Low prevalence of upper endoscopic gastrointestinal findings despite high frequency of alarm symptoms at the time of diagnosis in adult coeliac disease

Abstract

Objectives Exclusion of organic disorders involving the upper gastrointestinal (UGI) is a mandatory step before considering a biopsy-avoidance diagnostic strategy for adult coeliac disease. We aim to evaluate the prevalence of alarm symptoms and coincidental UGI endoscopic findings at the time of diagnosis of coeliac disease. To develop consensus criteria to identify patients with coeliac disease requiring a gastroscopy and to evaluate whether alarm symptoms prompting gastroscopy were predictive of endoscopic findings. Methods Presenting symptoms and UGI endoscopic findings at diagnosis of coeliac disease were collected retrospectively in 278 adult patients with coeliac disease diagnosed in Pavia between January 1999 and December 2017. A panel of experts developed criteria to evaluate which clinical scenarios warrant gastroscopy, which was then applied retrospectively to patients diagnosed in Pavia. Results At least one alarm symptom was present in 177/278 patients, 121/278 met our criteria for gastroscopy. Major UGI endoscopic findings included 3 cases of autoimmune atrophic gastritis, 19 oesophagitis and 20 Helicobacter pylori infections. No organic disorders were found. Prevalence of major endoscopic findings did not differ between patients who met our criteria and those who did not. Conclusions Despite the high prevalence of alarm symptoms at diagnosis, coincident major UGI endoscopic findings are rare in adult coeliac disease. These results may be relevant for future developments in coeliac disease diagnosis in adults.

Letter: the BSG COVID‐19 interim coeliac disease guidance no‐biopsy approach is safe in adults

“…However, a recent study from Italy reassuringly reported no such concerns. 3 One prospective and two retrospective studies from England evaluating the feasibility of an NBP in adults with tTG-IgA ≥10 × ULN, revealed no other co-existing organic pathologies, and definite histological correlation with coeliac disease was reported in >95% cases across all three studies. 2,4,5 Our study echoes the findings of two recently published English studies in which 33% and 17% patients, respectively, were not referred for gastroscopy following a positive coeliac serology.…”

“…However, a recent study from Italy reassuringly reported no such concerns. 3 One prospective and two retrospective studies from England evaluating the feasibility of an NBP in adults with tTG‐IgA ≥10 × ULN, revealed no other co‐existing organic pathologies, and definite histological correlation with coeliac disease was reported in >95% cases across all three studies. 2 , 4 , 5 …”

Letter: no‐biopsy pathway for diagnosing adult coeliac disease—authors' reply

“…5,6 It has also been feared that omitting the biopsy may result in missing a co-existing organic condition, but a recent study from Italy does not support this. 7 An unavoidable consequence of the no-biopsy strategy is a lack of reference histology if follow-up endoscopy is performed, but the necessity of invasive follow-up in noncomplicated coeliac disease could also be questioned. 8 We hope that our experiences and the study by Paul and colleagues will pave the way for similar international consensus on the no-biopsy approach in adult coeliac disease as that established by European paediatricians.…”

“…One major challenge is the lack of standardisation of serological tests, although there is evidence that high positive transglutaminase values of many different commercial tests can provide a reliable diagnosis when appropriately validated 5,6 . It has also been feared that omitting the biopsy may result in missing a co‐existing organic condition, but a recent study from Italy does not support this 7 . An unavoidable consequence of the no‐biopsy strategy is a lack of reference histology if follow‐up endoscopy is performed, but the necessity of invasive follow‐up in non‐complicated coeliac disease could also be questioned 8 .…”

Upper gastrointestinal endoscopic findings in celiac disease at diagnosis: A multicenter international retrospective study

“…This is of particular concern in patients with alarm symptoms such as weight loss, anemia, or abdominal pain[ 2 , 12 , 13 ]. However, relatively few studies have explored this in-depth, particularly in adult patients undergoing endoscopy to confirm CeD diagnosis[ 14 - 16 ].…”