Intestinal biopsy is not always required to diagnose celiac disease: a retrospective analysis of combined antibody tests

There is no single test — not even jejunal biopsy — that can conclusively diagnose or exclude CD in every individual. Therefore, we propose the following two-step diagnostic procedure: The first step is the combined,simultaneous determination of IgA anti-dpgli and IgGanti-dpgli + IgA anti-tTG and/or EMA. The vast majority of patients will have either three positive or three negative results, obviating the need for a biopsy. The second step, jejunal biopsy, should be performed only in patients with discordant antibody results (i.e., in patients whose CD status cannot be classified by antibody tests alone). In any case, effects of a gluten-free diet must be controlled.
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Publikation: Two-step approach

The authors reference as the basis for their summary the different evidence based guidelines that have been developed over recent years, and a literature search, whose search strategy included,among others, all publications from the past 10 years identified by using the search terms “celiac disease” and “diagnosis”


S Razeghi focuses on the importance of symptoms in the ESPEGHAN recommendation for the rare case in which a duo-denal biopsy is not needed (in a child or adolescent with at least tenfold raised anti-TG2-IgA and EMA confirmation, positivity for HLA-DQ2 or DQ8). If this is applied in any symptom that raises suspicions of celiac disease (for example, abdominal pain), the expected result will be diagnostic overkill. The ESPAGHAN guidelines refer, among others, to the Dahlborn study (reference 27 in our article) (1), in which a highly significant or a significant difference in the TG2-IgA titers existed between children with severe malabsorption and mild symptoms.
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Publikation Zöliakie

Intestinal biopsy is not always required to diagnose celiac disease: a retrospective analysis of combined antibody tests.


Background: The objective of this study was to compare celiac disease (CD)– specific antibody tests to determineif they could replace jejunal biopsy in patients with a high pretest probability of CD.Methods: This retrospective study included sera from 149 CD patients and 119 controls, all with intestinal biopsy.All samples were analyzed for IgA and IgG antibodies against native gliadin (ngli) and deamidated gliadin peptides(dpgli), as well as for IgA antibodies against tissue transglutaminase and endomysium.Results: Tests for dpgli were superior to ngli for IgG antibody determination: 68% vs. 92% specificity and 79% vs.85% sensitivity for ngli and dpgli, respectively. Positive (76% vs. 93%) and negative (72% vs. 83%) predictive valueswere also higher for dpgli than for ngli. Regarding IgA gliadin antibody determination, sensitivity improved from61% to 78% with dpgli, while specificity and positive predictive value remained at 97% (P < 0.00001). Acombination of four tests (IgA anti-dpgli, IgG anti-dpgli, IgA anti- tissue transglutaminase, and IgAanti-endomysium) yielded positive and negative predictive values of 99% and 100%, respectively and a likelihoodratio positive of 86 with a likelihood ratio negative of 0.00. Omitting the endomysium antibody determination stillyielded positive and negative predictive values of 99% and 98%, respectively and a likelihood ratio positive of 87with a likelihood ratio negative of 0.01.Conclusion: Antibody tests for dpgli yielded superior results compared with ngli. A combination of three or fourantibody tests including IgA anti-tissue transglutaminase and/or IgA anti- endomysium permitted diagnosis orexclusion of CD without intestinal biopsy in a high proportion of patients (78%). Jejunal biopsy would be necessaryin patients with discordant antibody results (22%). With this two-step procedure, only patients with no CD-specificantibodies would be missed.
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