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ESPGHAN 'biopsy-sparing' guidelines for celiac disease in children with low antitransglutaminase during COVID-19
Chiara Maria Trovato1, Monica Montuori, Salvatore Cucchiara
1Maternal and Child Health Department, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Italy.
Insights
A biopsy-free approach is feasible for diagnosing celiac disease in children with lower antitransglutaminase (TGA-IgA) antibody levels (5-10 ULN) if endomysial antibodies (EMAs) are positive. This strategy avoids endoscopy, facilitating diagnosis during the COVID-19 pandemic.
Area of Science:
- Pediatric Gastroenterology
- Immunology
- Diagnostic Medicine
Background:
- Recent celiac disease guidelines permit a biopsy-free diagnosis for children with high antitransglutaminase (TGA-IgA) antibody titers (>10 ULN) and positive endomysial antibodies (EMAs).
- Diagnosis in children with lower TGA-IgA titers (<10 ULN) traditionally requires esophagogastroduodenoscopy.
- The COVID-19 pandemic significantly reduced elective pediatric endoscopy, leading to delays in celiac disease diagnosis and treatment.
Purpose of the Study:
- To evaluate the feasibility and accuracy of a biopsy-free diagnostic approach for suspected celiac disease in children with TGA-IgA levels below 10 ULN.
- To facilitate the diagnosis of celiac disease by avoiding invasive endoscopic procedures.
Main Methods:
- Retrospective analysis of biopsy-confirmed celiac disease cases diagnosed between 2014 and 2019.
- Determination of the positive predictive value (PPV) of TGA-IgA titers between 5-10 ULN in conjunction with positive EMA.
- Confirmation of diagnosis by assessing mucosal atrophy and symptom resolution following a gluten-free diet (GFD).
Main Results:
- Out of 430 celiac disease patients, 84 met the criteria (TGA-IgA 5-10 ULN and positive EMA).
- The PPV of TGA-IgA (5-10 ULN) and positive EMA for diagnosing celiac disease was 0.93 (95% CI: 0.90-0.96).
- All children in this subgroup experienced symptom resolution and antibody normalization after adhering to a GFD.
Conclusions:
- A reduced TGA-IgA threshold for a biopsy-sparing approach is feasible in EMA-positive children with titers between 5-10 ULN.
- This strategy can aid in diagnosing celiac disease during public health crises like the COVID-19 pandemic.
- The findings support expanding non-invasive diagnostic criteria for pediatric celiac disease.
Objectives:
Recent guidelines for celiac disease have allowed a biopsy-free approach in endomysial antibodies (EMAs) positive children with high antitransglutaminase (TGA-IgA) titer [>10 time upper limit of normal (ULN)]. Esophagogastroduodenoscopy is still necessary for diagnosis in children with lower title. Because elective pediatric endoscopy has been substantially shouted down during coronavirus disease (COVID-19) pandemic, many children remained undiagnosed - and therefore untreated - for a long time. We aimed to analyze the feasibility and accuracy of a biopsy-free approach in suspected celiac disease children with TGA-IgA values <10 ULN to facilitate the diagnostic process by avoiding endoscopy.
Methods:
In this study cohort, we retrospectively analyzed all biopsy-confirmed diagnosis of celiac disease in our center (between 2014 and 2019). The positive predictive value (PPV) of TGA-IgA titers between 5 and 10 ULN and positive EMA in diagnosing celiac disease were determined. Mucosal atrophy and resolution of symptoms after gluten-free diet (GFD) were considered to confirm initial diagnosis.
Results:
Of 430 celiac disease patients (F: 274; mean age 7.54 years) diagnosed by endoscopy, 84 (F: 46; mean age 8 years) with TGA-IgA between 5 and 10 ULN and positive EMA were identified. The PPV of TGA-IgA between 5 and 10 ULN and positive EMA was 0.93 (95% confidence interval 0.90-0.96). All these children had a symptom resolution and antibodies normalization after GFD.
Conclusion:
During the COVID-19 outbreak, a temporarily reduction of the TGA-IgA threshold for biopsy-sparing approach seems feasible in EMA positive children with TGA-IgA between 5 and 10 ULN.
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