52nd Annual Meeting of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition, 5 - 08 Haziran 2019, cilt.68, sa.1
Objectives and Study: The response to gluten-free diet (GFD) in coeliac disease (CD) is generally
assessed by improvement in clinical symptoms and normalization of the serologic tests. Current
guidelines recommend follow-up serology both to assess dietary adherence and to use as a surrogate
marker of mucosal recovery. However, the data regarding the correlation between the serological tests
and the mucosal recovery in patients treated with GFD are equivocal. We aimed to investigate
whether celiac-specific antibodies correlate with the mucosal damage in coeliac children who were on
Methods: Between July 1, 2017 and October 30, 2018, a prospective, cross-sectional study was
performed at Marmara University Paediatric Gastroenterology Department. Patients who were older
than 2 years, and had Marsh 3 lesions in duodenal biopsies at the time of diagnosis were included. A
total of 88 children underwent a second endoscopy at least 12 months after the initiation of GFD. A
blood sample was drawn for tTG and EMA IgA tests on the day of endoscopy. The same paediatric
pathologist, who was blind to the clinical and serological information, evaluated at least six biopsies for
each patient. Marsh 1 or Marsh 0 histopathology were defined as recovery. Furthermore, a standard,
validated questionnaire was filled by the same physician at the time of repeat endoscopy.
Results: During the study period, an endoscopy was offered to 102 coeliac patients, 88 out of which
accepted the procedure, and included into the study. Patients were 7.9±4.1 years of age at diagnosis,
and 62.5% were girls. The mean/median duration of gluten free diet was 5.1±4.1 years / 3.7 years.
(Range: 1-15.7 years). The histopathologic findings were consistent with either Marsh 1 or Marsh 0 in
64 (72.7%) of the patients (n=33 Marsh 0 and n=31 Marsh 1). However, 21 (23.8%) children had either
partial or complete villous atrophy. There were 38 celiac children whose tTG were positive, and 17 out
of whom had a tTG titer of 10 times of the upper limit of normal. Only one child with high titer of tTG
demonstrated histopatological recovery. The sensitivity and specificity of tTG IgA as a marker of
mucosal recovery was 87.5% and 73.4%, respectively, with a high negative predictive value (NPV) of
94% but a very low positive predictive value (PPV) of 55.3%. EMA was an important predictor of
mucosal healing with a sensitivity of 79.2%, and a specificity of 92.2% (NPV 92.2% and PPV 79.2%).
When the patients who had positive results for both serologic markers were evaluated separately, the
PPV of the serology was strengthened to 82.6%. The dietary questionnaire was moderately correlated
with the pathology (NPV 87.7%, PPV 54.8%).
Conclusion: The major goal of treatment with GFD is to achieve clinical and serological recovery in
coeliac disease. However, symptoms neither reflect nor correlate with the histopathology, namely
mucosal recovery. The need for a follow-up biopsy has been questioned in monitoring coeliac children.
Our results indicated that the combination of tTG IgA and EMA antibodies are useful as proxy markers
of mucosal recovery in the follow-up of children with CD. Combined use of serological tests and
validated dietary questionnaires may obviate the need for an endoscopy in in the majority of patients