Celiac Disease in India

Abstract

We have read the article of Bhatnagar et al. (1) with keen interest. The study is relevant in northern India; however, certain points need to be clarified. There is some misinterpretation of Marsh grading (2). In grade I, there is no change in villous architecture; there is only increased intraepithelial lymphocytes (IEL). In grade II, crypts are elongated and in grade III, there is various degree of villous atrophy starting from partial to total (grades IIIa, IIIb and IIIc) (2,3). The authors (1) have separated grade III into mild, moderate and severe mucosal changes. Data should have been interpreted as celiac disease (CD) was diagnosed on the basis of Marsh grade III changes, and depending on the severity of villous atrophy, they were further subclassified as mild, moderate and severe. Accordingly, 86% of their cases had either subtotal (44%) or total (42%) villous atrophy, and the other 14% had partial villous atrophy, and this figure matches perfectly with other studies published from India (subtotal/total villous atrophy in 70%-80% of cases) (4,5). Therefore, it would not be right to state that most Indian children with CD have mild to moderate histological changes (1). The number of CD patients diagnosed is 138 that constitute 53% (138/259) of chronic diarrhea rather than 40% mentioned in the article (1). In this study (1), cases were not from unselected group of children with chronic diarrhea alone as they had also associated abdominal distension and failure to thrive. It has been shown from north India that the prevalence of CD is just 17% in unselected group (5) and 50% in selected group of children with chronic diarrhea (4). The role of antiendomysial antibody (AEA) in the diagnosis of CD has been underplayed in this study (1). According to the authors, approximately 5% of the cases would have been missed if only AEA assay was used for diagnostic purpose. However, they have ignored those 20 of 57 cases with mild mucosal changes where AEA was positive, and 19 of them responded to gluten-free diet (GFD). Had the authors not done AEA, they would have missed the diagnosis in 19 cases. If histology was the sole criteria to decide about GFD trial, then what about the other 37 cases who were not put on GFD? In developing countries, serology plays an important role to distinguish villous atrophy caused by CD from other causes. This fact has been highlighted and emphasized from India (5,6). The above facts raised by us have direct implication on diagnosis of CD in developing countries. Shinjini Bhatnagar, PhD Alan D. Phillips, PhD Maharaj K. Bhan, MD Pediatric Gastroenterologist and Scientist Centre for Diarrhoeal Diseases Research and Nutrition, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India