Çölyak hastalığında serolojik, endoskopik ve histopatolojik bulguların karşılaştırılması; tanı için öneriler

Öz

Giriş ve Amaç: Dünya genelinde %1 prevalans ile görülen bir antite olan çölyak hastalığı, farklı yaşlarda ve farklı klinikler ile prezente olabilen bir hastalıktır. Tanı için klinik, serolojik ve histolojik özelliklerin korelasyonu önem arz eder. Bu çalışmanın amacı; çölyak hastalığı düşünülen olguların, serolojik, endoskopik ve histopatolojik bulgularını karşılaştırarak tanıya katkılarını belirlerken aynı zamanda tanı karmaşasına neden olabilecek parametreleri de vurgulamaktır. Gereç ve Yöntem: 01.01.2015 ve 31.12.2019 tarihleri arasında iki farklı üniversite hastanesinde çölyak hastalığı ön tanısı ile endoskopi yapılarak biyopsileri alınmış çocukluk çağında ve erişkin, toplam 204 hasta çalışmaya dahil edilmiştir. Bu hastaların klinik, serolojik, endoskopik ve histopatolojik bulguları retrospektif olarak karşılaştırılarak aralarındaki ilişki değerlendirilmiştir. Bulgular: Olguların 130’u (%63.7) 18 yaşın altında iken 74’ü (%36.3) 18 yaş ve üzeriydi. Çocukluk çağı dönemine ait ortalama yaş 8.6 iken (standart sapma 4.3), erişkinde ortalama yaş 43.5 (standart sapma 15.0) idi. Hastaların hastaneye en sık başvuru nedeni karın ağrısı iken (n=60, %29.4), en sık görülen endoskopik bulgu “tarak sırtı görünümü” idi. Histopatolojik değerlendirme sonucu Marsh 2 ve üzeri şeklinde skorlanan 163 olgu (%79.9) çölyak hastalığını desteklemekte iken, Marsh 1 şeklinde skorlanan 41 olgu (%20.1) ise çölyak hastalığı yanı sıra ayırıcı tanıya birçok hastalığın girebileceği bir grubu temsil etmekteydi. Olguların büyük çoğunluğu serolojik olarak pozitif iken (n=125, %82.8), 26 olguda (%17.2) ise seroloji negatifti. Sonuç: Çalışmamızda elde ettiğimiz tüm verilerin birbirleri ile ilişkisi değerlendirilmiş ve patoloji raporlarında Marsh 2 ve Marsh 3 şeklinde skorlanan hastaların endoskopik bulgularının olma olasılığının Marsh 1 şeklinde skorlanan hastalara göre anlamlı oranda fazla olduğunu gördük. Tanıda altın standart olduğunu düşündüğümüz histopatolojik değerlendirme sonucunda Marsh 1 şeklinde skorlanan olgularda görülen bulguların nonspesifik bulgular olduğunun vurgulanmasının klinisyene daha doğru bir mesaj vereceğini düşünmekteyiz.

Anahtar Kelimeler

• Çölyak hastalığı
• seroloji
• endoskopi
• histopatoloji
• Marsh

Comparison of serological, endoscopic, and histopathological findings in celiac disease: Recommendations for diagnosis

Öz

Background and Aims: Celiac disease, an entity with a prevalence of 1% worldwide, is an immune disease that can be identified at various ages and in different clinics. The correlation of serological, endoscopic, and histological characteristics is critical for diagnosis. The purpose of this study is to compare the serological, endoscopic, and histopathological findings in order to determine their contribution to the diagnosis and to emphasize the parameters that may cause diagnostic uncertainty. Materials and Methods: Between January 1, 2015, and December 31, 2019, a total of 204 pediatric and adult patients, who have undergone endoscopy with a pre-diagnosis of celiac disease, were included in the study. Retrospectively, the serological, endoscopic, and histopathological findings of these patients were compared, and their relationship was evaluated. Results: While 130 (63.7%) of the cases were under 18 years of age, 74 (36.3%) of them were over 18 years of age. While the mean childhood age was 8.6 (standard deviation 4.3), the mean adult age was 43.5 (standard deviation 15.0). While the most common cause for hospital admission was abdominal pain (n=60, 29.4%), the most common endoscopic finding was “comb tooth appearance.” While 163 (79.9%) cases scored as Marsh 2 and above as a result of histopathological evaluation supported celiac disease, 41 (20.1%) cases scored as Marsh 1 represented a group in which many diseases could be included in the differential diagnosis in addition to celiac disease. While the majority of the cases were serologically positive (n=125, 82.8%), serology was negative in 26 (17.2%) cases. Conclusion: The relationship between all the data we collected in our study was analyzed, and we found that the probability of endoscopic findings in patients rated as Marsh 2 and Marsh 3 in the pathology reports was significantly higher than in patients rated as Marsh 1. We agree that emphasizing the findings in cases scored as Marsh 1 as a result of the histopathological assessment, which we believe to be the gold standard of diagnosis, as nonspecific, will give a more accurate message to the clinician.

Anahtar Kelimeler

• Celiac disease
• serology
• endoscopy
• histopathology
• Marsh

Kaynakça

1. 1. Green PH, Cellier C. Celiac disease. N Engl J Med 2007;357:1731-43.
2. 2. Belei O, Dobrescu A, Heredea R, et al. Histologic recovery among children with celiac disease on a gluten-free diet. A long-term follow up single center experience. Arch Med Sci 2018;14:94-100.
3. 3. Tuncel F, Bozkurt F, Gulseren A, Usta Y. The incidence of and relationship between celiac disease and Helicobacter pylori gastritis in childhood. Endoskopi 2019;27:16-9.
4. 4. Semwal P, Gupta RJ, Sharma R, Garg K. Comparision of endoscopic and histological findings between typical and atypical celiac disease in children. Pediatr Gastroenterol Hepatol Nutr 2018;21:86-92.
5. 5. Smyk DS, Koutsoumpas AL, Mytilinaiou MG, et al. Helicobacter pylori and autoimmune disease: cause or by stander. World J Gastroenterol 2014;20:613-29.
6. 6. Kalhan S, Joseph P, Sharma S, et al. Comparative study of histopathological Marsh grading with clinical and serological parameters in celiac iceberg of North India. Indian J Pathol Microbiol 2011;54:279-83.
7. 7. Oberhuber G, Granditssch G, Vogelsang H. The histopathology of coeliac disease: time for a standardized report scheme for pathologists. Eur J Gastroenterol Hepatol 1999;11:1185-94.
8. 8. Rosa RM, Ferrari Mde L, Pedrosa MS, et al. Correlation of endoscopic and histological features in adults with suspected celiac disease in a referral center of Minas Gerais, Brazil. Arq Gastroenterol 2014;51:290-6.

9. 9. Poddar U. Pediatric and adult celiac disease: similarities and differences. Indian J Gastroenterol 2013;32:283-8.
10. 10. Yönal O, Özdil S. Çölyak hastalığı. Güncel Gastroenteroloji 2014;18:93-100.
11. 11. Akman S, Sahaloğlu O, Dalkan C, Bahçeciler NN, Arıkan C. Is celiac disease misdiagnosed in children with functional constipation? Turk J Gastroenterol 2018;29:210-4.
12. 12. Riznik P, Márta B, Bódi P, et al. The use of biopsy and “No-biopsy” approach for diagnosing paediatric coeliac disease in the Central European Region. Gastroenterol Res Pract 2019;11:1-6.
13. 13. Werkstetter KJ, Korponay-Szabó IR, Popp A, et al. Accuracy in diagnosis of celiac disease without biopsies in clinical practice. Gastroenterology 2017;153:924-35.
14. 14. Herrod PJJ, Lund JN. Random duodenal biopsy to exclude coeliac disease as a cause of anaemia is not cost‑efective and should be replaced with universally performed pre‑endoscopy serology in patients on a suspected cancer pathway. Tech Coloproctol 2018;22:121-4.
15. 15. Roca M, Donat E, Marco-Maestud N, et al. Efficacy study of anti-endomysium antibodies for celiac disease diagnosis: A retrospective study in a Spanish Pediatric Population. J Clin Med 2019;8:2179.
16. 16. Rajani S, Huynh HQ, Shirton L, et al. A Canadian study toward changing local practice in the diagnosis of pediatric celiac disease. Can J Gastroenterol Hepatol. 2016;2016:6234160.
17. 17. Alper A, Hardee S, Rojas-velasquez D, et al. Prevalence, clinical, endoscopic and pathological features of duodenitis in children. J Pediatr Gastroenterol Nutr 2014;62:314-6.
18. 18. Marsh MN. Gluten, major histocompatibility complex, and the small intestine A molecular and immunobiologic approach to the spectrum of gluten sensitivity ('celiac sprue') Gastroenterology 1992;102:330-54.
19. 19. Corazza GR, Villanacci V. Coeliac disease. J Clin Pathol 2005;58:573-4.
20. 20. Ensari A. Gluten-sensitive enteropathy (celiac disease): controversies in diagnosis and classification. Arch Pathol Lab Med 2010;134:826-36.
21. 21. McCarty TR, O’Brien CR, Gremida A, Ling C, Rustag T. Efficacy of duodenal bulb biopsy for diagnosis of celiac disease: a systematic review and meta-analysis. Endosc Int Open 2018;06:E1369-E1378.
22. 22. Silvester JA, Faucher EA, McCarty CE, et al. Red spot lesions in the duodenal bulb are a highly specific endoscopic sign of celiac disease: A prospective study. Pediatr Gastroenterol Nutr 2019;68:251-5.
23. 23. Aldaghi MA, Deghani SM, Haghiat M. Evaluation of the correlation between tTG-IgA titer and duodenal biopsy findings in children with suspected celiac disease. Iran J Pediatr 2016;26:e3615.
24. 24. Chan J, Mack DR, Manuel DG, et al. Validation of an algorithm to identify children with biopsy-proven celiac disease from within health administrative data: An assessment of health services utilization patterns in Ontario, Canada. PLoS One 2017;12:e0180338.