Published online September 30, 2005
PEDIATRICS Vol. 116 No. 4 October 2005, pp. 1055 (doi:10.1542/peds.2005-1710)

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Diagnosing Celiac Disease With a Positive Serological Test and Without an Intestinal Biopsy: In Reply

Collin C. Barker, MD
Department of Pediatrics

Thomas Mock, PhD
Department of Pathology and Laboratory Medicine
British Columbia Children's Hospital,
University of British Columbia,
Vancouver, British Columbia, Canada V6H 3V4

In Reply.—

We agree with Dr Rashid that it is too early to abandon the small-intestinal biopsy for diagnosing celiac disease accurately. We currently continue to biopsy all patients who potentially have celiac disease.

Our study¹ was a small retrospective study that found that most children with a very high tissue transglutaminase antibody titer (>100 units on the assays used) had a positive small-intestinal biopsy for celiac disease. These results need confirmation with larger prospective cohorts to determine if this observation can be replicated. It is recognized that results from preliminary clinical investigations do not always concur with results from subsequent, large, comparative trials. Therefore, we recommended in our discussion section that larger and more robust prospective studies be performed to validate this initial observation.

This study was written to focus light on a clinical observation that with improved screening tests and a suitably enriched population, as was seen in our study, the screening tests may be a possible replacement in the future. Our Table 5 demonstrated the poor positive predictive ability in lower prevalent populations such as the general population or primary care offices. This was meant to demonstrate that the screening tests have lower reliability in the general population and thus would be less able to make the diagnosis dependably outside of a specialist clinic. That is why we specifically included this table in our article.

In the future, newer or improved screening tests may be able to be used to make the diagnosis of celiac disease. However, we are not at that stage yet.

The current gold standard is the small-intestinal biopsy.² However, even with this, there is disagreement among experts in the field as to whether increased intraepithelial lymphocytes (one of the Marsh criteria) alone in the presence of appropriate genetic background, history, and physical examination is enough to warrant the diagnosis of either celiac disease or latent celiac disease. Latent celiac disease will require follow-up to determine if the patient develops full-blown celiac disease.³ We continue to follow-up patients that have a negative small-intestinal biopsy to observe their clinical course.

The point made that 2% would be labeled as having celiac disease when they do not is valid. However, the proposal would have the patient seen in follow-up to ensure that the patient has clinically improved on the gluten-free diet. Most patients have symptom resolution within a couple of months.⁴ If the patient has not improved, the outlined plan would be to then go to endoscopy, because the diagnosis would be in doubt. If the patient is clinically improved and the follow-up screening test normalizes, then the patient would be motivated to remain on the diet simply from a clinical standpoint.

We follow-up our patients with celiac disease more closely than the current North American guidelines recommend² because of our recognition of the difficulty in understanding and adhering to the diet. We use a dietitian with specific expertise in celiac disease for all newly diagnosed patients to maximize quality assurance. We recommend that all patients be seen by the gastroenterology service to ensure that they are seen and appropriately worked-up regardless of whether they are found to have celiac disease. They are also evaluated by the clinic dietitian at the time of the clinic visit.

A gluten-free diet can be challenging, especially for the diabetic population, because a major source of carbohydrates is removed from the diet. However, the assertion that the gluten-free diet is not healthful and balanced when the patient is managed by a dietitian with experience in dealing with patients with celiac disease, which would be the case in our proposal, would seem doubtful considering the specific instruction on nutrition, macronutrients, and micronutrients that these patients and their families receive through an appropriate subspecialty clinic. Our dietitian specifically reviews calcium, vitamin D, and iron along with general food groups at the time of diagnosis and at the 6-month follow-up to ensure that nutritional issues and growth are attended to as identified previously by Thompson.⁵

In conclusion, we recommend that all screened patients be evaluated by an appropriate specialist to ensure that these issues are not and will not become problematic. We thank Dr Rashid for enabling us to clarify any misconceptions that may have arisen from this article.

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? Pediatrics. 2005;115 :1341 –1346[Abstract/Free Full Text]
2. 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]
3. Piccoli A, Capelli P, Castagnin A, et al. Latent celiac disease in subjects with serum anti-endomysial antibodies and normal intestinal biopsy [in Italian]. Pediatr Med Chir. 2002;24 :358 –362[Medline]
4. Murray JA, Watson T, Clearman B, Mitros F. Effect of a gluten-free diet on gastrointestinal symptoms in celiac disease. Am J Clin Nutr. 2004;79 :669 –673[Abstract/Free Full Text]
5. 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]

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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Barker, C. C. Articles by Mock, T. Search for Related Content PubMed Articles by Barker, C. C. Articles by Mock, T. Related Collections Nutrition & Metabolism Social Bookmarking                         What's this?