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Letters to the Editor

Can We Really Skip the Biopsy in Diagnosing Symptomatic Children With Celiac Disease

Guandalini, Stefano*; Newland, Catherine

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Journal of Pediatric Gastroenterology and Nutrition: October 2013 - Volume 57 - Issue 4 - p e24
doi: 10.1097/MPG.0b013e3182a1cda3
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To the Editor:

In the March 2013 issue of the Journal of Pediatric Gastroenterology and Nutrition, Klapp et al (1) reviewed 150 symptomatic children with celiac disease, finding that the positive predictive value of applying these new criteria was 97.4%, and concluding that the diagnosis of celiac disease can be accurately made in a selected population without the requirement of a duodenal biopsy, following the new European Society for Pediatric Gastroenetrology, Hepatology, and Nutrition guidelines (2). We performed a multicenter retrospective chart review (3) aimed at determining how many patients would avoid the biopsy and at verifying potential drawbacks of eliminating endoscopy.

A total of 279 symptomatic patients (mean age 8.6 years) from 4 US centers had data available for both tissue transglutaminase-immunoglobulin A (tTG) and endomysium antibodies-immunoglobulin A. One hundred twenty-six patients (45%) had tTG >10× normal and positive EMA. Of these 126 patients, 115 (91%) underwent endoscopy with biopsies. Pathology reports showed all of them to have celiac disease (74% Marsh 3); however, 10% of them had unexpected additional diagnoses: chronic gastritis (2), reflux esophagitis (5), esophagitis (2), eosinophilic esophagitis (1), and Helicobacter pylori (1). Sixteen additional asymptomatic patients in our series also had tTG >10× normal and positive endomysium antibodies-immunoglobulin A. Of them, only 1 had an unexpected diagnosis (H pylori).

Thus, although we also found that a large portion of our patients would have been properly diagnosed as having celiac disease without a biopsy, by avoiding the diagnostic procedure, additional, unexpected diagnoses would have been missed in >10% of such symptomatic patients. We urge careful follow-up of symptomatic patients after they are diagnosed without a biopsy to avoid overlooking associated conditions.


1. Klapp G, Masip E, Bolonio M, et al. Coeliac disease: the new proposed ESPGHAN diagnostic criteria do work well in a selected population. J Pediatr Gastroenterol Nutr 2013; 56:251–256.
2. Husby S, Koletzko S, Korponay-Szabo IR, et al. ESPGHAN guidelines for the diagnosis of celiac disease in children and adolescents: an evidence-based approach. J Pediatr Gastroenterol Nutr 2012; 54:136–160.
3. Newland C, Reilly N, Bracken J, et al.. A multicenter review of the new ESPGHAN guidelines for coeliac disease: how many biopsies can we really skip? Manuscript submitted.
© 2013 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,