearing duodenal mucosa was 19%. Additional tests confirmed celiac disease in 12 patients. Lactose malabsorption was present in 42%, bacterial overgrowth in 14%, and H. pylori infection in 28%. Colonoscopy performed in 92 patients revealed non specific colitis (25%), microscopic colitis (28%), Crohn's disease (1%), and diverticulosis (15%). CONCLUSION. Duodenal biopsies revealed abnormalities in the majority of adults with chronic diarrhea and/or abdominal pain despite macroscopically normal gross findings. These results suggest that duodenal biopsies could be helpful in patients with chronic diarrhea and/or abdominal pain for the following work up.
Role of routine small intestinal biopsy in adult patient with irritable bowel syndrome-like symptoms.
PMID: 20562801 June 2010

The medical files of 50 CVID patients with gastrointestinal symptoms were analyzed retrospectively. Histological, phenotypic, and molecular analysis of intestinal endoscopic specimens was centrally performed.RESULTS:Chronic diarrhea was the most frequent gastrointestinal symptom (92%), and biological evidence of malabsorption was observed in 54% of patients. Chronic gastritis associated or not with pernicious anemia and microscopic colitis were the most frequently observed histopathological features in gastric and colonic mucosa, respectively. Small-bowel biopsies available in 41 patients showed moderate increase in intestinal intraepithelial lymphocytes in 31 patients (75.6%) and villous atrophy in 21 patients (51%). Distinctive features from CS were a profound depletion in plasma cells and follicular lymphoid hyperplasia. Presence of peripheral blood CD8+ hyperlymphocytosis was predictive of intestinal intraepithelial hyperlymphocytosis. Intravenous (i.v.) immunoglobulin (Ig) therapy had no effect on enteropathy-related symptoms. Gluten-free diet improved only two out of 12 patients with villous atrophy, whereas all patients (7/7) responded to steroid therapy.CONCLUSIONS:Several distinctive features differentiate CVID enteropathy from other causes of enteropathy including CS. Replacement i.v. Ig therapy is insufficient to improve gastrointestinal symptoms. Steroids are effective in reducing inflammation and restoring mucosal architecture.
The Enteropathy Associated With Common Variable Immunodeficiency: The Delineated Frontiers With Celiac Disease.

PMID: 20551941 
2010 Jun 15

Symposium 1: Joint BAPEN and British Society of Gastroenterology Symposium on 'Coeliac disease: basics and controversies' Coeliac disease: optimising the management of patients with persisting symptoms?
PMID: 19555521 June 2009

Bovine milk intolerance in celiac disease is related to IgA reactivity to alpha- and beta-caseins.
PMID: 19268534  June 2009

Conclusion: Celiac disease is the most common cause of malabsorption syndrome in both adults and children. These people harbor significantly more pathogenic parasites and are more frequently colonized with harmless commensals as compared to healthy controls. Intestinal coccidia are associated with malabsorption syndrome, particularly in malnourished children.
Parasites in Patients with Malabsorption Syndrome: A Clinical Study in Children and Adults.
PMID: 17763958 Aug 2007

[Focal villous atrophy of the duodenum in children who have outgrown cow's milk allergy. Chromoendoscopy and magnification endoscopy evaluation]
PMID: 17625280  June 2007

Gluten exposure was the most common cause of NRCD (36%), followed by irritable bowel syndrome (22%), refractory CD (10%), lactose intolerance (8%), and microscopic colitis (6%).
Etiologies and predictors of diagnosis in nonresponsive celiac disease.  PMID: 17382600   April 2007

Pancreatic exocrine insufficiency with steatorrhea is a major consequence of pancreatic diseases (eg, chronic pancreatitis, cystic fibrosis, severe acute necrotizing pancreatitis, pancreatic cancer), extrapancreatic diseases such as celiac disease and Crohn's disease, and gastrointestinal and pancreatic surgical resection. Recognition of this entity is highly relevant to avoid malnutrition-related morbidity and mortality.
Pancreatic enzyme therapy for pancreatic exocrine insufficiency.

PMID: 17418056  April 2007

A mucosal inflammatory response similar to that elicited by gluten was produced by CM protein in about 50% of the patients with coeliac disease. Casein, in particular, seems to be involved in this reaction.
Mucosal reactivity to cow's milk protein in coeliac disease.
PMID: 17302893 March 2007
Conclusions Low faecal elastase is common in patients with coeliac disease and chronic diarrhoea, suggesting exocrine pancreatic insufficiency. In this group of patients, pancreatic enzyme supplementation may provide symptomatic benefit.
Is exocrine pancreatic insufficiency in adult coeliac disease a cause of persisting symptoms? PMID: 17269988 Feb 2007
Primary hyperparathyroidism may present with non-specific symptoms, and this may be one reason why patients with coeliac disease fail to improve despite compliance with a gluten-free diet.
Coeliac disease and primary hyperparathyroidism: an association?
PMID: 17148709 Dec 2006

"The major cause of failure to respond to a gluten-free diet is continuing ingestion of gluten, but other underlying diseases must be considered."

"If a patient is not responding well to a gluten-free diet, three considerations are necessary: (1) the initial diagnosis of celiac disease must be reassessed;(2) the patient should be sent to a dietician to check for errors in diet or compliance problems, because problems with the gluten-free diet are the most important cause for persisting symptoms; (3) other reasons for persisting symptoms (eg, pancreatic insufficiency, irritable bowel syndrome, bacterial overgrowth, lymphocytic colitis, collagenous colitis, ulcerative jejunitis, protein-losing enteropathy,T-cell lymphoma, fructose intolerance, cavitating lymphadenopathy, and tropical sprue) should be considered.Other causes for villous atrophy are Crohn's disease, collagenous sprue, and autoimmune enteropathy. "

"Of the 15 patients, 10 had small intestinal bacterial overgrowth, 2 showed lactose malabsorption causing the described symptoms, 1 had mistakenly taken an antibiotic containing gluten, and 1 patient each had Giardia lamblia and Ascaris lumbricoides."
Monitoring nonresponsive patients who have celiac disease. 
PMID: 16644460 April 2006 

DIAGNOSIS, DIFFERENTIAL DIAGNOSIS, AND THERAPY: It is essential to exclude alarm symptoms. IBS can be positively diagnosed with a sensitivity and specificity of > 90% by standardized questionnaires. Indications of PI-IBS are the acute onset of symptoms, fever, vomiting, diarrhea and/or positive stool culture. Differential diagnoses include lactose intolerance, small bowel bacterial overgrowth, bile acid malabsorption, celiac disease, giardiasis, chronic inflammatory bowel disease, collagenous colitis, and diverticulitis.
[Functional and inflammatory bowel disorders]
PMID: 16802539 Mar 2006

CONCLUSION: In patients with celiac disease partially responsive or unresponsive to GFD, SIBO and lactose intolerance should be suspected; appropriate investigations and treatment for these may result in complete recovery.
Partially responsive celiac disease resulting from small intestinal bacterial overgrowth and lactose intolerance. PMID: 15154971  May 2004  FULL TEXT

High prevalence of small intestinal bacterial overgrowth in celiac patients with persistence of gastrointestinal symptoms after gluten withdrawal.
PMID: 12738465  Apr 2003

"Of the 49 patients with celiac disease, 25 were identified as having gluten contamination. Additional diagnoses accounting for persistent symptoms included: pancreatic insufficiency, irritable bowel syndrome, bacterial overgrowth, lymphocytic colitis, collagenous colitis, ulcerative jejunitis, T-cell lymphoma, pancreatic cancer, fructose intolerance, protein losing enteropathy, cavitating lymphadenopathy syndrome, and tropical sprue. "
Etiology of nonresponsive celiac disease: results of a systematic approach. PMID: 12190170 Aug 2002

Giardia lamblia infection in patients with irritable bowel syndrome and dyspepsia: a prospective study. PMID: 16610003 Mar 2006

Giardiasis in patients with dyspeptic symptoms. PMID: 16425362  2005

Helicobacter pylori Infection in patients with celiac disease.
PMID: 16780559  Aug 2006

Duodenal intraepithelial lymphocytosis with normal villous architecture: common occurrence in H. pylori gastritis.
PMID: 15803187  Aug 2005

RESULTS: Sixty-two of the 78 patients (79%) experienced diarrhea before treatment, and 13 (17%) had chronic diarrhea (of lesser severity) after treatment. The causes of diarrhea in 11 patients consenting to this study were microscopic colitis, steatorrhea secondary to exocrine pancreatic insufficiency, dietary lactose or fructose malabsorption, anal sphincter dysfunction causing fecal incontinence, and the irritable bowel syndrome.
The prevalence and causes of chronic diarrhea in patients with celiac sprue treated with a gluten-free diet.
Fine KD, Meyer RL, Lee EL.
Gastroenterology. 1997 Jun;112(6):1830-8. Erratum in: Gastroenterology 1998 Feb;114(2):424-5. PMID: 9178673

The sensitivity of antibodies to casein, beta-lactoglobulin, and ovalbumin in active coeliac disease varied from 36% to 48% without significant difference between IgG and IgA antibodies.
Antibodies to dietary antigens in coeliac disease.
PMID: 3775259  Oct 1986