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  • Scott Adams
    Scott Adams

    Biopsies Unnecessary for Celiac Diagnosis in Most Children

    Reviewed and edited by a celiac disease expert.

    European study confirms the reliability of diagnosing celiac disease without upper endoscopy in children and teens who meet set criteria. 

    Biopsies Unnecessary for Celiac Diagnosis in Most Children - Kids no longer need a biopsy to diagnose their CD. Image: CC BY 2.0--Pakus Futuro Bloguero
    Caption: Kids no longer need a biopsy to diagnose their CD. Image: CC BY 2.0--Pakus Futuro Bloguero

    Celiac.com 04/13/2020 - Current guidelines set by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), permit doctors to diagnose celiac disease without upper endoscopy in children and adolescents who meet specific criteria. 

    A team of researchers recently set out to to assess exactly how many pediatric gastroenterologists in Central Europe used the “no-biopsy” approach to make a celiac diagnosis, and how many biopsies could have been avoided. 



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    The research team included Petra Riznik, Márta Balogh, Piroska Bódi, Luigina De Leo, Jasmina Dolinsek, Ildikó Guthy, Judit Gyimesi, Ágnes Horváth, Ildikó Kis, Martina Klemenak, Berthold Koletzko,0, Sibylle Koletzko,, Ilma Rita Korponay-Szabó,, Tomaz Krencnik, Tarcisio Not, Goran Palcevski, Éva Pollák, Daniele Sblattero, István Tokodi, Matej Vogrincic, Katharina Julia Werkstetter, and Jernej Dolinsek.

    The team analyzed 2016 medical records for celiac patients under 19 years old, who were diagnosed in five European countries. They concentrated on transglutaminase antibody (TGA) levels at diagnosis, and on whether celiac diagnosis was confirmed with or without duodenal biopsy. Using diagnostic guidelines, they also noted clinical presentation and any delays in the final diagnosis.

    The gathered data from 653 children from Croatia, Hungary, Germany, Italy, and Slovenia. Subjects ranged in age from 7 months-18.5 years, with an average patient age of 7 years. Just under 64% were female,

    A total of 134 children were asymptomatic at diagnosis. Of 519 children who did show symptoms, 107, nearly 21%, were diagnosed without biopsy. Out of 412 children diagnosed via biopsy, 214, or nearly 52% had TGA at or above 10 times upper level of normal (ULN) and thus could have been diagnosed without biopsy. Signs and symptoms of malabsorption were more frequent in children diagnosed without duodenal biopsies.

    The data showed no differences in diagnostic times with the no-biopsy approach. In this study, about 60% of celiac patients who show symptoms could have been diagnosed without duodenal biopsies. However, only 20% of eligible patients are getting a biopsy-free celiac diagnosis.

    The research team recommends educating doctors about the ease and reliability of biopsy-free celiac diagnosis as part of the ESPGHAN guidelines.

    Read more in Hindawi
     

    The researchers are variously affiliated with the University Medical Centre Maribor, Department of Paediatrics, Gastroenterology, Hepatology and Nutrition Unit, Maribor, Slovenia; Markusovszky Teaching Hospital, Szombathely, Hungary, Pándy Kálmán Hospital, Gyula, Hungary; IRCCS Burlo Garofolo Trieste, Institute for Maternal and Child Health, Trieste, Italy; Municipality of Maribor, Project Office, Maribor, Slovenia; Jósa András County Hospital, Nyíregyháza, Hungary; Heim Pál National Paediatric Institute, Coeliac Disease Centre, Budapest, Hungary; Csolnoky Ferenc County Hospital, Veszprém, Hungary; St. Barbara County Hospital, Tatabánya, Hungary; Stiftung Kindergesundheit (Child Health Foundation) at Dr. von Hauner Children’s Hospital, LMU Munich, Munich, Germany; Dr. von Hauner Children’s Hospital, Clinical Medical Centre, LMU Munich, Munich, Germany; Department of Pediatrics, Gastroenterology and Nutrition, School of Medicine Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland; University of Debrecen, Faculty of Medicine, Department of Paediatrics, Debrecen, Hungary; University Hospital Rijeka, Department for Gastroenterology, Paediatric Clinic, Rijeka, Croatia; Ajka County Hospital, Ajka, Hungary; University of Trieste, Trieste, Italy; St. George Fejér County University Teaching Hospital, Székesfehérvár, Hungary; University Medical Centre Maribor, Department of Informatics, Maribor, Slovenia; and the Medical Faculty, Department of Paediatrics, University of Maribor, Maribor, Slovenia.

    Edited by Scott Adams



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  • About Me

    Scott Adams

    Scott Adams was diagnosed with celiac disease in 1994, and, due to the nearly total lack of information available at that time, was forced to become an expert on the disease in order to recover. In 1995 he launched the site that later became Celiac.com to help as many people as possible with celiac disease get diagnosed so they can begin to live happy, healthy gluten-free lives.  He is co-author of the book Cereal Killers, and founder and publisher of the (formerly paper) newsletter Journal of Gluten Sensitivity. In 1998 he founded The Gluten-Free Mall which he sold in 2014. Celiac.com does not sell any products, and is 100% advertiser supported.


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  • Related Articles

    Jefferson Adams
    Celiac.com 03/09/2016 - Can doctors reliably diagnose celiac disease in kids without duodenal biopsy?
    A team of researchers recently set out to see if they could use predictive values of transglutaminase (tTG) antibodies to diagnose celiac disease in kids, without performing duodenal biopsy.
    The research team included MA Aldaghi, SM Dehghani, and M Haghighat, of the Department of Pediatrics at Shiraz University of Medical Sciences in Shiraz, Iran.
    For their study, the team selected patients with likely celiac disease, who had been referred to a gastrointestinal clinic. The team first conducted physical examinations of the patients and performed tissue transglutaminase-immunoglobulin A (tTG-IgA) tests. For patients with serological titers higher than 18 IU/mL, the team performed upper endoscopy.
    The team assessed a total of 121 children, 69 female and 52 male, averaging 8.4 years of age. They found a significant association between blood tests and biopsy results; in other words, subjects with high antibody levels had more positive pathologic results for celiac disease, compared to others (P < 0.001).
    They achieved maximum sensitivity and maximum specificity of about 65% with a serological titer of 81.95 IU/ml. The calculated accuracy was lower in comparison with other studies.
    The team found lower antibody levels in patients with failure to gain weight and higher antibody levels in diabetic patients.
    In this study, a single blood test (tTg-IgA test) was not sufficient for researchers to reliably diagnose celiac disease without duodenal biopsy.
    Source:
    Iran J Pediatr. 2016 Feb;26(1):e3615. doi: 10.5812/ijp.3615. Epub 2016 Jan 30.


    Jefferson Adams
    Celiac.com 05/19/2016 - Using a prospective cohort study, a team of researchers recently set out to assess the outcomes of the latest celiac diagnosis guidelines from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN).
    The research team included Elisa Benelli, Valentina Carrato, Stefano Martelossi, Luca Ronfani, Tarcisio Not, and Alessandro Ventura. They are variously affiliated with the Department of Medical, Surgical and Health Sciences, University of Trieste in Trieste, Italy, and the Institute for Maternal and Child Health IRCCS 'Burlo Garofolo' in Trieste, Italy. The study was conducted at the Institute for Maternal and Child Health IRCCS Burlo Garofolo in Trieste, Italy.
    For the study, the team prospectively enrolled children diagnosed with celiac disease without a duodenal biopsy (group 1), following the last ESPGHAN and BSPGHAN guidelines, and children diagnosed with a duodenal biopsy, matched for sex, age and year of diagnosis (group 2). All of this was done over a 3-year period. The team made sure all patients were on a gluten-free diet (gluten-free diet) and then followed them for clinical conditions and laboratory testing at 6 months every year since diagnosis. The average follow up period was just under two years.
    Their analysis looked at resolution of symptoms, body mass index, levels of hemoglobin and anti-transglutaminase IgA, adherence to a gluten-free diet, quality of life, and supplementary post-diagnosis medical consultations. Out of 468 patients, the team found 51 patients (11%) who were diagnosed without a duodenal biopsy (group 1; median age 2.1 years), and matched those patients to 92 patients diagnosed with a biopsy (group 2; median age 2.4 years).
    At the end of follow-up the two groups showed statistically comparable clinical and nutritional status, anti-transglutaminase IgA antibody levels, quality of life, adherence to a gluten-free diet, and number of supplementary medical consultations.
    This study indicates that celiac disease can be reliably diagnosed without a duodenal biopsy in approximately 11% of cases.
    At least during a medium-term follow-up, this approach has no negative consequences relating to clinical remission, adherence to diet, and quality of life of children with celiac disease.
    Source:
    Arch Dis Child 2016;101:172-176. doi:10.1136/archdischild-2015-309259


    Jefferson Adams
    Celiac.com 06/05/2017 - Doctors diagnose celiac disease by confirming various clinical, genetic, serologic, and duodenal morphology features. Based on retrospective data, recent pediatric guidelines propose eliminating biopsy for patients with IgA-TTG levels more than 10-times the upper limit of normal (ULN), along with a few other criteria.
    One retrospective study showed that researchers using levels of IgA-TTG and total IgA, or IgA-TTG and IgG against deamidated gliadin (IgG-DGL) could identify patients both with and without celiac disease. A team of researchers recently set out to validate the positive and negative predictive values (PPV and NPV) of these diagnostic procedures.
    The research team included Johannes Wolf, David Petroff, Thomas Richter, Marcus KH. Auth, Holm H. Uhlig, Martin W. Laass, Peter Lauenstein, Andreas Krahl, Norman Händel, Jan de Laffolie, Almuthe C. Hauer, Thomas Kehler, Gunter Flemming, Frank Schmidt, Astor Rodriques, Dirk Hasenclever, and Thomas Mothes.
    Their team conducted a prospective study of 898 children undergoing duodenal biopsy analysis to confirm or rule out celiac disease at 13 centers in Europe. They then compared results from antibody tests with results from biopsies, follow-up data, and diagnoses made by the pediatric gastroenterologists. In all cases, diagnosis was made for celiac disease, no celiac disease, or no final diagnosis.
    Blinded researchers measured levels of IgA-TTG, IgG-DGL, and endomysium antibodies, while tissue sections were analyzed by local and blinded reference pathologists. The team validated two procedures for diagnosis: total-IgA and IgA-TTG, as well as IgG-DGL with IgA-TTG. Patients whose antibody concentrations for all tests were below 1-fold the ULN were assigned to the no celiac disease category.
    Those whose antibody concentrations for at least one test were above 10-fold the ULN were assigned to the celiac disease category. All other cases were considered to require biopsy analysis.
    The team calculated the ULN values using the cut-off levels suggested by the test kit manufacturers. They conducted HLA-typing for 449 participants. To extrapolate the PPV and NPV to populations with lower rates of celiac disease, they used models that accounted for how specificity values change with prevalence.
    In all, the team found 592 patients with celiac disease, 345 who did not have celiac disease, and 24 with no final diagnosis.
    The TTG-IgA procedure identified celiac disease patients with a PPV of 0.988 and an NPV of 0.934. The TTG-DGL procedure identified celiac disease patients with a PPV of 0.988 and an NPV of 0.958.
    Their extrapolation model estimated that PPV and NPV would remain above 0.95 even at a disease prevalence as low as 4%. Meanwhile, tests for endomysium antibodies and HLA type did not increase the PPV of samples with levels of IgA-TTG 10-fold or more above the ULN.
    Interestingly, the pathologists disagreed in their analyses of duodenal morphology about 4.2% of the time, a rate comparable to the error rate for serologic tests.
    This study validates the use of the TTG-IgA procedure and the TTG-DGL procedure in lieu of biopsy to diagnose pediatric patients with or without celiac disease.
    Source:
    Gastroenterology. DOI: http://dx.doi.org/10.1053/j.gastro.2017.04.023  
    The researchers are variously affiliated with the Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, Medical Faculty of the University and University Hospital, Leipzig, Germany, the Institute for Medical Informatics, Statistics & Epidemiology (IMISE), University of Leipzig, Germany, the Department of Paediatrics, University of Oxford, Oxford, United Kingdom, the Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom, the, University Children's Hospital Halle, Germany, the Medical School, Hannover, Germany, Helios Hospital, Department of Paediatrics, Plauen, Germany, the Children's Hospital Prinzessin Margaret, Darmstadt, Germany, the University Children's Hospital Graz, Austria, the Children's Hospital, Justus Liebig University Giessen, Germany, the University Children's Hospital Leipzig, Germany, the Children's Hospital of the Clinical Centre Sankt Georg Leipzig, Germany, the Clinical Trial Centre, University of Leipzig, Germany, the DKD Helios Children's Hospital, German Clinic for Diagnostics, Wiesbaden, Germany, the University Children's Hospital, Technical University Dresden, Germany, and the Alder Hey Children's National Health Service Foundation Trust, Liverpool, United Kingdom.


    Jefferson Adams
    Celiac.com 03/02/2020 - Current practice of using biopsy to diagnose children with celiac disease is changing to diagnosis without biopsy. 
    The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) recently issued new guidelines that recommend doctors diagnosing celiac disease omit biopsy in favor of a two-stage blood test, for the majority of children suspected of having the disease.
    New guidelines for diagnosing celiac disease in children call for avoiding biopsies in favor of a two-stage blood test. Until now, about half of all kids diagnosed with celiac disease got a biopsy. The new guidelines mean that nearly all kids will avoid the procedure in favor of a two-stage blood test.
    The new guidelines recommend that doctors:
    Conduct antibody screening in children with suspected celiac disease; Diagnose symptomatic children without biopsy, using the same criteria as in patients with symptoms; Invite parents and, where appropriate, children into any discussion about using biopsy; The new guidelines appear in the Journal of Pediatric Gastroenterology and Nutrition and call for clinicians diagnosing children with celiac disease to rely on accurate serology-based diagnosis without biopsy.
    Being able to diagnose children without biopsy is a major advance in celiac disease diagnosis, and will save millions of parents and children from what can be a costly, intimidating, and uncomfortable procedure that is not free of risk. 
    Read more at News-medical.net


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