Is under diagnosis of celiac disease compounded by mismanagement in the primary care setting? A survey in the Italian Province of Brescia

AIM

Celiac disease is under diagnosed in the primary care setting, mainly because of lack of awareness on the heterogenic manifestation of the disease. Furthermore, patients diagnosed at open access endoscopy may be mismanaged with incomplete dietary information. The aim of this paper was to evaluate prevalence and incidence in 1996 and 1997 for celiac disease in the Italian Province of Brescia and to obtain information on the extent of underdiagnosis and mismanagement.

METHODS

The authors assessed the under diagnosis of celiac disease by relating the number of patients on gluten-free diet at 31 December 1997 (prevalent cases) to the expected number of patients in a population of 1,055,499 assuming 1/200 disease prevalence. Post-diagnosis management was assessed by questionnaire for all incident cases in the hospital practice and in the primary care setting.

RESULTS

Five hundred and ninety-four prevalent cases were identified compared with an estimated disease prevalence of 5,000 cases, a figure corresponding to 8/9 under diagnosis. One hundred and thirty-five incident cases during 1996-1997 have been identified. Overall 80% of incident cases were symptomatic, but 40% only with the classical symptoms of malabsorption. Forty-three of the 135 incident cases did not receive appropriate dietary education following diagnosis, a figure corresponding to 1:3 mismanagement, and all of them were diagnosed in the primary care setting at open access endoscopy.

CONCLUSIONS

Our study indicates that under diagnosis of celiac disease in the primary care setting is compounded by disease mismanagement, a finding suggesting the need for increasing awareness not only on the heterogenicity of clinical manifestation but also on the appropriate dietary management of celiac disease.

Prevalence and diagnosis of celiac disease in IgA-deficient children

BACKGROUND

Reported frequencies of celiac disease in selective IgA deficiency in childhood vary widely and this is probably due to the different characteristics of the patients studied and to the different criteria used for intestinal biopsy: all patients or only those with symptoms of malabsorption. Diagnosis of celiac disease is of considerable importance in IgA deficiency because of its increased frequency and also because avoidance of dietary gluten permits elimination of the symptoms and complications of celiac disease.

OBJECTIVES

To obtain a more reliable estimate of the incidence of celiac disease in childhood IgA deficiency jejunal biopsies were performed in 65 consecutively diagnosed IgA-deficient children whose parents consented. Some clinical and laboratory parameters including IgA-antigliadin and IgG-antigliadin antibodies were evaluated to predict their usefulness in selecting IgA-deficient patients for intestinal biopsy.

METHODS

All IgA-deficient patients had serum IgA levels below 5 mg/dL and salivary IgA below 0.5 mg/dL. Jejunal biopsy was performed using a peroral Watson capsule and IgA-antigliadin and IgG-antigliadin antibodies were performed by an ELISA assay.

RESULTS

Biopsy findings of severe villous atrophy permitted diagnosis of celiac disease in 7.7% (5/65 children). IgG-antigliadin antibody levels, elevated in 16 patients including all five celiacs, were the best parameter for predicting celiac disease and gave no false negatives.

CONCLUSIONS

The 7.7% frequency of celiac disease observed in these IgA-deficient children is about 20 times higher than in the general Italian population, and the lowest among the studies biopsying all patients; this is probably attributable to the presence of a substantial proportion of healthy children (20/65) and very few (2/65) with autoimmune disorders. The elevated sensitivity and negative-predictive value of IgG-antigliadin antibodies lead us to suggest that positive IgG-antigliadin antibodies can be used to select IgA-deficient children for jejunal biopsy with a very low probability of missing celiac disease while allowing a drastic reduction in the number of biopsies performed.