Adherence to guidelines, pitfalls, and emerging technologies in endoscopic practice for celiac disease: a nationwide...

Upper gastrointestinal endoscopy (UGIE) with duodenal biopsies remains the gold standard for diagnosing celiac disease (CD) in children and adolescents. Despite clear guidelines, clinical practices may vary across centers. This self-reported survey study assessed adherence to European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines for pediatric CD in endoscopic practice, focusing on pitfalls and the use of novel technologies. A web-based, multicenter survey was distributed to pediatric gastroenterology centers that are members of the Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (SIGENP). Thirty-eight responses from 34 SIGENP centers were analyzed. Overall, 31/34 (91%) respondents reported taking ≥ 5 duodenal biopsies for suspected CD, all including samples from both the duodenal bulb and distal duodenum. However, 9/31 (29%) endoscopists reported not correctly orienting the biopsy specimens. Among patients with persistently elevated anti-transglutaminase IgA (TGA-IgA) despite adherence to a gluten-free diet (GFD), 16 of 33 respondents (48%) performed a second UGIE at a time point other than the recommended 2 years after GFD initiation. Only 8/36 (22%) reported using novel endoscopic technologies, and 10/37 (27%) occasionally employed wireless capsule endoscopy. Artificial intelligence had not yet been incorporated into clinical practice.

This study demonstrates overall compliance with ESPGHAN guidelines, although gaps persist in biopsy orientation and follow-up timing for patients with persistent TGA-IgA positivity. The use of novel endoscopic technologies is still limited, indicating the need for further studies and dedicated training programs to support their implementation in clinical practice.

• Diagnostic pitfalls in celiac disease remain a major challenge in endoscopy practice. • New endoscopic tools proved to be useful to decrease the number of misdiagnoses and related healthcare costs of celiac disease.

• Major gaps remain regarding proper orientation of biopsies, and the timing of follow-up endoscopy in patients with persistent TGA-IgA positivity. • Further studies and dedicated training programs are required to facilitate the effective integration of advanced endoscopic technologies into the diagnostic workflow.