From the Journals

Biopsy not required to diagnose most cases of pediatric celiac disease



In most cases, a biopsy is no longer required to diagnose celiac disease in children, according to new guidance from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). The authors recommend that the diagnosis be established with a two-stage blood test instead of an endoscopy, which children often find distressing.

The guidance was published in the Journal of Pediatric Gastroenterology and Nutrition. The document is an update of ESPGHAN’s 2012 guidance.

About half of children with suspected celiac disease undergo a biopsy to confirm the diagnosis. By reducing the number of biopsies, and the anesthesia required to perform them, the new guidelines could reduce European health care costs.

Steffen Husby, MD, of Odense (Denmark) University Hospital, and colleagues recommend testing for total IgA and anti-intestinal transglutaminase 2 (TGA-IgA) antibodies as initial screening in children with suspected celiac disease. An IgG-based test is indicated only when total IgA is low or undetectable, according to the authors. Physicians should refer children with positive results to a pediatric gastroenterologist. If the level of TGA-IgA is 10 or more times the upper limit of normal, and the family agrees, the physician may diagnose celiac disease without a biopsy, provided that endomysial antibodies test positive in a second blood sample, according to the guidance. For children with a positive TGA-IgA level of less than 10 times the upper limit of normal, however, at least four biopsies from the distal duodenum and at least one from the bulb are required to establish the diagnosis.

Physicians can diagnose celiac disease in children with no symptoms without the need for a biopsy using the same criteria as they use for symptomatic children, wrote Dr. Husby and colleagues. Clinicians, parents, and, when appropriate, children should participate in the decision about whether to perform a biopsy.

Celiac disease is the most prevalent food-related chronic disease in European children, but as much as 80% of children with celiac disease are undiagnosed. The prevalence of celiac disease is increasing, and undiagnosed children with this disease are at risk of nutritional and developmental problems, as well as long-term health complications. Although celiac disease is easy to detect and treat, 10-13 years may elapse between symptom onset and the time of diagnosis. The new guidelines are intended to facilitate diagnosis and increase its accuracy, thus enabling earlier diagnosis and improved detection, according to ESPGHAN.

“These new guidelines mean that more than half of all children being investigated for celiac disease will no longer need to have an invasive biopsy,” said Luisa Mearin Manrique, MD, PhD, professor of pediatrics at Leiden (the Netherlands) University and senior author of the guidelines, in a press release. “This is a big step forward in our mission to ensure that children can be diagnosed and effectively treated for celiac disease. It is scandalous that so many children go so long, often up to 10 years, without diagnosis. Removing the need for biopsy in order to achieve diagnosis will reduce the stresses associated with such an invasive procedure and mean that diagnoses are quicker and cheaper for health care systems.”

No conflicts of interest were reported.

SOURCE: Husby S et al. J Pediatr Gastroenterol Nutr. 2020;70(1):141-56.

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