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  • Scott Adams
    Scott Adams

    No Biopsy Needed to Accurately Diagnose Celiac Disease in Nearly All Adults

    Reviewed and edited by a celiac disease expert.

    In a potentially game-changing move, new research supports the elimination of biopsy in the diagnosis of most cases of adult celiac disease, in favor of the no-biopsy approach.

    No Biopsy Needed to Accurately Diagnose Celiac Disease in Nearly All Adults -

    Celiac.com 12/14/2020 - The science behind celiac disease diagnosis has been moving rapidly away from biopsy. First, biopsy screening was eliminated for celiac diagnosis in most children. Then, the European Society for the Study of Paediatric Gastroenterology, Hepatology and Nutrition guidelines suggested that celiac disease can be diagnosed without taking duodenal biopsies. The latest diagnostic guidelines suggest that a 10-fold increase in IgA antitissue transglutaminase (tTG) antibody levels, in combination with EMA positivity, supports a diagnosis of celiac disease, without the need for a duodenal biopsy. 

    However, this approach has not yet been widely adopted into clinical practice for diagnosing adults, mainly due to a limited international multi-center data, and testing in groups with low celiac disease rates. New research confirms that most adults do not require a biopsy for a reliable celiac disease diagnosis. A recent study by a team of researchers showed that a 10-fold increase in serum IgA antitissue transglutaminase (tTG) antibody levels has high predictive capacity and diagnostic reliability for detecting small intestinal injury diagnostic of celiac disease in adults.

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    The research team included Hugo A Penny, Suneil A Raju, Michelle S Lau, Lauren JS Marks, Elisabeth MR Baggus, Julio C Bai, Gabrio Bassotti, Hetty J Bontkes, Antonio Carroccio, Mihai Danciu, Mohammad H Derakhshan, Arzu Ensari, Azita Ganji, Peter H R Green, Matt W Johnson, Sauid Ishaq, Benjamin Lebwohl, Adam Levene, Roxana Maxim, Hamid Mohaghegh Shalmani, Mohammad Rostami-Nejad, David Rowlands, Irene A Spiridon, Amitabh Srivastava, Umberto Volta, Vincenzo Villanacci, Graeme Wild, Simon S Cross1, Kamran Rostami, and David S Sanders.

    Their study looked at three different groups of people: Group 1 featured 740 patients assessed in the specialist celiac disease clinic at a UK center; Group 2 featured 532 patients with low suspicion for celiac disease referred for upper GI endoscopy at a UK centre; while Group 3 included 145 patients with raised tTG levels from multiple international sites. 

    The team used Marsh 3 histology as a reference standard to determine the performance features of an IgA tTG titre of ≥10×ULN for a diagnosing celiac disease in adults.

    Across all three groups of adult patients, the data shows that nearly every person with IgA tTG levels of ≥10×ULN has small intestinal mucosal changes (Marsh 3 lesions) that are hallmarks of clinical celiac disease as diagnosed via the former "gold standard" of duodenal biopsy.

    The team's data reveal that IgA tTG levels of 10×ULN have 100% specificity at detecting Marsh 3 lesions in Group 2's 532 adults with low suspicion of celiac disease, for a disease rate of 3.2%. The team also found that an IgA tTG cut-off of 10×ULN was effective at spotting patients with Marsh 3 lesions using different tests at various international locations. 

    However, the team feels that establishing test-specific thresholds and/or standardized tTG tests used with this pathway could help to refine this method for widespread clinical use.

    The results of this study show that IgA tTG levels of ≥10×ULN strongly reflect intestinal changes consistent with adult celiac disease diagnosis. As such, the results support the elimination of biopsy in the diagnosis of most cases of adult celiac disease, in favor of the no-biopsy approach.

    Read more, including detailed data, at Gut.bmj.com

     

    The researchers are variously affiliated with the Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield, UK; the Medicine, Gastroenterology Hospital Dr C Bonorino Udaondo, Buenos Aires, Argentina; the Gastroenterology & Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia, Italy; the Department Clinical Chemistry, Amsterdam Gastroenterology and Metabolism and Infection and Immunity Institutes, Amsterdam UMC, Amsterdam, The Netherlands; the Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; the Pathology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania; the Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK; the Department of Pathology, Ankara University Medical School, Ankara, Turkey; the Department of Gastroenterology and Hepatology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; the Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA; Gastroenterology, Luton and Dunstable Hospital NHS Foundation Trust, Luton, UK; the Department of Gastroenterology, Dudley Group NHS Foundation Trust, Birmingham City University, Birmingham, UK; the Gastroenterology Department, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania; the Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran; the Department of Gastroenterology, Queen Elizabeth II Hospital, Hertfordshire, UK; the Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA; the Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; the Department of Pathology, Spedali Civili, Brescia, Italy; and with the Department of Gastroenterology, MidCentral District Health Board, Palmerston North, New Zealand. 

    Edited by Scott Adams



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    Posterboy

    Scott,

    Thanks for that article! Kudos to Celiac.com

    Dr. Hyman advocated this strategy nearly 10 years ago.

    https://www.huffpost.com/entry/gluten-what-you-dont-know_b_379089

    It has only taken another 10 years for research to confirm itself.

    I just hope it doesn't take another 10 years to make it down to the clinical level.

    I have always been glad my doctor knew enough to confirm my diagnosis without biopsy.

    I was lucky I was not the first Celiac patient he had.....so he was well trained by other Celiac's in his practice! by the time he diagnosed by Serology alone....

    Dr. Hyman said quoting

    "We can no longer say that. Positive is positive and, as with all illness, there is a continuum of disease, from mild gluten sensitivity to full-blown celiac disease. If your antibodies are elevated, you should go off gluten and test to see if it is leading to your health problems."

    And now researchers are again confirming themselves 10 years later!

    I hope this is end of Endoscopy....but it won't probably won't be!  But at least it is a good start!

    I hope this is helpful but it is not medical advise.

    Posterboy,

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    AnonyousCda

    Great potential. Its would create a strong possibility of testing children early. Hopefully free, we only need universal healthcare now.  A for profit healthcare severely limits care for celiacs. I could be wrong. How would my celiacs respond. 

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    Guest Doug

    This is good news for positive tests.  But what about false negative cases (like myself many years ago)... I was told then (thankfully) that a biopsy was needed to assess with certainty.  Seems this article should point this out? 

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    Scott Adams

    The article is just a summary of the published research. We typically don't inject other ideas or topics into our research summaries, but we do that when doing our own original articles that are not just summaries of research.

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    Posterboy
    7 hours ago, Guest Doug said:

    This is good news for positive tests.  But what about false negative cases (like myself many years ago)... I was told then (thankfully) that a biopsy was needed to assess with certainty.  Seems this article should point this out? 

    Doug,

    FWIW they now have better diagnostic tests than they did several years ago....

    It might be awhile for it reaches clinical practice but they can now tell the difference between Celiac disease and NCGS using newly developed diagnostic tests.

    It was discovered just this year...

    There is probably no reason for "a biopsy" proven diagnosis anymore today....

    But I don't expect this new research to be applied at the clinical level.....for another 10+ years....because we always do....what we always did!

    It takes "a generation" IE another generation to pickup the new ways of doing things.....even if it is more advanced!

    I have always felt lucky to have been diagnosed with blood tests alone!

    But if someone still feels they need a biopsy "proven" diagnosis.....those procedures are still widely available.

    I hope this is helpful but it is not medical advice.

    Posterboy,

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    M Susan

    My niece was diagnosed despite a negative biopsy because -

    1 - her blood test numbers were very high (I don't know which tests) and 

    2 - she has celiac on both sides of her family - her father and her maternal aunt (me)

    She just didn't have to go through 10+ years of damage to her villi before she was diagnosed.  She was given the blood test for celiac the first time she saw a doctor with her symptoms because of the strong family history. 

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    Guest Tammie

    This is great news my husband was diagnosed about ten yrs ago. Antibodies were off the charts but doc insisted he have a biopsy to confirm. He also wanted him to remain eating gluten until time of biopsy. Of course my husband stopped eating gluten immediately, not wanting to do any further damage. It took about 3 months before biopsy was done and at that time he was 3b on the marsh scale. If he would have continued to eat the gluten over this time period I'm sure more damage would have been done to his stomach. The sooner you find out the better. He was rapidly loosing weight and extremely low iron levels. I was watching him waste away so even one more day of gluten consumption was very serious in regards to his health. The sooner you know the better before your faced with stomach cancer or some other serious problem. Doctors really need to pay more attention to celiac we were on a 6 year journey before we found out what was wrong. I think about how much difference this would have made in his recovery if we had only know sooner. Even with a strict gluten and dairy and starch free diet and peptide injections and the help of a great natroupath my husband still has some issues. If not found early celiac can be a struggle health wise. I wish everyone were able to have antibody tests done before they are faced with this condition. Many people walking around today have no idea that this is happening to them because many doctors don't have a clue about the severity or how prevalent this is.  Thank you to all the people who are trying to make a difference.

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    Guest Vicki T

    Posted

    This has been my GI doctor's approach for some  time. My level were quite high and no biopsy was needed. So why is it that with every clinical trial I see recruiting participants,  they require biopsy confirmed diagnosis in order to be eligible?   I certainly hope that changes soon. I would like to participate in many of them,  but am always excluded.  

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    Guest Celiac 'Burgher

    Posted

    On 12/19/2020 at 11:47 PM, AnonyousCda said:

    Great potential. Its would create a strong possibility of testing children early. Hopefully free, we only need universal healthcare now.  A for profit healthcare severely limits care for celiacs. I could be wrong. How would my celiacs respond. 

    I think universal healthcare would severely delay diagnosis for most people.  Children or adults presenting with non-specific abdominal "discomfort" would be last in line to be seen by what would definitely become scarce doctors.  I, personally had only unexplained weight loss.  My PCP referred me to a gastroenterologist who scheduled an endoscopy and colonoscopy sight unseen and they were done within 5 days of the referral.  An inflamed polyp led to standard celiac blood testing and I was diagnosed within a 10 days of the initial PCP visit.   There is no way that occurs in a universal health care scenario. 

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    trents

    Burgher, you raise a good point. My observation is that our European forum participants, who live under universal health care, consistently testify of the difficulty and the wait times of getting appointments with specialists for endoscopies. And your experience with the polyp reminds us that an endoscopy may have more value than just a means of confirming celiac disease. It may catch other, and sometimes serious, health threats.

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    Somar Lane
    15 hours ago, trents said:

    Burgher, you raise a good point. My observation is that our European forum participants, who live under universal health care, consistently testify of the difficulty and the wait times of getting appointments with specialists for endoscopies. And your experience with the polyp reminds us that an endoscopy may have more value than just a means of confirming celiac disease. It may catch other, and sometimes serious, health threats.

    This was the point I wanted to chime in with, too.  A biopsy solely to confirm celiac disease may not be needed, but an autoimmune disease increases the risk of other health issues.

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    Guest ANTHONY COLATRELLA

    Posted

    On 12/19/2020 at 11:47 PM, AnonyousCda said:

    Great potential. Its would create a strong possibility of testing children early. Hopefully free, we only need universal healthcare now.  A for profit healthcare severely limits care for celiacs. I could be wrong. How would my celiacs respond. 

    First of all nothing is ever truly free and I am not sure that it is a for profit healthcare system that SEVERELY limits care for celiacs---the only treatment is a gluten free diet---where will you get free food!?

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  • About Me

    Scott Adams

    Scott Adams was diagnosed with celiac disease in 1994, and, due to the nearly total lack of information available at that time, was forced to become an expert on the disease in order to recover. In 1995 he launched the site that later became Celiac.com to help as many people as possible with celiac disease get diagnosed so they can begin to live happy, healthy gluten-free lives.  He is co-author of the book Cereal Killers, and founder and publisher of the (formerly paper) newsletter Journal of Gluten Sensitivity. In 1998 he founded The Gluten-Free Mall which he sold in 2014. Celiac.com does not sell any products, and is 100% advertiser supported.


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