The importance of disease prevalence in assessing the diagnostic value of a test: endoscopic markers in celiac disease

Opportunities for Improving Biopsy and Non-Biopsy-Based Diagnosis of Celiac Disease

The accumulating data regarding a non-biopsy diagnosis of celiac disease has led to its adoption in certain scenarios, although debate on whether and when to use non-biopsy criteria in clinical practice is ongoing. Despite the growing popularity and evidence basis for a biopsy-free approach to diagnosis in the context of highly elevated serologies, there will continue to be a role for a biopsy in some groups. This review summarizes the current evidence supporting a non-biopsy approach and arguments supporting continued reliance on biopsy, and focuses on opportunities to improve both approaches.

Daily Dilemmas in Pediatric Gastrointestinal Pathology

The evaluation of gastrointestinal pathology in children often requires a different approach from that in adults. In this concise review, the authors outline 3 diagnostic challenges that are often encountered in daily practice; these include eosinophilic diseases, duodenal intraepithelial lymphocytosis with preserved villous architecture, and terminal ileal inflammation in the setting of idiopathic inflammatory bowel disease.

Diagnostic values of duodenal endoscopic markers in paediatric coeliac patients

BACKGROUND AND STUDY AIMS

The recognition of suggestive endoscopic markers in the duodenum during open access endoscopy can help identifying patients who are likely to develop coeliac disease (CD). This study aims to determine the diagnostic accuracy of duodenal endoscopic markers for the diagnosis of CD.

PATIENTS AND METHODS

All children (0-15 years) who underwent oesophagogastroduodenoscopy (EGD) for any reason suggestive of CD at the paediatric department of Al-Assad University Hospital in Latakia, Syria during a 4-year period (from January 2010 to December 2013) were retrospectively included, in the study; this yielded a consecutive cohort without selection bias. The relevant data were obtained from the patients' files. Four duodenal endoscopic markers, including scalloping, reduction of duodenal folds, nodular mucosal pattern, and scattered white spots, were evaluated.

RESULTS

During the study period, 504 children underwent EGD of whom 123 (24.4%) were ultimately diagnosed with CD. At least one marker was observed in 200/504 children (39.6%) and the diagnostic values were as follows: Sensitivity (91%), specificity (76%), positive predictive value (56%), and negative predictive value (97%). Scalloping had the highest sensitivity and specificity of 89% and 96%, respectively.

CONCLUSION

Careful examination of the second and third parts of the duodenum during endoscopy can be helpful in identifying CD. Scalloping is the most common endoscopic marker, and the high NPV values of endoscopic markers should be interpreted cautiously, as the diagnosis of CD can be missed.

Statement on Best Practices in the Use of Pathology as a Diagnostic Tool for Celiac Disease: A Guide for Clinicians and Pathologists

Small intestinal biopsy interpretation has been the cornerstone for the diagnosis of celiac disease for over 50 years. Despite the existence of sensitive and specific serological tests, duodenal mucosal biopsies continue to be obtained in the vast majority of patients in whom a diagnosis of celiac disease is being considered. The accurate evaluation of these biopsies requires coordination and information sharing between the gastroenterologist, laboratory, and pathologist in order to optimize tissue sampling, preparation and interpretation. This document, a collaboration between the Rodger C. Haggitt Gastrointestinal Pathology Society and the North American Association for the Study of Celiac Disease, is intended to provide clinicians and pathologists with a summary of best practices in the use of endoscopy and biopsy for patients with suspected celiac disease. The authors present a comprehensive and critical appraisal of the literature with respect to the topics of endoscopic findings, best methods for the obtaining biopsies, completing the pathology form and pathologic assessment, including evaluating intraepithelial lymphocytes and villous architecture. A discussion of conditions with overlapping pathologic findings in duodenal mucosal biopsies is presented. In order to provide additional guidance for challenging situations, the authors include an appendix containing practical suggestions. This review may be utilized in interdisciplinary discussions to optimize care for patients with possible celiac disease.

Optimizing the diagnosis of celiac disease

PURPOSE OF REVIEW

The diagnostic approach in celiac disease is continuously evolving as our understanding of its pathophysiology improves. This review aims to provide a summary of contemporary work that supports optimization of the diagnosis of this common yet underdiagnosed condition.

RECENT FINDINGS

The recently updated National Institute of Clinical Excellence and European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines and the contentious biopsy-free diagnostic approach will be discussed. We will review the evidence advocating optimal biopsy techniques such as single bite biopsy and controversial bulb biopsy sampling to increase diagnostic yield. Recent data providing phenotypical characterization and clinical outcomes of celiac subtypes such as potential celiac disease, seronegative celiac disease and ultrashort celiac disease will be covered. We will present emerging evidence on novel case finding strategies with point of care tests. Promising novel markers for celiac disease such as serum intestinal fatty acid binding protein and in-vitro gluten challenge will be included.

SUMMARY

Recent work has demonstrated the clinical significance of the celiac disease subtypes, emphasizing the importance of careful diagnosis and recognition. There is a move toward a less invasive and perhaps more cost-effective diagnostic approach in celiac disease, but duodenal biopsy remains the gold standard at present for all adults and the majority of pediatric patients.

Diagnostic yield of endoscopic markers for celiac disease

RATIONALE

In the setting of open access endoscopy, the recognition of suggestive endoscopic features in the duodenum can select patients with probability of celiac disease (CD). This could add to the current efforts to increase the diagnostic rate of this disease.

AIM

The aim of this study was to evaluate the diagnostic accuracy of these markers for CD in an adult population undergoing endoscopy, without a prior serological testing.

METHODS AND RESULTS

Over a period of 3 years, between June 2012 and 2015, all the patients who underwent upper gastrointestinal endoscopy and presented one or more of the endoscopic markers consistent with CD, or those suspected for CD, irrespective of the presence of these markers, were included. Sensitivity, specificity, positive and negative predictive values were calculated for these markers in CD diagnosis. Among the 182 patients, 56.04% were females, with a mean age of 47.6 ± 13.9 years. 20/182 (10.99%) had a final diagnosis of CD. The presence of any endoscopic marker had a high sensitivity (95%) and a negative predictive value (98.41%). Bulb atrophy and reduced folds in the descending duodenum had a low diagnostic accuracy, while scalloping, mosaic pattern and fissures were highly specific for CD (98.77%, 99.38% and 98.77%) and their presence greatly increased the probability of CD, with a positive likelihood ratio of 24.3, 24.3 and 12.15, respectively.

DISCUSSIONS

A wide set of endoscopic markers, including the duodenal bulb, were evaluated in this study. Our results showed that the endoscopy with a careful examination of the duodenum is a sensitive indicator for CD.

ABBREVIATIONS

CD = celiac disease, GI = gastrointestinal, VA = villous atrophy, NSAID = nonsteroidal anti-inflammatory drug, Sn = sensitivity, Sp = specificity, PPV = positive predictive value, NPV = negative predictive value, AUC = area under the curve, ROC = receiver operating characteristics, WLE = white light endoscopy, NBI = narrow band imaging, tTG = tissue transglutaminase, EMA = anti-endomysial antibodies.

Advances in pediatric celiac disease

PURPOSE OF REVIEW

To summarize the recent advances in celiac disease in children.

RECENT FINDINGS

New clues to the pathogenesis of celiac disease continue to emerge that may implicate the role of microbiome changes, antirotavirus VP7 antibodies, and the Parkinson's disease seven gene in celiac disease. Updated guidelines in pediatrics no longer support biopsies in all patients with celiac disease who have been identified by serology, clinical signs, and genetics. Serology screening of total immunoglobulin A in all patients may not be necessary in select patients. Prevalence and additional diseases associated with celiac disease continue to be elucidated.

SUMMARY

Our knowledge of celiac disease continues to grow with increasing evidence of the pathogenesis, genetics, diagnosis, and risk factors of the disease. Major changes have been made with respect to the guidelines for pediatric celiac disease, and potential improvements to simplify the algorithms for diagnosis and elimination of unessential testing have been proposed by new studies.