Is villous atrophy always and only the result of gluten sensitive disease of the intestine?

'Flat and flexible truths are beat out by every hammer' (Sir Thomas Browne, writer and physician) The prevalence of gluten-sensitive enteropathy (GSE) or coeliac disease is likely to be as high as 1:200 to 1:400 in the developed world. Current medical practice leaves a significant proportion of these cases undiagnosed. An association between untreated coeliac disease and intestinal malignancy is well described so it is possible that patients with undiagnosed coeliac disease constitute a significant reservoir of preventable gastrointestinal malignancy. However, it is not clear whether all patients with coeliac disease are equally at risk of malignancy nor are all cases of intestinal malignancy necessarily associated with wheat protein sensitivity. Thus the precise links between GSE, villous atrophy and malignancy have not yet been established. However, there is evidence that products of activated T-cell clones, be they antigen specific or malignant, influence epithelial cell proliferation, differentiation and function thus contributing to the histological lesion characteristic of GSE or small bowel lymphoma.