Abstract
A new diagnostic tool (algorithm-1) for coeliac disease (CD) permitting the diagnosis without performing the duodenal biopsy has been recently proposed by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). It combines symptoms associated with CD, high anti-transglutaminase type 2 antibody (anti-TG2) levels, anti-endomysium-IgA antibodies (EMA), and at-risk HLA. Our aims were (i) to evaluate retrospectively in 227 individuals (149 CD patients and 78 controls) the algorithm-1, (ii) to reduce the number of duodenal biopsies among CD patients for whom algorithm-1 is not applicable through the addition of antiactin IgA antibodies (AAA-IgA), and (iii) to evaluate prospectively algorithm-1 and AAA-IgA in 50 patients with suspected CD. Algorithm-1 identified 70 out of 149 CD patients with Marsh 3 lesions. Adding AAA-IgA to the remaining patients with anti-TG2 levels comprised between 4 and 10 times upper limit of normal (ULN) allowed the detection of further 20 patients with a Marsh 3 damage. In our prospective study, algorithm-1 identified 23 out of 50 patients, whilst further 7 were recognized adding AAA-IgA. We confirm that algorithm-1 may avoid the duodenal biopsy in many CD patients and underscores the usefulness of AAA-IgA in reducing the number of duodenal biopsies in patients with moderate anti-TG2 levels.
Highlights
A synopsis summarizing some of the evidence statements and recommendations of the guidelines in Coeliac disease (CD) diagnosis for use in clinical practice has been formulated by a working group within the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) [2]
The one hundred and forty-nine CD patients and 78 controls were classified in 3 different Subgroups according to algorithm-1 based on the presence of symptoms and signs suggestive of CD, anti-TG2 levels, positivity for endomysium-IgA antibodies (EMA) and for HLA-DQ2, or -DQ8 (Figure 1)
We found that all patients with symptoms and signs suggestive of CD, anti-TG2 levels >10 times upper limit of normal (ULN), positivity for EMA and for HLA-DQ2, or -DQ8 had coeliac disease with a Marsh 3 atrophy (Subgroup 1 of Figure 1)
Summary
We have considered in the present work the most interesting of the two new algorithms, algorithm-1 It allows diagnosis of CD without performing the duodenal biopsy in children and adolescents with symptoms and signs suggestive of CD, anti-transglutaminase type 2 antibody (anti-TG2) levels >10 times upper limit of normal (ULN), and positive confirmation tests of anti-endomysium-IgA antibodies (EMA) and with the presence of at-risk HLA-DQ2 or -DQ8. If all these requirements are fulfilled, the diagnosis of CD is confirmed, gluten-free diet is started, and the patient is studied for improvement of symptoms and decline of autoantibodies. A later gluten challenge in these patients is not required [2]
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