Rates of Duodenal Biopsy During Upper Endoscopy Differ Widely Between Providers: Implications for Diagnosis of Celiac Disease

Prevalence of Coagulopathy in Patients with Celiac Disease: A Single-Center Retrospective Case-Control Study

Introduction: Despite being one of the most frequent chronic digestive diseases worldwide, with a prevalence of 1%, celiac disease (CD) remains severely underdiagnosed. Among the instruments used to improve its diagnostic rate, hematologic parameters have been proposed as screening tests to select patients with an increased probability of having CD. Assessment of coagulation is included in routine check-ups, and CD has been reported to be associated with coagulopathy. We aimed to assess if subtle changes in coagulation tests could be used in clinical practice to prompt testing for CD. Methods: We retrospectively recruited all patients with clinical suspicion for CD during a study period of 7 years (between 2015 and 2022), who were tested using IgA tissue transglutaminase (tTG) serology and serum total IgA (IgG tTG in case of IgA deficiency) and who underwent upper gastrointestinal endoscopy with multiple biopsy sampling of the duodenal bulb and distal duodenum. We stratified patients into three groups: newly diagnosed CD, gluten-free diet-treated CD, and non-CD controls. Results: Altogether, there were 133 CD patients (71 newly diagnosed, 62 GFD-treated) and 57 non-CD controls. Mean age and gender distribution were similar among the three groups: 43.3 years for newly diagnosed CD, 41.6 years for non-CD controls, and 44 years for GFD-treated CD patients, with a male gender distribution of 21.1%, 28%, and 24.1%, respectively. Among the included newly diagnosed CD patients, 14% had a prolonged INR. The mean INR was slightly higher in newly diagnosed CD patients, compared to GFD-treated CD patients and non-CD controls: 1.12 ± 0.30, 1.02 ± 0.83, and 1.00 ± 0.08, respectively (p = 0.009). Consequently, prothrombin activity was slightly lower in newly diagnosed CD patients, compared to GFD-treated CD and non-CD controls: 94.9 ± 19.3%, 102.3 ± 12.8%, and 101.9 ± 15.15, respectively. Interestingly, after GFD, the mean INR and prothrombin activity of CD individuals reached a value similar to that of non-CD controls. Conclusions: Subtle changes in INR, defined as a value within the normal range, but closer to the upper limit, could be an indicator of probability for CD.

The role of female endoscopists: are women gastroenterologists better at obtaining biopsies for celiac disease than men?

OBJECTIVES

Celiac disease (CD) is commonly found in women. Given the sex differences in diagnosed patients, we hypothesized sex differences in physicians obtaining biopsies for CD may exist.

MATERIALS AND METHODS

We retrospectively reviewed duodenal biopsies for suspected CD excluding pre-existing CD patients. Appropriate biopsy practice was defined as ≥5 specimens per ACG guidelines.

RESULTS

We included 125 patients (females, 92). There were 85 properly (68%) biopsied. Presence of a female endoscopist was associated with better adherence to biopsy guidelines (OR, 2.99, 95% CI, 1.19-7.54; p = .02) which remained significant after multivariable adjustment (adjusted OR, 2.7; p = .047).

CONCLUSIONS

Physician sex-based differences in biopsy patterns may exist.

Epidemiology, Presentation, and Diagnosis of Celiac Disease

The incidence of celiac disease is increasing, partly because of improved recognition of, and testing for, the disease. The rise in incidence is also due to a real increase of this immune-based disorder, independent of disease detection. The reasons for this true rise in recent decades are unknown but may be related to environmental factors that may promote loss of tolerance to dietary gluten. Strategies to reduce the development of celiac disease have not been proven successful in randomized trials, but the quantity of early-life gluten exposure has been a major focus of prevention efforts. The criteria for the diagnosis of celiac disease are changing, but in adults, diagnosis still depends on the presence of duodenal villous atrophy while the patient is on a gluten-containing diet, along with findings from serology analysis. Although guidelines in the United States continue to mandate a biopsy at all ages, some children receive a diagnosis of celiac disease without a biopsy. If proven accurate and scalable, assays that detect gluten-HLA tetramer complexes might be used in diagnosis to be made in the context of a gluten-free diet without intestinal biopsy.

Routine Multiple Duodenal Biopsy during Endoscopy of Dyspeptic Patients Seems Unnecessary for Screening of Celiac Disease

Introduction

Celiac disease (CD) is a chronic and common cause of dyspepsia with a rising prevalence worldwide. This study is aimed at investigating the prevalence of CD in dyspeptic patients based on serology and biopsy, determining the associated factors, and assessing the necessity of regular duodenal biopsies from normal mucosa in diagnosis of CD among dyspeptic patients.

Methods

This cross-sectional study was performed on 530 adult dyspeptic patients who underwent gastroduodenoscopy in Imam Reza hospital, Mashhad, during 2016-2018. Demographic characteristics, clinical data, and laboratory analyses were extracted from hospital records. CD was diagnosed based on intestinal biopsy and serum antitissue transglutaminase (anti-TTG) levels. Mucosal lesions were classified according to the modified Marsh classification. Data were analyzed in SPSS with P < 0.05 being considered significant.

Results

Overall, 163 males (30.8%) and 367 females (69.2%) with an average age of 46.38 ± 15.54 years were studied. High anti-TTG levels were seen in 36 (6.8%) patients, and duodenal pathologies were seen in 23 (4.5%) patients. Fifteen (2.8%) were diagnosed with CD based on both serology and biopsy. Bloating was the most common type of dyspepsia in CD patients (7, 46.7%), followed by epigastric pain (6, 40%), and postprandial fullness (2, 13.3%). Two CD patients (13.3%) reported a positive family history for CD. Logistic regression model showed that iron deficiency anemia (IDA), anti-TTG level, and Helicobacter pylori infection were predictors of histological changes of CD, whereas IDA was the only independent predictor of CD in dyspeptic patients (OR = 17.65, 95%CI = 1.53‐202.52, and P = 0.021).

Conclusion

CD is prevalent in dyspeptic patients, but routine biopsy from normal-appearing duodenal mucosa is not recommended for all patients. Serological studies, complete history, and careful endoscopic evaluation may provide better cost-effective clinical solutions to improve the diagnostic yield of celiac disease in dyspeptic patients.

Prevalence and Clinical Features of Celiac Disease in Healthy School-Aged Children

BACKGROUND/AIMS

The aim of this study was to determine the prevalence of celiac disease (CD) in healthy school-aged children in the northern region of Cyprus and to investigate the existence of potential markers that may accompany CD. This is the first study to measure the prevalence of CD in the northern region of Cyprus.

METHODS

This study included 3792 school-aged children who were between the ages of 6 and 10 years between January 2015 and October 2016. CD was screened using total serum IgA, IgA anti-tissue transglutaminase (tTG), and IgA antiendomysial (EMA) antibodies. Subjects with selective IgA deficiency were further tested for IgG-tTG. Small intestinal biopsies were performed on all subjects with tTG antibody positivity. Risk factors and symptoms related to CD were evaluated using questionnaires in both the CD and control groups.

RESULTS

Of the 3792 subjects, 39 were antibody positive (IgA-tTG was positive only in 14 subjects, IgA-tTG plus IgA-EMA in 21 subjects, and IgG-tTG in 4 subjects). IgA deficiency was detected in 11 subjects (0.29%). IgG-tTG was positive in 4 subjects with IgA deficiency (36.3%). Intestinal biopsies were performed on 28 of the 39 seropositive subjects. The biopsy findings of 15 children were consistent with CD (IgA-tTG positive in 3, IgA-tTG and IgA-EMA positive in 10, and IgG-tTG positive in 2). Thus, biopsies confirmed CD in 1:256 children (0.39%).

CONCLUSIONS

Our study, which is the first study of school-aged children from the northern region of Cyprus, revealed that CD is a prevalent disease in this region.