PEDIATRICS Vol. 116 No. 4 October 2005, pp. 1054-1055 (doi:10.1542/peds.2005-1480)
Diagnosing Celiac Disease With a Positive Serological Test and Without an Intestinal Biopsy
Mohsin Rashid, MD, FRCP(C)Department of Pediatrics,
Dalhousie University,
IWK Health Center,
Halifax, Nova Scotia, Canada B3K 6R8
To the Editor.—
In a recent study, Barker et al1 proposed that a small-intestinal biopsy may not be necessary to diagnose celiac disease in the presence of high tissue transglutaminase (tTG) antibody titers. They report that most children with a tTG antibody titer of >100 U had a positive biopsy and thus question the usefulness and expense associated with a biopsy in this select group of patients. This is an interesting and a provocative study, but the results should be interpreted with great caution.
Celiac disease (gluten-sensitive enteropathy) is a chronic autoimmune disorder that may affect as many as 1% of the pediatric population in North America and Europe.2,3 It is a permanent intolerance to gluten, and the only effective treatment is a lifelong adherence to a strict gluten-free diet (GFD). Therefore, it is imperative that diagnosis be fully confirmed before subjecting the patient to a lifelong dietary restriction.
The definitive test for diagnosing celiac disease is a small-intestinal biopsy.4,5 Endoscopic intestinal biopsy is a safe procedure. Serological tests are good for screening minimally symptomatic and at-risk individuals but false-negative and false-positive results are possible.4 The diagnosis of celiac disease is of great significance to the individual patient, because a GFD is not only for life but also can be very challenging and restrictive. The diet is complex and can be expensive. A significant number of children with celiac disease and their families have difficulty coping with the lifestyle changes associated with such a diet.6,7 If the authors' proposal of not doing a small-bowel biopsy in children with a tTG antibody titer of >100 U is accepted, then according to their own data, 
2% of children may be incorrectly labeled as having celiac disease and put on an a GFD. The saving of $347 per patient in this setting should be weighed against the risks of making an inappropriate diagnosis of a condition that requires lifelong dietary therapy and monitoring. The cost of follow-up clinic visits, surveillance blood work, and the expense of GFD over the lifetime of the incorrectly diagnosed child will certainly outweigh the initial savings of an intestinal biopsy.
The authors' comments in the discussion section regarding the safety and nutritional appropriateness of a GFD are not completely accurate. There is concern that because the gluten-free cereal products generally are not enriched/fortified, a GFD may lack in micronutrients.8–11 This will remain a problem until the health authorities mandate the fortification of gluten-free foods by manufacturers.
The findings of this study are merely an observation of a small number of patients and should not be translated into a proposal or recommendation at this time. More study of a large number of patients is needed, especially in relation to serology and genetic testing. The time to abandon an intestinal biopsy in the diagnosis of celiac disease has not come yet. The concern is that this study may send the wrong message to primary care physicians and other health professionals, who may start children on a GFD based on a positive serological test alone without confirmation by biopsy. No child should be started on a GFD without confirmation of celiac disease with a small-intestinal biopsy.
REFERENCES
1. Barker CC, Mitton C, Jevon G, Mock T. Can tissue transglutaminase antibody titers replace small-bowel biopsy to diagnose celiac disease in select pediatric populations?
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2. Hoffenberg EJ, MacKenzie T, Barriga KJ, et al. A prospective study of the incidence of childhood celiac disease. J Pediatr. 2003;143 :308 –314[CrossRef][Web of Science][Medline]
3. Maki M, Mustalahati K, Kokkonen J, et al. Prevalence of celiac disease among children in Finland.
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4. Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2005;40 :1 –19[CrossRef][Web of Science][Medline]
5. National Institutes of Health consensus development conference statement on celiac disease, June 28–30, 2004. Gastroenterology. 2005;128(4 suppl 1) :S1 –S9[CrossRef]
6. Rashid M, Cranny AB, Zarkadas M, et al. Canadian Celiac Health Survey: pediatric data [abstract]. J Pediatr Gastroenterol Nutr. 2003;37 :369
7. Case S. The gluten-free diet: how to provide effective education and resources. Gastroenterology. 2005;128(4 suppl 1) :S128 –S134[CrossRef]
8. Mariani P, Viti MG, Montuori M, et al. The gluten-free diet: a nutritional risk factor for adolescents with celiac disease? J Pediatr Gastroenterol Nutr. 1998;27 :519 –523[CrossRef][Web of Science][Medline]
9. Thompson T. Thiamin, riboflavin, and niacin contents of the gluten-free diet: is there cause for concern? J Am Diet Assoc. 1999;99 :858 –862[Medline]
10. Thompson T. Folate, iron, and dietary fiber contents of the gluten-free diet. J Am Diet Assoc. 2000;100 :1389 –1396[CrossRef][Web of Science][Medline]
11. Thompson T, Dennis M, Higgins LA, Lee AR, Sharrett MK. Gluten-free diet survey: are Americans with celiac disease consuming recommended amounts of fibre, iron, calcium and grain foods? J Hum Nutr Diet. 2005;18 :163 –169[Medline]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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