Thank you for your feedback! Coeliac disease is currently diagnosed by blood test and histology. Sooner or later, patients withcoeliac disease willproduce endomysial antibodies (EMA) and tissue transglutaminase antibodies (tTGA) when gluten is ingested.
The IgA tTGA and IgA EMA serological tests have high levels of sensitivity and specificity in thediagnosis. Patients with a positive blood test and those with negative antibodies who are suspected to have coeliac disease should be referred to a gastroenterologist, who will decide if a gastroscopy with duodenal biopsies to diagnose coeliac disease is necessary.
In the UK, many patients with vague and non-specific abdominal discomfort are referred for an unnecessary gastroscopy with duodenal biopsies to diagnose Coeliac disease. The reason why an endoscopy is unnecessary is that coeliac serology is an excellent screening test. If a tTG test is negative, the diagnostic yield of a gastroscopy is vanishingly small. Money and resources are better spent elsewhere!
Naturally, the condition can be enigmatic and patient can sero-convert "late" and become serology positive when they were initially sero-negative. Naturally, checking the serology every 3-4 months, in someone in which you think is developing celiac disease, is no big deal. In contrast, 3-monthly repeat duodenal biopsies would quickly become burdensome for the patient and expensive for the health service.
In this case, the mucosa is a little lumpy (you see this best along the valvulae conniventes) and completely flat. Nevertheless, currently the “correct answer” would be to take another set of samples (no big deal perhaps as the patient is undergoing a gastroscopy anyway). However, I believe that in the future this may be seen as another example of wasteful excess which deprived patients with GI cancer from a prompt diagnosis. In the West we tend to leave the ultimate diagnosis to our histopathologists whilst paediatricians are happy to rely on serology.
This case is presented by Camila Adour (Gastroenterology Residentat the "Hospital Naval Marcílio Dias", Rio de Janeiro, Brazil)
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