Published online Dec 5, 2018. doi: 10.4292/wjgpt.v9.i6.55
Peer-review started: May 25, 2018
First decision: June 13, 2018
Revised: July 9, 2018
Accepted: July 21, 2018
Article in press: July 21, 2018
Published online: December 5, 2018
Coeliac disease (CD) is a common gastrointestinal disorder that involves an immune response to dietary gluten. The condition is under recognised, particularly because silent or atypical presentations are becoming more common. Diagnosis is made with the combination of symptoms, serology and characteristic features seen on duodenal biopsy. It remains unclear whether there is an association between symptoms at diagnosis and the degree of small bowel injury. In addition, it is unclear whether symptoms and serology at the time of repeat duodenal biopsy are associated with the degree of mucosal healing.
The aim of this study was to analyze the association between both pre-diagnosis coeliac serology and initial duodenal histopathology, and primary presenting symptoms, coeliac related comorbidity and response to a gluten-free diet (GFD). Most patients in this study were asymptomatic at diagnosis. Neither symptoms nor serology were associated with the severity of small bowel injury. Many patients had persistent mucosal damage at the time of repeat duodenal biopsy despite reported adherence to a GFD suggesting that mucosal healing may take longer than previously reported. These findings have revealed the increasing difficulty in recognizing the symptoms of CD. Further research is needed to develop more reliable non-invasive biomarkers to be used as surrogates to assess mucosal healing.
This was a retrospective cohort study which included 99 participants who presented to a single Gastroenterology practice in Victoria, Australia from 1999-2013. Patients were referred from General Practitioners or other specialists. All patients were assessed by a Gastroenterologist. Data recorded included: baseline demographics, co-morbidities, family history, duration of symptoms, complications of CD. Serology and histology results were recorded for each patient. The majority of these patients underwent repeat duodenal biopsy after a period on a GFD to check for mucosal healing. Results were compared to repeat serology and symptoms. Numerical data were presented as median and inter-quartile range (IQR). The association of severity of duodenal blunting to symptoms and serology were examined using logistic regression.
The mean age at diagnosis was 43 years (IQR 30-53 years) and the majority was female. Most patients (n = 51, 52%) were asymptomatic at diagnosis. 17 (17%) patients had an associated autoimmune condition, the majority of whom had thyroid pathology (n = 10, 59%). The majority of patients with Marsh-Oberhuber Score (MS) ≥ 3a were symptomatic at diagnosis. There was no difference in symptoms between patients in a combined group of MS 3a/b compared to MS 3c. There was no difference of concomitant autoimmune conditions between patients with MS 3a/b (n = 4, 10%) and MS 3c (n = 9, 18%). Multivariate analysis did not reveal an association between MS ≥ 3a at diagnosis of CD and positive serology or symptoms at diagnosis. 87 (88%) patients had repeat biopsy. Lack of improvement in small bowel histology was not associated with persistently positive coeliac serology or ongoing symptoms at the time of repeat biopsy.
This study supports larger studies that have reported an increase in asymptomatic presentations of CD. Severity of villous blunting at diagnosis was not associated with symptoms. This study did not find an association between symptoms and serology at the time of repeat duodenal biopsy with persistent villous blunting. Duodenal healing whilst on a GFD may persist for longer than previously reported. Discovery of new non-invasive biomarkers is needed to better predict the degree of villous blunting.
Duodenal healing whilst on a GFD may persist for longer than previously reported. Discovery of new non-invasive biomarkers is needed to better predict the degree of villous blunting.