Pediatric Celiac Disease Diagnosis And Management Practices Concern Experts
by David Wild, Gastroenterology & Endoscopy News.
More than one-third (34.7%) of clinicians, for example, said serology findings alone would be enough to make a diagnosis of the condition—a stance not supported by current guidelines from a major U.S. specialty group.
Lead investigator Anthony Porto, MD, MPH, assistant professor of pediatrics and associate clinical chief in the Section of Pediatric Gastroenterology at Yale University, in New Haven, Conn., noted the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) recommends that diagnoses be made using a combination of serology results and duodenal biopsies (J Pediatr Gastroenterol Nutr 2005;40:1-19).
Dr. Porto said he was particularly troubled that most physicians who said positive serology would suffice for a diagnosis also indicated that a level of tissue transglutaminase (tTG) immunoglobulin (Ig)A of at least 10 times the upper limit of normal would be enough for them to make a diagnosis.
“Even ESPGHAN [European Society for Pediatric Gastroenterology, Hepatology and Nutrition] guidelines, which leave the option open to a diagnosis based on serology alone, indicate that an elevated tTG-IgA of at least 10 times the upper limit of normal alone is insufficient for a diagnosis, and that a positive endomysial antibody test and the presence of genetic markers are needed as well,” Dr. Porto said.
Stefano Guandalini, MD, a co-author of the 2005 NASPGHAN guidelines and not involved in the study, echoed Dr. Porto’s concern with the finding that a substantial portion of surveyed physicians would diagnose celiac disease on tTG-IgA serology alone.
“Basing a diagnosis solely on tTG titers that are often not even high is highly dubious and blatantly wrong,” said Dr. Guandalini, professor and chief of pediatric gastroenterology at the University of Chicago, and founder and medical director of the University of Chicago Celiac Disease Center. He pointed to a finding from the survey indicating that some physicians would proceed with a diagnosis based only on tTG-IgA levels lower than 10 times the upper limit of normal.
Dr. Guandalini also cautioned that skipping a biopsy could leave comorbid conditions undetected. In a letter he and a colleague published in 2013, they reported that 12% of children with celiac disease who had been diagnosed using serology alone could have additional undetected diagnoses such as peptic esophagitis, Helicobacter pylori and eosinophilic esophagitis (J Pediatr Gastroenterol Nutr 2013;57:e24).
“If a patient has not undergone upper endoscopy as part of their diagnosis, they should be carefully monitored to ensure their symptoms resolve completely, and to rule out other diagnoses,” Dr. Guandalini told Gastroenterology & Endoscopy News.