Downloaded from gut.bmj.com on October 18, 2014 - Published by group.bmj.com
Gut Online First, published on October 9, 2014 as 10.1136/gutjnl-2014-308420 PostScript
LETTER
British Society of Gastroenterology guidelines on the diagnosis and management of coeliac disease The British Society of Gastroenterology (BSG) guidelines1 on diagnosis and management of coeliac disease (CD) contain much useful information, but in our opinion are badly misleading on the important topic of diagnosis and the relative merits of small intestinal biopsy and serology tests. The authors recommend that a duodenal biopsy is essential for diagnosis in all patients and cannot be replaced by serology alone even in a subset of patients. Other studies have now confirmed earlier work showing that using an appropriate cut-off for IgA-class anti-tissue transglutaminase antibody (IgA-tTG), the diagnosis can be made with a positive predictive value (PPV) of 100% in a high proportion of adults with CD2 or that with a combination of serological tests biopsy can be avoided in 78% of patients with CD.3 Although generally safe, endoscopy is invasive, expensive, unpleasant, often requires sedation and is time consuming for patient and endoscopist. With the advent of reliable serological tests, it is surely time to move on and acknowledge the limitations of biopsies. Criteria for the selection of IgA-tTG kits have previously been proposed,4 but these guidelines missed the opportunity to discuss variability in sensitivity and specificity of current diagnostic kits and to recommend only those having good analytical and diagnostic performance. The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition
(ESPGHAN) guidelines5 acknowledge both the failings of biopsy and the advantages of serology and do not insist on biopsy in every case. They proposed a ’triple test’ of IgA-tTG (>10 times the upper limit of normal) plus the presence of endomysial antibodies and HLA DQ2/DQ8 to establish the diagnosis. A retrospective review6 confirmed that this strategy gave a PPV of 100% and that biopsy could have been avoided in many children. It is regrettable and regressive that the new BSG guidelines are at variance with those advanced by the paediatricians; the diagnosis of CD in children and adults is based now on different criteria. General practitioners and gastroenterologists in the UK, when confronted by a patient with strongly positive serological tests for CD obtained using a reliable kit, are increasingly asking “What else could the diagnosis be?” and “Is obtaining a biopsy by an invasive technique justified?” What should practitioners advise patients with strongly positive serological tests who question whether an invasive test is really necessary? In Derby where the profile of CD is high, over 50% of patients are diagnosed without recourse to biopsy and probably other areas are experiencing the same trend. We are not suggesting that a biopsy can be replaced by a serological diagnosis in all cases; however, it is clear that current practice is moving from the morphological to the serological diagnosis of CD.7 As useful as these guidelines will be, with respect to diagnosis we believe that they fall short and in this aspect are likely to be widely ignored.
3
Department of Clinical Biochemistry, Royal Derby Hospital, Derby, Derbyshire, UK 4 Emeritus Consultant Gastroenterologist, Royal Derby Hospital, Derby, UK Correspondence to Dr Andrew Austin, Derby Digestive Diseases Centre, Royal Derby Hospital, Derby, UK; [email protected] Contributors All authors contributed to the content of this letter. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. To cite Hill P, Austin A, Forsyth J, et al. Gut Published Online First: [ please include Day Month Year] doi:10.1136/gutjnl-2014-308420 Received 11 September 2014 Accepted 19 September 2014 Gut 2014;0:1. doi:10.1136/gutjnl-2014-308420
REFERENCES 1
2
3
4
5
6
Peter Hill,1 Andrew Austin,2 Julia Forsyth,3 Geoffrey Holmes4 1
Emeritus Consultant Clinical Biochemist, Royal Derby Hospital, Derby, Derbyshire, UK 2 Derby Digestive Diseases Centre, Royal Derby Hospital, Derby, UK
7
Ludvigsson JF, Bai JC, Biagi F, et al. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014;63:1210–28. Zanini B, Magni A, Caselani F, 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. Burgin-Wolff A, Mauro B, Faruk H. Intestinal biopsy is not always required to diagnose celiac disease: a retrospective analysis of combined antibody tests. BMC Gastroenterol 2013;13:19–24. Hill PG, McMillan SA. Anti-tissue transglutaminase antibodies and their role in the investigation of coeliac disease. Ann Clin Biochem 2006;43:105–17. Husby S, Koletzko S, Korponay-Szabo IR, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr 2012;54:136–60. Klapp G, Masip E, Bolonio M, et al. Celiac disease: the new proposed ESPGHAN diagnostic criteria do work well in a selected population. J Pediatr Gastroenterol Nutr 2013;56:251–6. Austin A, Seddon H. Southern Derbyshire Shared Care Pathology Guidelines: Coeliac Disease. http://www. derbyhospitals.nhs.uk/easysiteweb/getresource.axd? assetid=153366&type=0&servicetype=1 (accessed Sept 2014).
Gut Month 2014 Vol by 0 NoBMJ 0 1 Copyright Article author (or their employer) 2014. Produced Publishing Group Ltd (& BSG) under licence.
Downloaded from gut.bmj.com on October 18, 2014 - Published by group.bmj.com
British Society of Gastroenterology guidelines on the diagnosis and management of coeliac disease Peter Hill, Andrew Austin, Julia Forsyth, et al. Gut published online October 9, 2014
doi: 10.1136/gutjnl-2014-308420
Updated information and services can be found at: http://gut.bmj.com/content/early/2014/10/09/gutjnl-2014-308420.full.html
These include:
References
This article cites 6 articles, 2 of which can be accessed free at: http://gut.bmj.com/content/early/2014/10/09/gutjnl-2014-308420.full.html#ref-list-1
P
Gut Online First, published on October 9, 2014 as 10.1136/gutjnl-2014-308420 PostScript
LETTER
British Society of Gastroenterology guidelines on the diagnosis and management of coeliac disease The British Society of Gastroenterology (BSG) guidelines1 on diagnosis and management of coeliac disease (CD) contain much useful information, but in our opinion are badly misleading on the important topic of diagnosis and the relative merits of small intestinal biopsy and serology tests. The authors recommend that a duodenal biopsy is essential for diagnosis in all patients and cannot be replaced by serology alone even in a subset of patients. Other studies have now confirmed earlier work showing that using an appropriate cut-off for IgA-class anti-tissue transglutaminase antibody (IgA-tTG), the diagnosis can be made with a positive predictive value (PPV) of 100% in a high proportion of adults with CD2 or that with a combination of serological tests biopsy can be avoided in 78% of patients with CD.3 Although generally safe, endoscopy is invasive, expensive, unpleasant, often requires sedation and is time consuming for patient and endoscopist. With the advent of reliable serological tests, it is surely time to move on and acknowledge the limitations of biopsies. Criteria for the selection of IgA-tTG kits have previously been proposed,4 but these guidelines missed the opportunity to discuss variability in sensitivity and specificity of current diagnostic kits and to recommend only those having good analytical and diagnostic performance. The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition
(ESPGHAN) guidelines5 acknowledge both the failings of biopsy and the advantages of serology and do not insist on biopsy in every case. They proposed a ’triple test’ of IgA-tTG (>10 times the upper limit of normal) plus the presence of endomysial antibodies and HLA DQ2/DQ8 to establish the diagnosis. A retrospective review6 confirmed that this strategy gave a PPV of 100% and that biopsy could have been avoided in many children. It is regrettable and regressive that the new BSG guidelines are at variance with those advanced by the paediatricians; the diagnosis of CD in children and adults is based now on different criteria. General practitioners and gastroenterologists in the UK, when confronted by a patient with strongly positive serological tests for CD obtained using a reliable kit, are increasingly asking “What else could the diagnosis be?” and “Is obtaining a biopsy by an invasive technique justified?” What should practitioners advise patients with strongly positive serological tests who question whether an invasive test is really necessary? In Derby where the profile of CD is high, over 50% of patients are diagnosed without recourse to biopsy and probably other areas are experiencing the same trend. We are not suggesting that a biopsy can be replaced by a serological diagnosis in all cases; however, it is clear that current practice is moving from the morphological to the serological diagnosis of CD.7 As useful as these guidelines will be, with respect to diagnosis we believe that they fall short and in this aspect are likely to be widely ignored.
3
Department of Clinical Biochemistry, Royal Derby Hospital, Derby, Derbyshire, UK 4 Emeritus Consultant Gastroenterologist, Royal Derby Hospital, Derby, UK Correspondence to Dr Andrew Austin, Derby Digestive Diseases Centre, Royal Derby Hospital, Derby, UK; [email protected] Contributors All authors contributed to the content of this letter. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed. To cite Hill P, Austin A, Forsyth J, et al. Gut Published Online First: [ please include Day Month Year] doi:10.1136/gutjnl-2014-308420 Received 11 September 2014 Accepted 19 September 2014 Gut 2014;0:1. doi:10.1136/gutjnl-2014-308420
REFERENCES 1
2
3
4
5
6
Peter Hill,1 Andrew Austin,2 Julia Forsyth,3 Geoffrey Holmes4 1
Emeritus Consultant Clinical Biochemist, Royal Derby Hospital, Derby, Derbyshire, UK 2 Derby Digestive Diseases Centre, Royal Derby Hospital, Derby, UK
7
Ludvigsson JF, Bai JC, Biagi F, et al. Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology. Gut 2014;63:1210–28. Zanini B, Magni A, Caselani F, 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. Burgin-Wolff A, Mauro B, Faruk H. Intestinal biopsy is not always required to diagnose celiac disease: a retrospective analysis of combined antibody tests. BMC Gastroenterol 2013;13:19–24. Hill PG, McMillan SA. Anti-tissue transglutaminase antibodies and their role in the investigation of coeliac disease. Ann Clin Biochem 2006;43:105–17. Husby S, Koletzko S, Korponay-Szabo IR, et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr 2012;54:136–60. Klapp G, Masip E, Bolonio M, et al. Celiac disease: the new proposed ESPGHAN diagnostic criteria do work well in a selected population. J Pediatr Gastroenterol Nutr 2013;56:251–6. Austin A, Seddon H. Southern Derbyshire Shared Care Pathology Guidelines: Coeliac Disease. http://www. derbyhospitals.nhs.uk/easysiteweb/getresource.axd? assetid=153366&type=0&servicetype=1 (accessed Sept 2014).
Gut Month 2014 Vol by 0 NoBMJ 0 1 Copyright Article author (or their employer) 2014. Produced Publishing Group Ltd (& BSG) under licence.
Downloaded from gut.bmj.com on October 18, 2014 - Published by group.bmj.com
British Society of Gastroenterology guidelines on the diagnosis and management of coeliac disease Peter Hill, Andrew Austin, Julia Forsyth, et al. Gut published online October 9, 2014
doi: 10.1136/gutjnl-2014-308420
Updated information and services can be found at: http://gut.bmj.com/content/early/2014/10/09/gutjnl-2014-308420.full.html
These include:
References
This article cites 6 articles, 2 of which can be accessed free at: http://gut.bmj.com/content/early/2014/10/09/gutjnl-2014-308420.full.html#ref-list-1
P
