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Application of the Biopsy-Sparing ESPGHAN Guidelines for Celiac Disease Diagnosis in Adults: A Real-Life Study

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Abstract

Background

Current adult celiac disease diagnosis requires histological confirmation. However, pediatric guidelines have proposed biopsy-sparing algorithms.

Aims

To explore the applicability of the ESPGHAN criteria and assess the accuracy of serology in predicting disease in adults.

Methods

We evaluated 234 consecutive adults showing elevated anti-tTG titers, EMA-positivity, and genetic susceptibility. Patients underwent upper endoscopy with duodenal biopsy. We determined optimal anti-tTG cutoff levels using ROC curves.

Results

Mean anti-tTG levels were 71.1 ± 66.5 U/ml; mean normalized levels were 14.8 ± 14.1 × ULN (mean ± SD). Partial/total villous atrophy was present in 36%/55% of cases, respectively. Anti-tTG levels correlated with histology (r s = 0.397, p < 0.001). AUC was similar before and after normalization (0.803 vs 0.807). Applying the ESPGHAN criterion (≥10 × ULN), we calculated a 97.66% PPV. ROC curve analysis showed an optimal cutoff of ≥16 × ULN, with a PPV of 98.86%. Eleven different assays were used for anti-tTG titer determination: Two were prevalent, labeled A (n = 141) and B (n = 59). They performed differently regarding disease prediction (AUC = 0.689 vs 0.925, p < 0.01), showing distinct optimal cutoff values (14.3 × ULN vs 3.7 × ULN), even after standardization (−0.14 vs −1.2).

Conclusion

In adult symptomatic patients showing EMA-positivity and genetic susceptibility, anti-tTG titers correlated with histology. ESPGHAN criteria performed similarly to previous studies. However, a calculated 16 × ULN cutoff showed an improved PPV. Among prevalent assays, PPV peaked differently both after normalization and standardization, indicating intrinsic differences in performance, thus preventing uniform prediction of disease in a real-life setting. Assay-specific optimal cutoffs seem possible, but would complicate diagnostic criteria. However, biopsy-sparing strategies in adults could prove useful in challenging patients.

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Abbreviations

CD:

Celiac disease

GFD:

Gluten-free diet

anti-tTG:

Anti-tissue transglutaminase antibodies

EMA:

Anti-endomysium antibodies

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Author information

Authors and Affiliations

  1. Department of Medicine and Ageing Sciences and Center for Excellence On Ageing and Translational Medicine (CeSI-MeT), “G. D’Annunzio” University and Foundation, Chieti, Italy

    Konstantinos Efthymakis, Mariaelena Serio, Angelo Milano, Francesco Laterza, Antonella Bonitatibus & Matteo Neri

  2. Department of Medical, Oral and Biotechnological Sciences, “G. D’Annunzio” University and Foundation, Chieti, Italy

    Marta Di Nicola

Authors
  1. Konstantinos Efthymakis
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  2. Mariaelena Serio
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  3. Angelo Milano
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  4. Francesco Laterza
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  5. Antonella Bonitatibus
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  6. Marta Di Nicola
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  7. Matteo Neri
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Contributions

This study was designed by KE and MN. Clinical evaluation of patients and data collection were performed by KE, MS, and MN. All endoscopic procedures were completed by KE, MS, AM, FL, and AB. Data handling and statistical analysis were performed by KE, MDN and MN. KE drafted the paper; it was revised by MN who acts as its guarantor. All authors approved the final version of this manuscript.

Corresponding author

Correspondence to Matteo Neri.

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The authors declare that they have no conflict of interest.

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Efthymakis, K., Serio, M., Milano, A. et al. Application of the Biopsy-Sparing ESPGHAN Guidelines for Celiac Disease Diagnosis in Adults: A Real-Life Study. Dig Dis Sci 62, 2433–2439 (2017). https://doi.org/10.1007/s10620-017-4672-1

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  • DOI: https://doi.org/10.1007/s10620-017-4672-1

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