Is the Diagnosis of Celiac Disease Possible Without Intestinal Biopsy?

Abstract

Background: Coeliac disease is defined as a state of immune-mediated hyper-responsiveness to dietary gluten from wheat, barley, or rye in genetically predisposed individuals that results in tissue damage. The diagnosis is made by microscopic examination of a small intestinal biopsy, although serological testing for antibodies against tissue transglutaminase and deamidated gliadin peptide can be of great advantage. It has been suggested that duodenal biopsy can be avoided in patients with high levels of the tissue transglutaminase antibody, since a relationship has been found to be present between tissue transglutaminase antibody titres and coeliac disease. Aims: To study the correlation between tissue transglutaminase titre and small intestinal biopsy findings in patients with coeliac disease. Study Design: Diagnostic accuracy study. Methods: Ninety-five cases of patients diagnosed with coeliac disease and with positive serum tissue transglutaminase titres were retrieved from the Jordan University Hospital archives between December 2014 and December 2015. All the cases were classified according to the Marsh classification. Results: Ninety-five cases with a positive titre for the antibody were included in this study, 73 (76.8%) of them were females and 22 cases (23.2%) were males. The age of the patients ranged between 4 and 75 years with a mean age ± standard deviation of 32.3±14.7. The sensitivity was the highest in Marsh IIIC and lowest in Marsh IIIA (95% versus 68% respectively). The specificity was moderate (76%) for all subtypes of Marsh III. Conclusion: This study showed a positive correlation between the tissue transglutaminase titre and the degree of duodenal damage (Marsh IIIC) in patients with coeliac disease. In the presence of high tissue transglutaminase levels, duodenal biopsy might not be always necessary for diagnosis, particularly in symptomatic patients.

Keywords

• Coeliac disease, intestinal biopsy, tissue transglutaminase

Kaynakça

1. 1. Evans KE, Aziz I, Cross SS, Sahota GR, Hopper AD, Hadjivassiliou M, et al. A prospective study of duodenal bulb biopsy in newly diagnosed and established adult celiac disease. Am J Gastroenterol 2011;106:1837-42.
2. 2. Walker MM, Murray JA, Ronkainen J, Aro P, Storskrubb T, D'Amato M, et al. Detection of celiac disease and lymphocytic enteropathy by parallel serology and histopathology in a population-based study. Gastroenterology 2010;139:112-9.
3. 3. Marsh MN. Gluten, major histocompatibility complex, and the small intestine. A molecular and immunobiologic approach to the spectrum of gluten sensitivity (’celiacsprue’). Gastroenterology 1992;102:330-54. 4. Marsh MN, Loft DE. Coeliac sprue: a centennial overview 1888-1988. Dig Dis 1988;6:216-28.
4. 5. Hovell CJ, Collett JA, Vautier G, Cheng AJ, Sutanto E, Mallon DF, et al. High prevalence of coeliac disease in a population-based study from Western Australia: a case for screening? Med J Aust 2001;175:247-50.
5. 6. Alessio MG, Tonutti E, Brusca I, Radice A, Licini L, Sonzogni A, et al. Correlation between IgA tissue transgluta-minase antibody ratio and histological finding in celiac disease. J Pediatr Gastroenterol Nutr 2012;55:44-9.
6. 7. Donaldson MR, Firth SD, Wimpee H, Leiferman KM, Zone JJ, Horsley W, et al. Correlation of duodenal histology with tissue transglutaminase and endomysial antibody levels in pediatric celiac disease. Clin Gastroenterol Hepatol 2007;5:567-73.
7. 8. Donaldson MR, Book LS, Leiferman KM, Zone JJ, Neuhausen SL. Strongly positive tissue transglutaminase antibodies are associated with Marsh 3 histopathology in adult and pediatric celiac disease. J Clin Gastroenterol 2008;42:256-60.
8. 9. Dieterich W, Ehnis T, Bauer M, Donner P, Volta U, Riecken EO, et al. Identification of tissue transglutaminase as the autoantigen of celiac disease. Nat Med 1997;3:797-801.

9. 10. Zanini B, Magni A, Caselani F, Lanzarotto F, Carabellese N, Villanacci V, et al. High tissue-transglutaminase antibody level predicts small intestinal villous atrophy in adult patients at high risk of celiac disease. Dig Liver Dis 2012;44:280-5.
10. 11. Vivas S, Ruiz de Morales JG, Riestra S, Arias L, Fuentes D, Alvarez N, et al. Duodenal biopsy may be avoided when high transglutaminase antibody titers are present. World J Gastroenterol 2009;15:4775-80.
11. 12. Mubarak A, Wolters VM, Gmelig-Meyling FH, Ten Kate FJ, Houwen RH. Tissue transglutaminase levels above 100 U/mL and celiac disease: a prospective study. World J Gastroenterol 2012;18:4399-403.
12. 13. Rostom A, Dubé C, Cranney A, Saloojee N, Sy R, Garritty C, et al. The diagnostic accuracy of serologic tests for celiac disease: a systematic review. Gastroenterology 2005;128(Suppl 1):38-46.
13. 14. Parizade M, Bujanover Y, Weiss B, Nachmias V, Shainberg B. Performance of serology assays for diagnosing celiac disease in a clinical setting. Clin Vaccine Immunol 2009;16:1576-82.
14. 15. Sugai E, Moreno ML, Hwang HJ, Cabanne A, Crivelli A, Nachman F, et al. Celiac disease serology in patients with different pretest probabilities: is biopsy avoidable? World J Gastroenterol 2010;16:3144-52.
15. 16. Mubarak A, Wolters VM, Gerritsen SA, Gmelig-Meyling FH, Ten Kate FJ, Houwen RH. A biopsy is not always necessary to diagnose celiac disease. J Pediatr Gastroenterol Nutr 2011;52:554-7.
16. 17. Hill PG, Holmes GK. Coeliac disease: a biopsy is not always necessary for diagnosis. Aliment Pharmacol Ther 2008;27:572-7.
17. 18. Hill ID. What are the sensitivity and specificity of serologic tests for celiac disease? Do sensitivity and specificity vary in different populations? Gastroenterology 2005;128(4 Suppl 1):S25-32.
18. 19. Van Meensel B, Hiele M, Hoffman I, Vermeire S, Rutgeerts P, Geboes K, et al. Diagnostic accuracy of ten second-generation (human) tissue transglutaminase antibody assays in celiac disease. Clin Chem 2004;50:2125-35.
19. 20. Reeves GE, Squance ML, Duggan AE, Murugasu RR, Wilson RJ, Wong RC, et al. Diagnostic accuracy of coeliac serological tests: a prospective study. Eur J Gastroenterol Hepatol 2006;18:493-501.
20. 21. Pinkas DM, Strop P, Brunger AT, Khosla C. Transglutaminase 2 undergoes a large conformational change upon activation. PLoS Biol 2007;5:e327.
21. 22. Lindfors K, Koskinen O, Kurppa K, Laurila K, Collin P, Haimila K, et al. Serodiagnostic assays for celiac disease based on the open or closed conformation of the autoantigen, transglutaminase 2. J Clin Immunol 2011;31:436-42.