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Punia P, Bala K, Verma M, Nandi A, Mahlotra P, Singh S, Garg S, Parmar A, Kumar D. Feasibility of a "No-Biopsy" Approach for the Diagnosis of Celiac Disease in Symptomatic Adults. Cureus 2024; 16:e54578. [PMID: 38523934 PMCID: PMC10957510 DOI: 10.7759/cureus.54578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
Celiac disease (CD) is an immune-mediated enteropathy, caused by hypersensitivity to gluten in genetically predisposed individuals. The worldwide prevalence of CD has been estimated to be approximately 1%. Most guidelines for diagnosis of CD rely on a sequential approach, with serological testing of antibodies against tissue transglutaminase (tTG) as a first-line test, followed by a duodenal biopsy. However, GI biopsy is an invasive procedure with various complications. Hence, this study was planned to ascertain whether it could be possible to have a non-biopsy approach, using only serological markers to establish the diagnosis of CD in adults. MATERIAL AND METHODS It was a retrospective analysis of medical records of all biopsy-diagnosed CD patients with available anti-tTGA antibodies reports from 2019 to 2023. The patients were divided into three groups based on Marsh grading and anti-tTGA antibody levels were compared using various statistical tests. RESULTS A total of 94 biopsy-diagnosed symptomatic CD patients with anti-tTGA antibody reports available formed the study group. Of these, 54 had biopsy findings consistent with Marsh 3 lesion, three had Marsh 2 lesion, and 37 had Marsh 1 lesion. A significant correlation existed between Marsh grading 3 lesion and anti-tTGA antibody levels above the upper limit of normal (ULN) x 10. CONCLUSION Serum levels of anti-tTGA antibodies greater than 10 x ULN can be used to identify symptomatic patients with Marsh grade 3 CD lesions.
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Affiliation(s)
- Parul Punia
- Microbiology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Kiran Bala
- Microbiology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Mansi Verma
- Microbiology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Ankita Nandi
- Microbiology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Parveen Mahlotra
- Gastroenterology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Sunita Singh
- Pathology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Seema Garg
- Microbiology, BPS Government Medical College for Women, Sonepat, IND
| | - Aparna Parmar
- Microbiology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Devender Kumar
- Oral Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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Losurdo G, Di Leo M, Santamato E, Giangaspero A, Rendina M, Luigiano C, Ierardi E, Di Leo A. May Antitransglutaminase Levels Predict Severity of Duodenal Lesions in Adults with Celiac Disease? Medicina (B Aires) 2021; 57:medicina57111212. [PMID: 34833430 PMCID: PMC8622174 DOI: 10.3390/medicina57111212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 01/11/2023] Open
Abstract
Background and Objective: Pediatric guidelines on celiac disease (CD) state that children with anti-transglutaminase antibodies (TGAs) >×10 upper limit of normal (ULN) may avoid endoscopy and biopsy. We aimed to evaluate whether these criteria may be suitable for villous atrophy diagnosis in CD adults. Materials and Methods: We retrospectively enrolled patients with CD aged >18 years. TGAs were expressed as xULN. Duodenal lesions were classified as atrophic or non-atrophic according to Marsh-Oberhuber. Fisher’s exact and t-test were used for variables comparison. Receiver operating characteristics (ROC) curve analysis was performed with estimation of area under the curve (AUC), sensitivity, specificity, and positive and negative predictive value (PPV/NPV). Results: One hundred and twenty-one patients were recruited. Sixty patients (49.6%) had TGA >×10 ULN, and 93 (76.8%) had villous atrophy. The cut-off of >×10 ULN had sensitivity = 53.7%, specificity = 64.3%, PPV = 83.3%, and NPV = 29.5% to predict atrophy. Therefore, considering pediatric criteria, in 50 (41.3%) patients, biopsy could have been avoided. Patient subgroup with atrophy had higher TGA levels despite being not significant (37.2 ± 15.3 vs. 8.0 ± 1.3 ULN, p = 0.06). In adults, a slightly better diagnostic performance was obtained using a cut-off of TGA >×6.2 ULN (sensitivity = 57.1%, specificity = 65.6%, and AUC = 0.62). Conclusions: Despite our confirmation that villous atrophy is linked to high TGA levels, CD and atrophy diagnosis based only on serology is not reliable in adults.
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Affiliation(s)
- Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
- Ph.D. Course in Organs and Tissues Transplantation and Cellular Therapies, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy
- Correspondence: ; Tel.: +39-080-559-4430
| | - Milena Di Leo
- Unit of Digestive Endoscopy, San Paolo Hospital, 20142 Milano, Italy; (M.D.L.); (C.L.)
| | - Edoardo Santamato
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
| | - Antonio Giangaspero
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
| | - Maria Rendina
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
| | - Carmelo Luigiano
- Unit of Digestive Endoscopy, San Paolo Hospital, 20142 Milano, Italy; (M.D.L.); (C.L.)
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, 70124 Bari, Italy; (E.S.); (A.G.); (M.R.); (E.I.); (A.D.L.)
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Penny HA, Raju SA, Lau MS, Marks LJS, Baggus EMR, Bai JC, Bassotti G, Bontkes HJ, Carroccio A, Danciu M, Derakhshan MH, Ensari A, Ganji A, Green PHR, Johnson MW, Ishaq S, Lebwohl B, Levene A, Maxim R, Mohaghegh Shalmani H, Rostami-Nejad M, Rowlands D, Spiridon IA, Srivastava A, Volta U, Villanacci V, Wild G, Cross SS, Rostami K, Sanders DS. Accuracy of a no-biopsy approach for the diagnosis of coeliac disease across different adult cohorts. Gut 2021; 70:876-883. [PMID: 33139268 PMCID: PMC8040155 DOI: 10.1136/gutjnl-2020-320913] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/29/2020] [Accepted: 07/18/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the predictive capacity and diagnostic yield of a 10-fold increase in serum IgA antitissue transglutaminase (tTG) antibody levels for detecting small intestinal injury diagnostic of coeliac disease (CD) in adult patients. DESIGN The study comprised three adult cohorts. Cohort 1: 740 patients assessed in the specialist CD clinic at a UK centre; cohort 2: 532 patients with low suspicion for CD referred for upper GI endoscopy at a UK centre; cohort 3: 145 patients with raised tTG titres from multiple international sites. Marsh 3 histology was used as a reference standard against which we determined the performance characteristics of an IgA tTG titre of ≥10×ULN for a diagnosis of CD. RESULTS Cohort 1: the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 54.0%, 90.0%, 98.7% and 12.5%, respectively. Cohort 2: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 50.0%, 100.0%, 100.0% and 98.3%, respectively. Cohort 3: the sensitivity, specificity, PPV and NPV for IgA tTG levels of ≥10×ULN at identifying individuals with Marsh 3 lesions were 30.0%, 83.0%, 95.2% and 9.5%, respectively. CONCLUSION Our results show that IgA tTG titres of ≥10×ULN have a strong predictive value at identifying adults with intestinal changes diagnostic of CD. This study supports the use of a no-biopsy approach for the diagnosis of adult CD.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Michelle S Lau
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Lauren JS Marks
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Elisabeth MR Baggus
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Julio C Bai
- Medicine, Gastroenterology Hospital 'Dr C Bonorino Udaondo', Buenos Aires, Argentina
| | - Gabrio Bassotti
- Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy
| | - Hetty J Bontkes
- Department Clinical Chemistry, Amsterdam Gastroenterology and Metabolism and Infection and Immunity Institutes, Amsterdam UMC, Amsterdam, The Netherlands
| | - Antonio Carroccio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Mihai Danciu
- Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | | | - Arzu Ensari
- Department of Pathology, Ankara University Medical School, Ankara, Turkey
| | - Azita Ganji
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Matt W Johnson
- Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group NHS Foundation Trust, Birmingham City University, Birmingham, UK
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Adam Levene
- Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK
| | - Roxana Maxim
- Gastroenterology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Hamid Mohaghegh Shalmani
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami-Nejad
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - David Rowlands
- Department of Gastroenterology, Queen Elizabeth II Hospital, Hertfordshire, UK
| | - Irene A Spiridon
- Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | | | - Umberto Volta
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Graeme Wild
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Simon S Cross
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
| | - Kamran Rostami
- Department of Gastroenterology, MidCentral District Health Board, Palmerston North, New Zealand
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK
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Badizadegan K, Vanlandingham DM, Hampton W, Thompson KM. Value of biopsy in a cohort of children with high-titer celiac serologies: observation of dynamic policy differences between Europe and North America. BMC Health Serv Res 2020; 20:962. [PMID: 33081760 PMCID: PMC7576777 DOI: 10.1186/s12913-020-05815-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/12/2020] [Indexed: 12/16/2022] Open
Abstract
Background Healthcare systems implement change at different rates because of differences in incentives, organizational processes, key influencers, and management styles. A comparable set of forces may play out at the national and international levels as demonstrated in significant differences in the diagnostic management of pediatric Celiac Disease (CD) between European and North American practitioners. Methods We use retrospective clinical cohorts of 27,868 serum tissue transglutaminase (tTG) immunoglobulin A levels and 7907 upper gastrointestinal endoscopy pathology reports to create a dataset of 793 pathology reports with matching tTG results between July 1 of 2014 and July 1 of 2018. We use this dataset to characterize histopathological findings in the duodenum, stomach and esophagus of patients as a function of serum tTG levels. In addition, we use the dataset to estimate the local and national cost of endoscopies performed in patients with serum tTG levels greater than 10 times the upper limit of normal. Results Using evidence from a US tertiary care center, we show that in the cohort of pediatric patients with high pre-test probability of CD as determined by serum tTG levels, biopsy provides no additional diagnostic value for CD, and that it counter-intuitively introduces diagnostic uncertainty in a number of patients. We estimate that using the European diagnostic algorithms could avoid between 4891 and 7738 pediatric endoscopies per year in the US for evaluation of CD. Conclusions This study considers the North American and European management guidelines for the diagnosis of pediatric CD and highlights the slow adoption in North America of evidence-based algorithms developed and applied in Europe for triage of endoscopy and biopsy. We suggest that system dynamics influences that help maintain the status quo in North America include a variety of social and economic factors in addition to medical evidence. This work contributes to the growing body of evidence that the dynamics that largely favor maintaining status quo management policies in a variety of systems extend to clinical medicine and potentially influence clinical decisions at the level of individual patients and the population. Supplementary information Supplementary information accompanies this paper at 10.1186/s12913-020-05815-0.
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Affiliation(s)
| | - David M Vanlandingham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Wesley Hampton
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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5
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Ylönen V, Lindfors K, Repo M, Huhtala H, Fuchs V, Saavalainen P, Musikka A, Laurila K, Kaukinen K, Kurppa K. Non-Biopsy Serology-Based Diagnosis of Celiac Disease in Adults Is Accurate with Different Commercial Kits and Pre-Test Probabilities. Nutrients 2020; 12:nu12092736. [PMID: 32911716 PMCID: PMC7551634 DOI: 10.3390/nu12092736] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 02/07/2023] Open
Abstract
Non-biopsy diagnosis of celiac disease is possible in children with anti-transglutaminase 2 antibodies (TGA) > 10× the upper limit of normal (ULN) and positive anti-endomysial antibodies (EMA). Similar criteria have been suggested for adults, but evidence with different TGA assays is scarce. We compared the performance of four TGA tests in the diagnosis of celiac disease in cohorts with diverse pre-test probabilities. Serum samples from 836 adults with either clinical suspicion or family risk of celiac disease were tested with four commercial TGA assays, EmA and celiac disease-associated genetics. The diagnosis was set based on duodenal lesion or, in some cases, using special methods. 137 (57%) patients with clinical suspicion and 85 (14%) of those with family risk had celiac disease. Positive predictive value (PPV) for 10×ULN was 100% in each TGA test. The first non-diagnostic investigations were encountered with ULN 1.0×–5.1× in the clinical cohort and 1.3×–4.9× in the family cohort, respectively. Using the assays’ own cut-offs (1×ULN) the PPVs ranged 84–100%. Serology-based diagnosis of celiac disease was accurate in adults using different commercial kits and pre-test probabilities using 10×ULN. The results also suggest that the ULN threshold for biopsy-omitting approach could be lower.
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Affiliation(s)
- Venla Ylönen
- Celiac Disease Research Centre, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland; (V.Y.); (K.L.); (M.R.); (V.F.); (A.M.); (K.K.)
| | - Katri Lindfors
- Celiac Disease Research Centre, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland; (V.Y.); (K.L.); (M.R.); (V.F.); (A.M.); (K.K.)
| | - Marleena Repo
- Celiac Disease Research Centre, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland; (V.Y.); (K.L.); (M.R.); (V.F.); (A.M.); (K.K.)
- Tampere Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland;
- Department of Pediatrics, Tampere University Hospital, 33520 Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, 33520 Tampere, Finland;
| | - Valma Fuchs
- Celiac Disease Research Centre, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland; (V.Y.); (K.L.); (M.R.); (V.F.); (A.M.); (K.K.)
| | - Päivi Saavalainen
- Research Programs Unit, Immunobiology, and Haartman Institute, Department of Medical Genetics, University of Helsinki, 00014 Helsinki, Finland;
| | - Alex Musikka
- Celiac Disease Research Centre, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland; (V.Y.); (K.L.); (M.R.); (V.F.); (A.M.); (K.K.)
| | - Kaija Laurila
- Tampere Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland;
| | - Katri Kaukinen
- Celiac Disease Research Centre, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland; (V.Y.); (K.L.); (M.R.); (V.F.); (A.M.); (K.K.)
- Department of Internal Medicine, Tampere University Hospital, 33520 Tampere, Finland
| | - Kalle Kurppa
- Tampere Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, 33520 Tampere, Finland;
- Department of Pediatrics, Tampere University Hospital, 33520 Tampere, Finland
- The University Consortium of Seinäjoki, 66320 Seinäjoki, Finland
- Department of Pediatrics, Seinäjoki Central Hospital, 66320 Seinäjoki, Finland
- Correspondence: ; Tel.: +358-50-318-6255
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Penny HA, Raju SA, Sanders DS. Progress in the serology-based diagnosis and management of adult celiac disease. Expert Rev Gastroenterol Hepatol 2020; 14:147-154. [PMID: 32011187 DOI: 10.1080/17474124.2020.1725472] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: This article provides a comprehensive overview of the development and application of serological tests used routinely in clinical practice for the diagnosis and management of adult celiac disease.Areas covered: We summarize existing scientific literature related to anti-endomyseal, anti-tissue transglutaminase, and anti-deamidated gliadin peptide antibodies and detail the current and potential future applications of these tests in celiac disease.Expert commentary: Current serological tests in celiac disease have some of the best performance characteristics among disease-specific tests. However, in adult celiac disease, current diagnostic algorithms still rely on duodenal biopsies to confirm the diagnosis. A 'biopsy avoidance strategy' has been implemented in pediatric celiac disease. Future high-quality studies will help inform on whether this approach can be implemented into adult gastroenterology services. It is envisaged that the next 5 years will see an increasing reliance on serology in the diagnosis of adult celiac disease.
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Affiliation(s)
- Hugo A Penny
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Suneil A Raju
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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7
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Fuchs V, Kurppa K, Huhtala H, Laurila K, Mäki M, Collin P, Salmi T, Luostarinen L, Saavalainen P, Kaukinen K. Serology-based criteria for adult coeliac disease have excellent accuracy across the range of pre-test probabilities. Aliment Pharmacol Ther 2019; 49:277-284. [PMID: 30592070 DOI: 10.1111/apt.15109] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 10/25/2018] [Accepted: 12/02/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The revised paediatric criteria for coeliac disease allow omission of duodenal biopsies in symptomatic children who have specific serology and coeliac disease-associated genetics. It remains unclear whether this approach is also applicable for adults with various clinical presentations. AIM To evaluate the accuracy of serology-based criteria in adults with variable pre-test probabilities for coeliac disease. METHODS Three study cohorts comprised adults with high-risk clinical coeliac disease suspicion (n = 421), moderate-risk family members of coeliac disease patients (n = 2357), and low-risk subjects from the general population (n = 2722). Serological and clinical data were collected, and "triple criteria" for coeliac disease comprised transglutaminase 2 antibodies >10× the upper limit of normal, positive endomysium antibodies, and appropriate genetics without requirement of symptoms. The diagnosis was based on intestinal biopsy. RESULTS The diagnosis of coeliac disease was established in 274 subjects. Of these, 59 high-risk subjects, 17 moderate-risk subjects, and 14 low-risk subjects fulfilled the "triple criteria". All had histologically proven coeliac disease, giving the criteria a positive predictive value of 100%. Altogether, 90 (33%) of all 274 newly diagnosed patients could have avoided biopsy, including 37% among high-risk, 20% among moderate-risk, and 48% among low-risk patients. No histological findings other than coeliac disease were found in the biopsies of "triple positive" subjects. CONCLUSIONS Coeliac disease can reliably and safely be diagnosed without biopsy in adults fulfilling the "triple criteria" regardless of the pre-test probability. Revised criteria would enable the number of endoscopies to be reduced by one-third.
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Affiliation(s)
- Valma Fuchs
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Kalle Kurppa
- Tampere Center for Child Health Research, University of Tampere, and Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Tampere Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Kaija Laurila
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Markku Mäki
- Tampere Center for Child Health Research, University of Tampere, and Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Pekka Collin
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Teea Salmi
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Dermatology, Tampere University Hospital, Tampere, Finland
| | - Liisa Luostarinen
- Department of Neurology, Päijät-Häme Central Hospital, Lahti, Finland
| | - Päivi Saavalainen
- Research Programs Unit, Immunobiology, and Haartman Institute, Department of Medical Genetics, University of Helsinki, Helsinki, Finland
| | - Katri Kaukinen
- Celiac Disease Research Center, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
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Abstract
Celiac disease is a common autoimmune disorder of the small intestine, triggered by an immunological response to the gluten present in wheat, barley, and rye in individuals who are genetically at risk. A key to reducing the complications of this disease is early diagnosis, preferably in childhood, and consuming a lifelong gluten-free diet once diagnosis is confirmed. Yet, the diagnosis of celiac disease is often considerably delayed, exposing patients to needless suffering and morbidity. It is also difficult to confirm histologically if dietary gluten has been restricted prior to obtaining a diagnostic biopsy, a significant problem given the current growing popularity of gluten-free diets. Furthermore, failure to understand or follow current guidelines means physicians may recommend patients commence the gluten-free diet before initiating referral to a gastroenterologist. Finally, adding further confusion, pediatric guidelines in Europe support a diagnosis based on serology rather than on histology, whereas those based in North America do not. The purpose of this review is to discuss these issues and other controversies in the diagnosis of celiac disease and to consider ways to optimize diagnosis across the lifespan.
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Affiliation(s)
- Justine M Turner
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, University of Alberta, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada.
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9
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Lewandowska K, Ciepiela O, Szypowska A, Wyhowski J, Głodkowska-Mrówka E, Popko K, Ostafin M, Pyrżak B, Demkow U. Celiac antibodies in children with type 1 diabetes – A diagnostic validation study. Autoimmunity 2018; 51:81-88. [DOI: 10.1080/08916934.2018.1427226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Katarzyna Lewandowska
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Olga Ciepiela
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | | | - Jan Wyhowski
- Department of Pathomorphology, Pediatric Hospital of Warsaw Medical University, Warsaw, Poland
| | - Eliza Głodkowska-Mrówka
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Popko
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Ostafin
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Beata Pyrżak
- Department of Pediatric Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Urszula Demkow
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
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Werkstetter KJ, Korponay-Szabó IR, Popp A, Villanacci V, Salemme M, Heilig G, Lillevang ST, Mearin ML, Ribes-Koninckx C, Thomas A, Troncone R, Filipiak B, Mäki M, Gyimesi J, Najafi M, Dolinšek J, Dydensborg Sander S, Auricchio R, Papadopoulou A, Vécsei A, Szitanyi P, Donat E, Nenna R, Alliet P, Penagini F, Garnier-Lengliné H, Castillejo G, Kurppa K, Shamir R, Hauer AC, Smets F, Corujeira S, van Winckel M, Buderus S, Chong S, Husby S, Koletzko S. Accuracy in Diagnosis of Celiac Disease Without Biopsies in Clinical Practice. Gastroenterology 2017. [PMID: 28624578 DOI: 10.1053/j.gastro.2017.06.002] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS The guidelines of the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition allow for diagnosis of celiac disease without biopsies in children with symptoms and levels of immunoglobulin A against tissue-transglutaminase (TGA-IgA) 10-fold or more the upper limit of normal (ULN), confirmed by detection of endomysium antibodies (EMA) and positivity for HLA-DQ2/DQ8. We performed a large, international prospective study to validate this approach. METHODS We collected data from consecutive pediatric patients (18 years or younger) on a gluten-containing diet who tested positive for TGA-IgA from November 2011 through May 2014, seen at 33 pediatric gastroenterology units in 21 countries. Local centers recorded symptoms; measurements of total IgA, TGA, and EMA; and histopathology findings from duodenal biopsies. Children were considered to have malabsorption if they had chronic diarrhea, weight loss (or insufficient gain), growth failure, or anemia. We directly compared central findings from 16 antibody tests (8 for TGA-IgA, 1 for TGA-IgG, 6 for IgG against deamidated gliadin peptides, and 1 for EMA, from 5 different manufacturers), 2 HLA-DQ2/DQ8 tests from 2 manufacturers, and histopathology findings from the reference pathologist. Final diagnoses were based on local and central results. If all local and central results were concordant for celiac disease, cases were classified as proven celiac disease. Patients with only a low level of TGA-IgA (threefold or less the ULN) but no other results indicating celiac disease were classified as no celiac disease. Central histo-morphometry analyses were performed on all other biopsies and cases were carefully reviewed in a blinded manner. Inconclusive cases were regarded as not having celiac disease for calculation of diagnostic accuracy. The primary aim was to determine whether the nonbiopsy approach identifies children with celiac disease with a positive predictive value (PPV) above 99% in clinical practice. Secondary aims included comparing performance of different serological tests and to determine whether the suggested criteria can be simplified. RESULTS Of 803 children recruited for the study, 96 were excluded due to incomplete data, low level of IgA, or poor-quality biopsies. In the remaining 707 children (65.1% girls; median age, 6.2 years), 645 were diagnosed with celiac disease, 46 were found not to have celiac disease, and 16 had inconclusive results. Findings from local laboratories of TGA-IgA 10-fold or more the ULN, a positive result from the test for EMA, and any symptom identified children with celiac disease (n = 399) with a PPV of 99.75 (95% confidence interval [CI], 98.61-99.99); the PPV was 100.00 (95% CI, 98.68-100.00) when only malabsorption symptoms were used instead of any symptom (n = 278). Inclusion of HLA analyses did not increase accuracy. Findings from central laboratories differed greatly for patients with lower levels of antibodies, but when levels of TGA-IgA were 10-fold or more the ULN, PPVs ranged from 99.63 (95% CI, 98.67-99.96) to 100.00 (95% CI, 99.23-100.00). CONCLUSIONS Children can be accurately diagnosed with celiac disease without biopsy analysis. Diagnosis based on level of TGA-IgA 10-fold or more the ULN, a positive result from the EMA tests in a second blood sample, and the presence of at least 1 symptom could avoid risks and costs of endoscopy for more than half the children with celiac disease worldwide. HLA analysis is not required for accurate diagnosis. Clinical Trial Registration no: DRKS00003555.
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Affiliation(s)
- Katharina Julia Werkstetter
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
| | - Ilma Rita Korponay-Szabó
- Celiac Disease Center Heim Pál Children's Hospital, Budapest and Department of Pediatrics, University of Debrecen, Debrecen, Hungary; Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Alina Popp
- Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland; University of Medicine and Pharmacy "Carol Davila" and National Institute for Mother and Child Health "Alessandrescu-Rusescu," Bucharest, Romania
| | | | | | - Gabriele Heilig
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
| | | | - Maria Luisa Mearin
- Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Carmen Ribes-Koninckx
- Department of Pediatric Gastroenterology and Hepatology, La Fe University Hospital, Valencia, Spain
| | - Adrian Thomas
- Department of Pediatric Gastroenterology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Riccardo Troncone
- Department of Translational Medical Sciences & European Laboratory for the Investigation of Food-Induced Diseases, University Federico II, Naples, Italy
| | - Birgit Filipiak
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany
| | - Markku Mäki
- Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Judit Gyimesi
- Celiac Disease Center Heim Pál Children's Hospital, Budapest and Department of Pediatrics, University of Debrecen, Debrecen, Hungary
| | - Mehri Najafi
- Department of Pediatric Gastroenterology & Hepatology, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jernej Dolinšek
- Department of Pediatrics, University Medical Center (UMC), Maribor, Slovenia
| | | | - Renata Auricchio
- Department of Translational Medical Sciences & European Laboratory for the Investigation of Food-Induced Diseases, University Federico II, Naples, Italy
| | - Alexandra Papadopoulou
- Division of Gastroenterology, Hepatology and Nutrition, First Department of Pediatrics, Children's Hospitals "Agia Sophia," University of Athens, Athens, Greece
| | - Andreas Vécsei
- Gastroenterology Outpatient Clinic, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Peter Szitanyi
- Department of Pediatrics and Adolescent Medicine, First Faculty of Medicine and General Teaching Hospital, Charles University, Prague, Czech Republic
| | - Ester Donat
- Department of Pediatric Gastroenterology and Hepatology, La Fe University Hospital, Valencia, Spain
| | - Rafaella Nenna
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | | | - Francesca Penagini
- Department of Pediatric Gastroenterology, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Hélène Garnier-Lengliné
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hôpital Necker-Enfants Malades, Paris, France
| | - Gemma Castillejo
- Department of Pediatric Gastroenterology and Nutrition, Hospital Universitari Sant Joan, Reus, Spain
| | - Kalle Kurppa
- Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Françoise Smets
- Université Catholique de Louvain, IREC, PEDI, Cliniques universitaires Saint Luc, Brussels, Belgium
| | - Susana Corujeira
- Department of Pediatric Gastroenterology, Hospital S. João, Porto, Portugal
| | - Myriam van Winckel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Ghent, Belgium
| | - Stefan Buderus
- Department of Pediatrics, St. Marien Hospital, Bonn, Germany
| | - Sonny Chong
- Queen Mary's Hospital for Children, Carshalton, United Kingdom
| | - Steffen Husby
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Sibylle Koletzko
- Dr. von Hauner Children's Hospital, Department of Pediatrics, University Hospital, LMU Munich, Munich, Germany.
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Jora R, Raghuvanshi V, Payal V, Sharma P, Vishnoi SK. Correlation of Tissue Transglutaminase with Modified Marsh Grading in Celiac Disease: A Prospective Cohort Study. Indian J Pediatr 2017; 84:515-520. [PMID: 28321610 DOI: 10.1007/s12098-017-2323-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/14/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To find out correlation between serum anti-tissue transglutaminase immunoglobulin-A (tTGA) levels and Marsh grading on duodenal histopathology in Celiac disease (CD). METHODS In a prospective cohort study, a total of 52 symptomatic patients between age group of 2-18 y were enroled. All enroled patients were subjected to upper GI endoscopy by an experienced endoscopist. Two biopsies each from the bulb (D1) and second part (D2) of the duodenum were taken and Marsh grading was performed by a single experienced pathologist. Serum tTGA levels were also performed to find out correlation between serum tTGA levels and Marsh grading. RESULTS The mean age of the patients was 8.21 ± 3.45 y (Range: 2-16 y). Anemia was the most common non-gastrointestinal (GI) sign and was present in 73% of the cases. However the authors could not find out any significant association between Marsh grading and hemoglobin levels (r = 0.32, p > 0.05). Serum tTGA levels were found to be positively correlated with Marsh grading (Spearmen correlation coefficient ρ = 0.74, p 0.000). Significant differences were found in tTGA levels between different Marsh gradings (ANOVA test) (p 0.000). Receiver-operator curve (ROC) analysis cut-off value of serum tTGA for predicting villous atrophy was 178.8 (nine times of cut-off value) with sensitivity of 100% and specificity of 85.7%. CONCLUSIONS Serum tTGA levels can be used to predict villous atrophy and biopsy may be avoided in strongly suspected cases with more than 9 times of cut-offs.
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Affiliation(s)
- Rakesh Jora
- Department of Pediatrics, Umaid Hospital for Women and Children, Dr. S.N. Medical College, Jodhpur, Rajasthan, 342003, India.
| | - Vikrant Raghuvanshi
- Department of Pediatrics, Umaid Hospital for Women and Children, Dr. S.N. Medical College, Jodhpur, Rajasthan, 342003, India
| | - Vikas Payal
- Department of Pediatrics, Umaid Hospital for Women and Children, Dr. S.N. Medical College, Jodhpur, Rajasthan, 342003, India
| | - Pramod Sharma
- Department of Pediatrics, Umaid Hospital for Women and Children, Dr. S.N. Medical College, Jodhpur, Rajasthan, 342003, India
| | - Shree Krishan Vishnoi
- Department of Pediatrics, Umaid Hospital for Women and Children, Dr. S.N. Medical College, Jodhpur, Rajasthan, 342003, India
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Ganji A, Esmaeilzadeh A, Bahari A, Ghafarzadegan K, Afzal Aghayee M, Mosanen Mozafari H, Hayatbakhsh A, Ghavami Ghanbarabadi V, Ravarian B, Rahimi L. Correlation Between Cut-off Level of Tissue Transglutaminase Antibody and Marsh Classification. Middle East J Dig Dis 2016; 8:318-322. [PMID: 27957296 PMCID: PMC5145300 DOI: 10.15171/mejdd.2016.42] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Duodenal biopsy is required for diagnosis of celiac disease in adults, although some studies have suggested adequate accuracy of serology alone. Objective: We aimed to assess the correlation between anti-tissue transglutaminase (tTG) titer and pathological findings and to define the specific level of tTG for predicting celiac disease in adults without the need for biopsy sampling. METHODS This descriptive study was done on 299 participants. The tTG titer and pathological findings of duodenal biopsy samples were used for this study. Analysis of Receiver operating characteristic (ROC) curve was used to find a cut-off point of anti-tTG antibody for mucosal atrophy. RESULTS Mean tTG titers was significantly higher in patients graded as Marsh III≥ 3 (p=0.023). ROC curve analysis showed 89.1% sensitivity for cut-off point≥76.5 IU/mL of anti-tTG. For Marsh≥ II, specificity was 28% and positive predictive value was 91%.CON CLUSION There is a linear correlation between increasing tTG level and Marsh I to III. Specificity of tTG titer more than 200 was 100% for Marsh >2.
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Affiliation(s)
- Azita Ganji
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abbas Esmaeilzadeh
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Bahari
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mehdi Afzal Aghayee
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Homan Mosanen Mozafari
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abdolrasol Hayatbakhsh
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vahid Ghavami Ghanbarabadi
- PHD candidate in Biostatistics, Department of Epidemiology and Biostatistics, School of Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Behdad Ravarian
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leili Rahimi
- Gastroenterology and Hepatology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Wang H, Zhou G, Luo L, Crusius JBA, Yuan A, Kou J, Yang G, Wang M, Wu J, von Blomberg BME, Morré SA, Peña AS, Xia B. Serological Screening for Celiac Disease in Adult Chinese Patients With Diarrhea Predominant Irritable Bowel Syndrome. Medicine (Baltimore) 2015; 94:e1779. [PMID: 26496305 PMCID: PMC4620784 DOI: 10.1097/md.0000000000001779] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Celiac disease (CD) is common in Caucasians, but thought to be rare in Asians. Our aim was to determine the prevalence of CD in Chinese patients with chronic diarrhea predominant irritable bowel syndrome (IBS-D).From July 2010 to August 2012, 395 adult patients with IBS-D and 363 age and sex-matched healthy controls were recruited in Zhongnan Hospital of Wuhan University and Xiaogan Central Hospital in Hubei province, central China. Patients with IBS-D were diagnosed according to the Rome III criteria. Serum Immunoglobulin (IgA/IgG) anti-human tissue transglutaminase (anti-htTG)-deamidated gliadin peptide (DGP) antibodies were measured in a single ELISA (QUANTA Lite h-tTG/DGP Screen). Upper endoscopy with duodenal biopsies and HLA-DQA1 and HLA-DQB1 genotyping were performed in seropositive subjects and a gluten-free diet was prescribed.Seven IBS-D patients (7/395, 1.77%) and 2 healthy controls (2/363, 0.55%), were positive for anti-htTG/DGP antibodies. Of these 9 cases, 1 was lost to follow-up, 3 were suspected to have CD and 5 were eventually diagnosed as CD with intestinal histological lesions classified as Marsh Type II in 2 and Type III in 3. Of these 5 diagnosed CD patients, 4 (4/395, 1.01%) were from the IBS-D group and 1 (1/363, 0.28%) from the healthy control had asymptomatic CD. Two Type III CD patients with relatively high titers in the serologic assay were homozygous and heterozygous for haplotype HLA-DQA1*03-DQB1*03:03 (HLA-DQ9.3), respectively.In the present study, CD was present in 1.01% of patients with IBS-D and in 0.28% of the control group. We like to suggest that the haplotype HLA-DQA1*03-DQB1*03:03 (HLA-DQ9.3), which is common in Chinese, is a new susceptibility factor for CD in China. Larger screening and genetic studies are needed in the Chinese population of different regions.
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Affiliation(s)
- Hongling Wang
- From the Department of Gastroenterology, Zhongnan Hospital of Wuhan University, and Hubei Clinical Center and Key Laboratory of Intestinal and Colorectal Diseases, Wuhan (HW, GZ, LL, BX); Department of Gastroenterology, Xiaogan Central Hospital, Xiaogan (AY, JK); Department of Pathology, Zhongnan Hospital of Wuhan University (GY); Department of Pathology, Basic Medicine School of Wuhan University, Wuhan University, Wuhan (MW); Department of Gastroenterology, Jiangsu Provincial Hospital of TCM, Nanjing (JW); Medical Immunology, Department of Pathology, VU University Medical Center, Amsterdam (BMEVB); and Laboratory of Immunogenetics at the Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, The Netherlands (JBAC, SAM, ASP)
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Abstract
Historically the diagnosis of celiac disease has relied upon clinical, serological, and histological evidence. In recent years the use of sensitive serological methods has meant an increase in the diagnosis of celiac disease. The heterogeneous nature of the disorder presents a challenge in the study and diagnosis of the disease with patients varying from subclinical or latent disease to patients with overt symptoms. Furthermore the related gluten-sensitive disease dermatitis herpetiformis, while distinct in some respects, shares clinical and serological features with celiac disease. Here we summarize current best practice for the diagnosis of celiac disease and briefly discuss newer approaches. The advent of next-generation assays for diagnosis and newer clinical protocols may result in more sensitive screening and ultimately the possible replacement of the intestinal biopsy as the gold standard for celiac disease diagnosis.
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Affiliation(s)
- Greg Byrne
- School of Biological Sciences, Dublin Institute of Technology, Kevin St., Dublin, 8, Ireland.
| | - Conleth F Feighery
- Immunology Department, Trinity College, Dublin, Ireland
- Immunology Department, St. James's Hospital, Dublin, Ireland
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Tortora R, Imperatore N, Capone P, De Palma GD, De Stefano G, Gerbino N, Caporaso N, Rispo A. The presence of anti-endomysial antibodies and the level of anti-tissue transglutaminases can be used to diagnose adult coeliac disease without duodenal biopsy. Aliment Pharmacol Ther 2014; 40:1223-9. [PMID: 25263177 DOI: 10.1111/apt.12970] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 08/21/2014] [Accepted: 09/05/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND The new ESPGHAN guidelines for diagnosis of paediatric coeliac disease suggest to avoid biopsy in genetically pre-disposed and symptomatic individuals with positive anti-endomysial antibodies (EMA) and anti-tissue transglutaminases (a-tTG). However, duodenal biopsy remains the gold standard in adult coeliac disease. AIMS To establish the cut-off values of a-tTG, which would: predict the presence of duodenal histology (Marsh ≥2) diagnostic for coeliac disease; and predict the presence of villous atrophy (Marsh 3) in adults. METHODS We performed an observational prospective study including all consecutive adult patients with suspected coeliac disease. All subjects were tested for EMA and a-tTG. Coeliac disease diagnosis was made in presence of Marsh ≥2, a-tTG >7 U/mL and positive EMA. A ROC curve was constructed to establish the best specificity cut-off of a-tTG levels, which would predict the presence of Marsh ≥2 and Marsh 3 at histology. RESULTS The study included 310 patients with positive antibodies. Histology showed Marsh 1 in 8.7%, Marsh 2 in 3.5%, Marsh 3 in 87.7%. The best cut-off value of a-tTG for predicting Marsh ≥2 was 45 U/mL (sensitivity 70%; specificity 100%; PPV 100%; NPV 24.1%); the best cut-off for predicting villous atrophy was 62.4 U/mL (sensitivity 69%, specificity 100%; PPV 100%; NPV 31%). CONCLUSIONS The diagnosis of coeliac disease can be reached without histology in adult patients with positive EMA and a-tTG levels >45 U/mL. An a-tTG level >62.4 was diagnostic for villous atrophy. These results could contribute to improving the diagnosis of coeliac disease by allowing for a significant reduction in diagnosis-related costs.
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Affiliation(s)
- R Tortora
- Gastroenterology, Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Italy
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Barak M, Rozenberg O, Froom P, Grinberg M, Reginashvili D, Henig C, Pacht A, Lerner A. Challenging our serological algorithm for celiac disease (CD) diagnosis by the ESPGHAN guidelines. Clin Chem Lab Med 2013; 51:e257-9. [DOI: 10.1515/cclm-2013-0267] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 06/13/2013] [Indexed: 12/15/2022]
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Fernández-Bañares F, Rosinach M, Esteve M. Comment to "high tissue-transglutaminase antibody level predicts small intestinal villous atrophy in adult patients at high risk of coeliac disease". Dig Liver Dis 2012; 44:885-6; author reply 886. [PMID: 22677004 DOI: 10.1016/j.dld.2012.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 04/30/2012] [Indexed: 12/11/2022]
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Authors’ reply: Comment to “High tissue-transglutaminase antibody level predicts small intestinal villous atrophy in adult patients at high risk of celiac disease”. Dig Liver Dis 2012. [DOI: 10.1016/j.dld.2012.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Lebwohl B, Rubio-Tapia A, Assiri A, Newland C, Guandalini S. Diagnosis of celiac disease. Gastrointest Endosc Clin N Am 2012; 22:661-77. [PMID: 23083985 PMCID: PMC4005880 DOI: 10.1016/j.giec.2012.07.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
This article reviews issues related to identifying the appropriate patient to test for celiac disease, the performance characteristics of serologic testing, the role of gene testing for human leukocyte antigen DQ2 and DQ8 haplotypes, and issues related to the performance of small intestinal biopsy. The article concludes with a review of special diagnostic considerations in pediatric patients.
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Affiliation(s)
- Benjamin Lebwohl
- Department of Medicine, Mailman School of Public Health, Celiac Disease Center, Columbia University, New York, NY 10032, USA.
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Mubarak A, Wolters VM, Gmelig-Meyling FHJ, ten Kate FJW, Houwen RHJ. Tissue transglutaminase levels above 100 U/mL and celiac disease: A prospective study. World J Gastroenterol 2012; 18:4399-403. [PMID: 22969205 PMCID: PMC3436057 DOI: 10.3748/wjg.v18.i32.4399] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 07/24/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether a tissue-transglutaminase antibody (tTGA) level ≥ 100 U/mL is sufficient for the diagnosis of celiac disease (CD).
METHODS: Children suspected of having CD were prospectively included in our study between March 2009 and September 2011. All patients with immune globulin A deficiency and all patients on a gluten-free diet were excluded from the study. Anti-endomysium antibodies (EMA) were detected by means of immunofluorescence using sections of distal monkey esophagus (EUROIMMUN, Luebeck, Germany). Serum anti-tTGA were measured by means of enzyme-linked immunosorbent assay using human recombinant tissue transglutaminase (ELiA Celikey IgA kit Phadia AB, Uppsala, Sweden). The histological slides were graded by a single experienced pathologist using the Marsh classification as modified by Oberhuber. Marsh II and III lesions were considered to be diagnostic for the disease. The positive predictive values (PPVs), negative predictive values (NPVs), sensitivity and specificity of EMA and tTGA along with their 95% CI (for the cut off values > 10 and ≥ 100 U/mL) were calculated using histology as the gold standard for CD.
RESULTS: A total of 183 children were included in the study. A total of 70 (38.3%) were male, while 113 (61.7%) were female. The age range was between 1.0 and 17.6 years, and the mean age was 6.2 years. One hundred twenty (65.6%) patients had a small intestinal biopsy diagnostic for the disease; 3 patients had a Marsh II lesion, and 117 patients had a Marsh III lesion. Of the patients without CD, only 4 patients had a Marsh I lesion. Of the 183 patients, 136 patients were positive for EMA, of whom 20 did not have CD, yielding a PPV for EMA of 85% (95% CI: 78%-90%) and a corresponding specificity of 68% (95% CI: 55%-79%). The NPV and specificity for EMA were 91% (95% CI: 79%-97%) and 97% (95% CI: 91%-99%), respectively. Increased levels of tTGA were found in 130 patients, although only 116 patients truly had histological evidence of the disease. The PPV for tTGA was 89% (95% CI: 82%-94%), and the corresponding specificity was 78% (95% CI: 65%-87%). The NPV and sensitivity were 92% (95% CI: 81%-98%) and 97% (95% CI: 91%-99%), respectively. A tTGA level ≥ 100 U/mL was found in 87 (47.5%) patients, all of whom were also positive for EMA. In all these 87 patients, epithelial lesions confirming CD were found, giving a PPV of 100% (95%CI: 95%-100%). The corresponding specificity for this cut-off value was also 100% (95% CI: 93%-100%). Within this group, a total of 83 patients had symptoms, at least gastrointestinal and/or growth retardation. Three patients were asymptomatic but were screened because they belonged to a group at risk for CD (diabetes mellitus type 1 or positive family history). The fourth patient who lacked CD-symptoms was detected by coincidence during an endoscopy performed for gastro-intestinal bleeding.
CONCLUSION: This study confirms based on prospective data that a small intestinal biopsy is not necessary for the diagnosis of CD in symptomatic patients with tTGA ≥ 100 U/mL.
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Panetta F, Ferretti F, Diamanti A. Positive serum IgA-tissue-transglutaminase antibodies are not all but enough to diagnose coeliac disease without a small bowel biopsy. J Crohns Colitis 2012; 6:804-5; author reply 806. [PMID: 22552274 DOI: 10.1016/j.crohns.2012.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 04/03/2012] [Indexed: 02/08/2023]
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