# Uncovering Hidden Gluten Exposure in Celiac Patients: A Case Study in Family-Based Management and the Role of Point-of-Care Urine Testing and Psychological Assessment

## TL;DR

A case study shows that urine tests can detect hidden gluten exposure in celiac patients, even when traditional methods suggest dietary adherence.

## Contribution

Introduces point-of-care urine testing for gluten immunogenic peptides as a rapid tool for monitoring gluten-free diet adherence in celiac disease.

## Key findings

- Urine gluten immunogenic peptide testing detected gluten exposure in three celiac patients despite negative serology and reported dietary adherence.
- Psychological assessment revealed anxiety symptoms that may have influenced gluten-free diet adherence.
- Improved adherence was confirmed after dietary reinforcement and follow-up testing.

## Abstract

Celiac disease (CD) is a chronic immune-mediated enteropathy that requires strict adherence to a gluten-free diet (GFD) to prevent intestinal damage. Traditional methods for monitoring GFD adherence, such as serology and dietary assessments, often poorly correlate with histological findings and typically involve a waiting period before results are available, limiting their usefulness for immediate clinical decision-making. This cross-sectional case study reports on a 45-year-old mother and her 11-year-old twin daughters, all diagnosed with CD and following a GFD for over two years. Despite being asymptomatic and showing negative anti-tTG serology, the mother continued to present Marsh 1 histological lesions, suggesting ongoing subclinical inflammation. Point-of-care testing (POCT) for gluten immunogenic peptides (GIP) in urine revealed positive results for all three individuals, indicating recent gluten exposure despite reported dietary adherence. A follow-up GIP test after dietary review and reinforcement yielded negative results, confirming improved adherence. Additionally, a psychological assessment using the Hospital Anxiety and Depression Scale (HADS) revealed anxiety symptoms in the mother and one of the daughters, which may have influenced adherence to the GFD. These findings underscore the clinical value of urinary GIP POCT as a rapid, non-invasive tool for detecting hidden gluten exposure, even when traditional monitoring appears normal. Integrating GIP testing and psychological screening into routine clinical practice may enhance management and support timely, personalized interventions in patients with CD.