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Fowler A, FitzPatrick M, Shanmugarasa A, Ibrahim ASF, Kockelbergh H, Yang HC, Williams-Walker A, Luu Hoang KN, Evans S, Provine N, Klenerman P, Soilleux EJ. An Interpretable Classification Model Using Gluten-Specific TCR Sequences Shows Diagnostic Potential in Coeliac Disease. Biomolecules 2023; 13:1707. [PMID: 38136579 PMCID: PMC10742135 DOI: 10.3390/biom13121707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/18/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
Coeliac disease (CeD) is a T-cell mediated enteropathy triggered by dietary gluten which remains substantially under-diagnosed around the world. The diagnostic gold-standard requires histological assessment of intestinal biopsies taken at endoscopy while consuming a gluten-containing diet. However, there is a lack of concordance between pathologists in histological assessment, and both endoscopy and gluten challenge are burdensome and unpleasant for patients. Identification of gluten-specific T-cell receptors (TCRs) in the TCR repertoire could provide a less subjective diagnostic test, and potentially remove the need to consume gluten. We review published gluten-specific TCR sequences, and develop an interpretable machine learning model to investigate their diagnostic potential. To investigate this, we sequenced the TCR repertoires of mucosal CD4+ T cells from 20 patients with and without CeD. These data were used as a training dataset to develop the model, then an independently published dataset of 20 patients was used as the testing dataset. We determined that this model has a training accuracy of 100% and testing accuracy of 80% for the diagnosis of CeD, including in patients on a gluten-free diet (GFD). We identified 20 CD4+ TCR sequences with the highest diagnostic potential for CeD. The sequences identified here have the potential to provide an objective diagnostic test for CeD, which does not require the consumption of gluten.
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Affiliation(s)
- Anna Fowler
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GF, UK
| | - Michael FitzPatrick
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK; (M.F.); (P.K.)
| | | | - Amro Sayed Fadel Ibrahim
- Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK; (A.S.F.I.); (H.-C.Y.); (A.W.-W.); (K.N.L.H.); (S.E.); (E.J.S.)
| | - Hannah Kockelbergh
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool L69 3GF, UK
| | - Han-Chieh Yang
- Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK; (A.S.F.I.); (H.-C.Y.); (A.W.-W.); (K.N.L.H.); (S.E.); (E.J.S.)
| | - Amelia Williams-Walker
- Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK; (A.S.F.I.); (H.-C.Y.); (A.W.-W.); (K.N.L.H.); (S.E.); (E.J.S.)
| | - Kim Ngan Luu Hoang
- Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK; (A.S.F.I.); (H.-C.Y.); (A.W.-W.); (K.N.L.H.); (S.E.); (E.J.S.)
| | - Shelley Evans
- Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK; (A.S.F.I.); (H.-C.Y.); (A.W.-W.); (K.N.L.H.); (S.E.); (E.J.S.)
| | - Nicholas Provine
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK; (M.F.); (P.K.)
| | - Paul Klenerman
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK; (M.F.); (P.K.)
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford OX1 3SY, UK
| | - Elizabeth J. Soilleux
- Department of Pathology, University of Cambridge, Cambridge CB2 1QP, UK; (A.S.F.I.); (H.-C.Y.); (A.W.-W.); (K.N.L.H.); (S.E.); (E.J.S.)
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Denholm J, Schreiber B, Evans S, Crook O, Sharma A, Watson J, Bancroft H, Langman G, Gilbey J, Schönlieb CB, Arends M, Soilleux E. Multiple-instance-learning-based detection of coeliac disease in histological whole-slide images. J Pathol Inform 2022; 13:100151. [PMID: 36605111 PMCID: PMC9808019 DOI: 10.1016/j.jpi.2022.100151] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
We present a multiple-instance-learning-based scheme for detecting coeliac disease, an autoimmune disorder affecting the intestine, in histological whole-slide images (WSIs) of duodenal biopsies. We train our model to detect 2 distinct classes, normal tissue and coeliac disease, on the patch-level, and in turn leverage slide-level classifications. Using 5-fold cross-validation in a training set of 1841 (1163 normal; 680 coeliac disease) WSIs, our model classifies slides as normal with accuracy (96.7±0.6)%, precision (98.0±1.7)%, and recall (96.8±2.5)%, and as coeliac disease with accuracy (96.7±0.5)%, precision (94.9±3.7)%, and recall (96.5±2.9)% where the error bars are the cross-validation standard deviation. We apply our model to 2 test sets: one containing 191 WSIs (126 normal; 65 coeliac) from the same sources as the training data, and another from a completely independent source, containing 34 WSIs (17 normal; 17 coeliac), obtained with a scanner model not represented in the training data. Using the same-source test data, our model classifies slides as normal with accuracy 96.5%, precision 98.4% and recall 96.1%, and positive for coeliac disease with accuracy 96.5%, precision 93.5%, and recall 97.3%. Using the different-source test data the model classifies slides as normal with accuracy 94.1% (32/34), precision 89.5%, and recall 100%, and as positive for coeliac disease with accuracy 94.1%, precision 100%, and recall 88.2%. We discuss generalising our approach to screen for a range of pathologies.
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Affiliation(s)
- J. Denholm
- Lyzeum Ltd, Salisbury House, Station Road, Cambridge CB1 2LA, Cambridgeshire, UK,Department of Applied Maths and Theoretical Physics, University of Cambridge, Centre for Mathematical Sciences, Wilberforce Road, Cambridge CB3 0WA, Cambridgeshire, UK,Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK,Corresponding author.
| | - B.A. Schreiber
- Department of Applied Maths and Theoretical Physics, University of Cambridge, Centre for Mathematical Sciences, Wilberforce Road, Cambridge CB3 0WA, Cambridgeshire, UK,Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
| | - S.C. Evans
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
| | - O.M. Crook
- The Alan Turing Institute, 96 Euston Rd, London NW1 2DB, UK
| | - A. Sharma
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
| | - J.L. Watson
- Oxford Medical School, University of Oxford, S Parks Road, Oxford OX1 3PL, Oxfordshire, UK
| | - H. Bancroft
- Department of Cellular Pathology, Birmingham Heartlands Hospital, University Hospitals Birmingham, 45 Bordesley Green East, Birmingham B9 5SS, West Midlands, UK
| | - G. Langman
- Department of Cellular Pathology, Birmingham Heartlands Hospital, University Hospitals Birmingham, 45 Bordesley Green East, Birmingham B9 5SS, West Midlands, UK
| | - J.D. Gilbey
- Department of Applied Maths and Theoretical Physics, University of Cambridge, Centre for Mathematical Sciences, Wilberforce Road, Cambridge CB3 0WA, Cambridgeshire, UK
| | - C.-B. Schönlieb
- Department of Applied Maths and Theoretical Physics, University of Cambridge, Centre for Mathematical Sciences, Wilberforce Road, Cambridge CB3 0WA, Cambridgeshire, UK
| | - M.J. Arends
- Division of Pathology, University of Edinburgh, Cancer Research UK Edinburgh Centre, Western General Hospital, Crewe Road South, Edinburgh, EH4 2XR, Lothian, Scotland
| | - E.J. Soilleux
- Lyzeum Ltd, Salisbury House, Station Road, Cambridge CB1 2LA, Cambridgeshire, UK,Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge CB2 1QP, Cambridgeshire, UK
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The global burden of coeliac disease: opportunities and challenges. Nat Rev Gastroenterol Hepatol 2022; 19:313-327. [PMID: 34980921 DOI: 10.1038/s41575-021-00552-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 02/06/2023]
Abstract
Coeliac disease is a systemic disorder characterized by immune-mediated enteropathy, which is caused by gluten ingestion in genetically susceptible individuals. The clinical presentation of coeliac disease is highly variable and ranges from malabsorption through solely extra-intestinal manifestations to asymptomatic. As a result, the majority of patients with coeliac disease remain undiagnosed, misdiagnosed or experience a substantial delay in diagnosis. Coeliac disease is diagnosed by a combination of serological findings of disease-related antibodies and histological evidence of villous abnormalities in duodenal biopsy samples. However, variability in histological grading and in the diagnostic performance of some commercially available serological tests remains unacceptably high and confirmatory assays are not readily available in many parts of the world. Currently, the only effective treatment for coeliac disease is a lifelong, strict, gluten-free diet. However, many barriers impede patients' adherence to this diet, including lack of widespread availability, high cost, cross-contamination and its overall restrictive nature. Routine follow-up is necessary to ensure adherence to a gluten-free diet but considerable variation is evident in follow-up protocols and the optimal disease management strategy is not clear. However, these challenges in the diagnosis and management of coeliac disease suggest opportunities for future research.
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Badizadegan K, Vanlandingham DM, Hampton W, Thompson KM. Value of biopsy in a cohort of children with high-titer celiac serologies: observation of dynamic policy differences between Europe and North America. BMC Health Serv Res 2020; 20:962. [PMID: 33081760 PMCID: PMC7576777 DOI: 10.1186/s12913-020-05815-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/12/2020] [Indexed: 12/16/2022] Open
Abstract
Background Healthcare systems implement change at different rates because of differences in incentives, organizational processes, key influencers, and management styles. A comparable set of forces may play out at the national and international levels as demonstrated in significant differences in the diagnostic management of pediatric Celiac Disease (CD) between European and North American practitioners. Methods We use retrospective clinical cohorts of 27,868 serum tissue transglutaminase (tTG) immunoglobulin A levels and 7907 upper gastrointestinal endoscopy pathology reports to create a dataset of 793 pathology reports with matching tTG results between July 1 of 2014 and July 1 of 2018. We use this dataset to characterize histopathological findings in the duodenum, stomach and esophagus of patients as a function of serum tTG levels. In addition, we use the dataset to estimate the local and national cost of endoscopies performed in patients with serum tTG levels greater than 10 times the upper limit of normal. Results Using evidence from a US tertiary care center, we show that in the cohort of pediatric patients with high pre-test probability of CD as determined by serum tTG levels, biopsy provides no additional diagnostic value for CD, and that it counter-intuitively introduces diagnostic uncertainty in a number of patients. We estimate that using the European diagnostic algorithms could avoid between 4891 and 7738 pediatric endoscopies per year in the US for evaluation of CD. Conclusions This study considers the North American and European management guidelines for the diagnosis of pediatric CD and highlights the slow adoption in North America of evidence-based algorithms developed and applied in Europe for triage of endoscopy and biopsy. We suggest that system dynamics influences that help maintain the status quo in North America include a variety of social and economic factors in addition to medical evidence. This work contributes to the growing body of evidence that the dynamics that largely favor maintaining status quo management policies in a variety of systems extend to clinical medicine and potentially influence clinical decisions at the level of individual patients and the population. Supplementary information Supplementary information accompanies this paper at 10.1186/s12913-020-05815-0.
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Affiliation(s)
| | - David M Vanlandingham
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Wesley Hampton
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Molder A, Balaban DV, Jinga M, Molder CC. Current Evidence on Computer-Aided Diagnosis of Celiac Disease: Systematic Review. Front Pharmacol 2020; 11:341. [PMID: 32372947 PMCID: PMC7179080 DOI: 10.3389/fphar.2020.00341] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/09/2020] [Indexed: 02/05/2023] Open
Abstract
Celiac disease (CD) is a chronic autoimmune disease that occurs in genetically predisposed individuals in whom the ingestion of gluten leads to damage of the small bowel. It is estimated to affect 1 in 100 people worldwide, but is severely underdiagnosed. Currently available guidelines require CD-specific serology and atrophic histology in duodenal biopsy samples for the diagnosis of adult CD. In pediatric CD, but in recent years in adults also, nonbioptic diagnostic strategies have become increasingly popular. In this setting, in order to increase the diagnostic rate of this pathology, endoscopy itself has been thought of as a case finding strategy by use of digital image processing techniques. Research focused on computer aided decision support used as database video capsule, endoscopy and even biopsy duodenal images. Early automated methods for diagnosis of celiac disease used feature extraction methods like spatial domain features, transform domain features, scale-invariant features and spatio-temporal features. Recent artificial intelligence (AI) techniques using deep learning (DL) methods such as convolutional neural network (CNN), support vector machines (SVM) or Bayesian inference have emerged as a breakthrough computer technology which can be used for computer aided diagnosis of celiac disease. In the current review we summarize methods used in clinical studies for classification of CD from feature extraction methods to AI techniques.
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Affiliation(s)
- Adriana Molder
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Center of Excellence in Robotics and Autonomous Systems, Military Technical Academy Ferdinand I, Bucharest, Romania
| | - Daniel Vasile Balaban
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Gastroenterology Department, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
- *Correspondence: Daniel Vasile Balaban,
| | - Mariana Jinga
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Gastroenterology Department, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - Cristian-Constantin Molder
- Center of Excellence in Robotics and Autonomous Systems, Military Technical Academy Ferdinand I, Bucharest, Romania
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Villanacci V, Lorenzi L, Donato F, Auricchio R, Dziechciarz P, Gyimesi J, Koletzko S, Mišak Z, Laguna VM, Polanco I, Ramos D, Shamir R, Troncone R, Vriezinga SL, Mearin ML. Histopathological evaluation of duodenal biopsy in the PreventCD project. An observational interobserver agreement study. APMIS 2018; 126:208-214. [PMID: 29372596 DOI: 10.1111/apm.12812] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/03/2017] [Indexed: 01/13/2023]
Abstract
Aim of the current study was to evaluate the inter-observer agreement between pathologists in the diagnosis of celiac disease (CD), in the qualified context of a multicenter study. Biopsies from the "PreventCD" study, a multinational- prospective- randomized study in children with at least one-first-degree relative with CD and positive for HLA-DQ2/HLA-DQ8. Ninety-eight biopsies were evaluated. Considering diagnostic samples with villous atrophy (VA), the agreement was satisfactory (κ = 0.84), but much less when assessing the severity of these lesions. The use of the recently proposed Corazza-Villanacci classification showed a moderately higher level of agreement (κ = 0.39) than using the Marsh-Oberhuber system (κ = 0.31). 57.1% of cases were considered correctly oriented. A number of >4 samples per patient was statistically associated to a better agreement; orientation did not impact on κ values. Agreement results in this study appear more satisfactory than in previous papers and this is justified by the involvement of centers with experience in CD diagnosis and by the well-controlled setting. Despite this, the reproducibility was far from optimal with a poor agreement in grading the severity of VA. Our results stress the need of a minimum of four samples to be assessed by the pathologist.
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Affiliation(s)
| | - Luisa Lorenzi
- Institute of Pathology, ASST Spedali Civili di Brescia, Brescia, Italy.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Francesco Donato
- Unit of Hygiene, Epidemiology and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Judit Gyimesi
- Coeliac Disease Center, Heim Pál Children's Hospital, Budapest, Hungary
| | - Sibylle Koletzko
- Children's Hospital, University of Munich Medical Centre, Munich, Germany
| | - Zrinjka Mišak
- Children's Hospital, University of Zagreb Medical School, Zagreb, Croatia
| | | | | | | | - Raanan Shamir
- Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | | | - M Luisa Mearin
- Leiden University Medical Center, Leiden, The Netherlands
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Abstract
Coeliac disease is increasingly recognized as a global problem in both children and adults. Traditionally, the findings of characteristic changes of villous atrophy and increased intraepithelial lymphocytosis identified in duodenal biopsy samples taken during upper gastrointestinal endoscopy have been required for diagnosis. Although biopsies remain advised as necessary for the diagnosis of coeliac disease in adults, European guidelines for children provide a biopsy-sparing diagnostic pathway. This approach has been enabled by the high specificity and sensitivity of serological testing. However, these guidelines are not universally accepted. In this Perspective, we discuss the pros and cons of a biopsy-avoiding pathway for the diagnosis of coeliac disease, especially in this current era of the call for more biopsies, even from the duodenal bulb, in the diagnosis of coeliac disease. In addition, a contrast between paediatric and adult guidelines is presented.
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Progress towards non-invasive diagnosis and follow-up of celiac disease in children; a prospective multicentre study to the usefulness of plasma I-FABP. Sci Rep 2017; 7:8671. [PMID: 28819290 PMCID: PMC5561259 DOI: 10.1038/s41598-017-07242-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/25/2017] [Indexed: 02/07/2023] Open
Abstract
This prospective study investigates whether measurement of plasma intestinal-fatty acid binding protein (I-FABP), a sensitive marker for small intestinal epithelial damage, improves non-invasive diagnosing of celiac disease (CD), and whether I-FABP levels are useful to evaluate mucosal healing in patients on a gluten-free diet (GFD). Ninety children with elevated tTG-IgA titres and HLA-DQ2/DQ8 positivity were included (study group). Duodenal biopsies were taken, except in those fulfilling the ESPGHAN criteria. Plasma I-FABP levels and tTG-IgA titres were assessed sequentially during six months of follow-up. Eighty children with normal tTG-IgA titres served as control group. In 61/90 (67.8%) of the children in the study group an increased I-FABP level was found; in all these children CD diagnosis was confirmed. Interestingly, in 14/30 (46.7%) children with slightly elevated tTG-IgA titres (<10x upper limit of normal), an increased I-FABP level was found. In all these children the diagnosis of CD was confirmed histologically. After gluten elimination for six weeks I-FABP levels had decreased towards levels in the control group. Measurement of plasma I-FABP, in addition to tTG-IgA, EMA-IgA and HLAtyping, enables non-invasive diagnosing of CD in a substantial number of children, and might therefore be of value in the diagnostic approach of CD.
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Dydensborg Sander S, Størdal K, Plato Hansen T, Nybo Andersen AM, Murray JA, Lillevang ST, Husby S. Validation of celiac disease diagnoses recorded in the Danish National Patient Register using duodenal biopsies, celiac disease-specific antibodies, and human leukocyte-antigen genotypes. Clin Epidemiol 2016; 8:789-799. [PMID: 28008283 PMCID: PMC5167452 DOI: 10.2147/clep.s122300] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose The purpose of this study was to validate the celiac disease diagnoses recorded in the Danish National Patient Register. To validate the diagnoses, we used information on duodenal biopsies from a national register of pathology reports (the Patobank) and information on celiac disease-specific antibodies and human leukocyte antigen (HLA) genotypes obtained from patient medical records. Patients and methods We included all the children who were born from 1995 to 2012 and who were registered as having celiac disease in the Danish National Patient Register. We reviewed all the pathology reports on duodenal biopsies in the Patobank and the information in the medical records on celiac disease-specific antibodies (ie, anti-tissue transglutaminase 2 IgA and IgG, endomysial antibodies IgA, and anti-deamidated gliadin peptide IgG) and HLA genotypes. Results We identified 2,247 children who were registered in the Danish National Patient Register with celiac disease. Duodenal biopsies for 1,555 of the children (69%) were registered in the Patobank; 1,127 (50%) had a biopsy that was compatible with celiac disease (ie, Marsh 2–3). We accessed the medical records of 95% of the children who were registered in the Danish National Patient Register with celiac disease. We found that 1,510 (67%) had one or more positive antibody-test results; 1,120 (50%) had anti-tissue transglutaminase 2, IgA at tenfold or greater the upper limit of the normal range and/or positive endomysial antibody results. The positive predictive value depended on the criteria used for validation and the types and numbers of registrations that were included in the analysis and ranged from 62% (95% confidence interval: 60%–64%) to 86% (95% confidence interval: 84%–87%). Conclusion Our findings indicate that the Danish National Patient Register is a valuable source to identify patients who have been diagnosed with celiac disease. However, validation of the diagnoses is warranted before data on the patients are used for research purposes.
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Affiliation(s)
- Stine Dydensborg Sander
- Hans Christian Andersen Children's Hospital, Odense University Hospital; Institute of Clinical Research, University of Southern Denmark; Odense Patient Data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Ketil Størdal
- Mental and Physical Health, Norwegian Institute of Public Health, Oslo; Department of Pediatrics, Ostfold Hospital Trust, Fredrikstad, Norway
| | | | | | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | | | - Steffen Husby
- Hans Christian Andersen Children's Hospital, Odense University Hospital; Institute of Clinical Research, University of Southern Denmark
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Montén C, Bjelkenkrantz K, Gudjonsdottir AH, Browaldh L, Arnell H, Naluai ÅT, Agardh D. Validity of histology for the diagnosis of paediatric coeliac disease: a Swedish multicentre study. Scand J Gastroenterol 2016; 51:427-33. [PMID: 26635075 DOI: 10.3109/00365521.2015.1101486] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Histological evaluation of intestinal biopsies for the diagnosis of coeliac disease can be challenging and compatible with risk of misdiagnosis. The aim was to evaluate the agreement of pathological diagnosis for coeliac disease in children investigated at four major paediatric university hospitals in Sweden. MATERIALS AND METHODS Intestinal duodenal biopsies were collected from 402 children at median 9.7 years (1.4-18.3 years). A pathologist at each hospital performed the primary evaluation. A designated pathologist, blinded to the primary evaluation, performed a second Marsh classification of biopsies (M0 to M3c) taken from the bulb and duodenum separately. Kappa (κ) scores between first and second evaluation determined the agreement. Plasma samples were collected at the day of intestinal biopsy and analysed for tissue transglutaminase autoantibodies (tTGA) using radioligand-binding assays. RESULTS Marsh scores were concordant in 229/356 biopsies (64%, κ = 0.52, p < 0.0001). Among discordant results, 15/127 (12%) showed M0 in distal duodenum but ≥ M2 in the bulb, whereas the opposite was true for 8/127 (6%) of the biopsies. There were fewer collected duodenal biopsies, more missing bulb biopsies and missing CD3 staining among discordant evaluations. The second evaluation revealed a Marsh score compliant with coeliac disease in 22 children of whom seven children were tTGA positive. CONCLUSIONS The variation between university hospitals on the pathological evaluation of biopsies may lead to misdiagnosis of coeliac disease in paediatric patients. Access to clinical and endoscopic information as well as tTGA levels may be useful for the pathologist to complement the evaluation in dubious cases.
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Affiliation(s)
- Caroline Montén
- a Department of Clinical Sciences , Diabetes & Celiac Disease Unit, Lund University , Malmö , Sweden
| | | | - Audur H Gudjonsdottir
- c Department of Pediatrics , Queen Silvia Children's Hospital, Sahlgrenska Academy , Gothenburg , Sweden
| | - Lars Browaldh
- d Department of Clinical Science & Education , Karolinska University Hospital, Karolinska Institutet, Södersjukhuset , Stockholm , Sweden
| | - Henrik Arnell
- e Department of Pediatric Gastroenterology , Hematology and Nutrition, Karolinska University Hospital, Karolinska Institutet , Stockholm , Sweden
| | - Åsa Torinsson Naluai
- f Department of Microbiology & Immunology , Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg , Gothenburg , Sweden
| | - Daniel Agardh
- a Department of Clinical Sciences , Diabetes & Celiac Disease Unit, Lund University , Malmö , Sweden
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Kaur Bilkhoo H, Ducruet T, Marchand V, Deslandres C, Djemli A, Dal Soglio D, Patey N. Revisiting Pathological Criteria for Earlier Diagnosis of Coeliac Disease. J Pediatr Gastroenterol Nutr 2016; 62:734-8. [PMID: 26529345 DOI: 10.1097/mpg.0000000000001026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The diagnosis of coeliac disease (CD) remains sometimes difficult because the histological criteria are not fully met. The aim of this study was to refine histological diagnostic criteria of CD. METHODS One hundred seventy-five duodenal bulb D1 (n = 79) and duodenal D2 (n = 96) biopsies of 96 patients with CD (58 girls, mean age 7 years), 135 normal D2 biopsies (69 girls, mean age 12 years), and 64 D2 biopsies of other digestive disorders (DDs) (39 girls, mean age 13 years) obtained from children during a period of 4 years were reviewed. RESULTS Interobserver agreement was greater for the classification of Corazza-Villanacci than for Marsh-Oberhuber (κ = 0.812 vs κ = 0.409, respectively). Between 40 and 70 intraepithelial lymphocytes (IELs) per 100 epithelial cells (ECs), 32% of patients were CD, whereas 50% had other DD. Above 70 IELs per 100 EC, 53% were CD, and only 6% had other DD. In CD, IELs were significantly located above EC nuclei compared with other DD, (12 IELs/100 EC vs 2 IELs/100 EC, respectively). In 21% of CD cases, D2 were normal and the diagnosis could only be made on D1. Finally, 6% of CD cases showed isolated increase of IELs in D1 without architectural modification. CONCLUSIONS D1 allowed diagnosis of CD in 21% of cases and IEL >70 per 100 EC correlated strongly with CD. Between 40 and 70 IELs per 100 EC, CD is very likely but other DD must be considered. Finally, the preferential localisation of IELs above EC nuclei favours CD, and increased IEL in D1 may be the sole abnormality.
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Affiliation(s)
- Harpreet Kaur Bilkhoo
- *Département de Pathologie †Unité de Recherche clinique appliquée ‡Département de Gastroentérologie Hépatologie et Nutrition §Département de Biochimie, CHU Sainte-Justine, Montréal, QC, Canada
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Gadermayr M, Uhl A, Vécsei A. Fully automated decision support systems for celiac disease diagnosis. Ing Rech Biomed 2016. [DOI: 10.1016/j.irbm.2015.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Unusually High Incidence of Paediatric Coeliac Disease in Sweden during the Period 1973 - 2013. PLoS One 2015; 10:e0144346. [PMID: 26658809 PMCID: PMC4676692 DOI: 10.1371/journal.pone.0144346] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/17/2015] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The prevalence of coeliac disease in Sweden during the "epidemic period" (1984-1996) was one of the highest in the world. The aim of this study was to assess the coeliac disease incidence in our region over the 41-year period, and how diagnostic activity and diagnostic accuracy were affected by the introduction of antibody testing. We also looked into how patients with mild enteropathy were evaluated. METHODS In the county of Östergötland in Sweden, 2790 paediatric patients were investigated for suspected coeliac disease between 1973 and 2013. Notes were scrutinised for data on sex, age, histopathological reports and final diagnosis. For comparative purposes this period was divided into three sub-periods (1973-1983, 1984-1996 and 1997-2013) named pre-epidemic, epidemic and post-epidemic. RESULTS Coeliac disease diagnosis was received by 1,030 patients. The peak incidence rate, 301 cases/100,000 in 1994 for the age group 0-1.9 years is the highest figure ever reported. The other age groups, 2-4.9, 5-14.9, and 15-17.9 years, also had high incidence rates. After the 1984-1996 "epidemic period" the incidence decreased for the youngest group but continued to increase for the other groups. The cumulative incidence at 18 years-of-age for children born during the epidemic reached 14 cases/1000 births, the highest figure hitherto reported. Diagnostic activity differed significantly between the three sub-periods (p<0.001) increasing gradually from 1984 and reaching a peak value of 0.87 in 2012. Cases of mild enteropathy were more frequently regarded as non-coeliac disease cases, decreasing significantly in the "post-epidemic" period (p<0.001). CONCLUSIONS The incidence rate and cumulative incidence of coeliac disease were possibly the highest ever reported. Changes in diagnostic activity and accuracy could not be attributed to the introduction of new antibody tests, possibly because of other changes e.g. variations in the symptoms at presentation and improved knowledge of the disease among parents and health professionals.
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Linee guida per la diagnosi di laboratorio e istologica della malattia celiaca. Revisione 2015. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13631-015-0086-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Hegenbart S, Uhl A, Vécsei A. Survey on computer aided decision support for diagnosis of celiac disease. Comput Biol Med 2015; 65:348-58. [PMID: 25770906 PMCID: PMC4593300 DOI: 10.1016/j.compbiomed.2015.02.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 12/13/2022]
Abstract
Celiac disease (CD) is a complex autoimmune disorder in genetically predisposed individuals of all age groups triggered by the ingestion of food containing gluten. A reliable diagnosis is of high interest in view of embarking on a strict gluten-free diet, which is the CD treatment modality of first choice. The gold standard for diagnosis of CD is currently based on a histological confirmation of serology, using biopsies performed during upper endoscopy. Computer aided decision support is an emerging option in medicine and endoscopy in particular. Such systems could potentially save costs and manpower while simultaneously increasing the safety of the procedure. Research focused on computer-assisted systems in the context of automated diagnosis of CD has started in 2008. Since then, over 40 publications on the topic have appeared. In this context, data from classical flexible endoscopy as well as wireless capsule endoscopy (WCE) and confocal laser endomicrosopy (CLE) has been used. In this survey paper, we try to give a comprehensive overview of the research focused on computer-assisted diagnosis of CD. The state-of-the-art research in automated diagnosis of celiac disease is presented. A systematic review of methods and techniques used in this field is given. Specific issues and challenges in the field are identified and discussed.
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Affiliation(s)
- Sebastian Hegenbart
- Department of Computer Sciences, University of Salzburg, Jakob-Haringer Strasse, 5020 Salzburg, Austria.
| | - Andreas Uhl
- Department of Computer Sciences, University of Salzburg, Jakob-Haringer Strasse, 5020 Salzburg, Austria.
| | - Andreas Vécsei
- St. Anna Children׳s Hospital, Medical University Vienna, 1090 Vienna, Austria.
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Husby S, Murray JA. Diagnosing coeliac disease and the potential for serological markers. Nat Rev Gastroenterol Hepatol 2014; 11:655-63. [PMID: 25266110 DOI: 10.1038/nrgastro.2014.162] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The diagnosis of coeliac disease has advanced in the past decade owing to increased clinical awareness and improved tests. Coeliac disease is now regarded as a common disease presenting at any age with a broad spectrum of symptoms. Previous guidelines on diagnosis relied on the histological analysis of duodenal biopsy samples. However, contemporary antibody analysis is a diagnostic tool with a comparatively high accuracy that has reduced reliance on performing biopsies. Furthermore, determination of HLA-based genetic susceptibility to coeliac disease has become routine. European and North American guidelines utilize symptoms, coeliac antibodies (primarily tissue transglutaminase 2 IgA and endomysial IgA antibodies), HLA determination and histological analysis of biopsy tissue for diagnosis. Some guidelines conclude that the diagnostic accuracy of tissue transglutaminase 2 IgA antibodies is sufficient to omit duodenal biopsies in selected children with very high antibody levels, in the presence of clear symptom response as well as a positive endomysial antibody test and confirmation of genetic susceptibility. This Review discusses if such a strategy is appropriate for children and adults in all populations. The performance characteristics of antibody tests (particularly of the tissue transglutaminase 2 IgA test) including quality control and characterisation of the population in whom testing is performed are also discussed.
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Affiliation(s)
- Steffen Husby
- Hans Christian Andersen Children's Hospital, Odense University Hospital, 29 Southern Boulevard, DK-5000 Odense C, Denmark
| | - Joseph A Murray
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street South West, Rochester, MN 55905, USA
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Gadermayr M, Uhl A, Vécsei A. Quality Based Information Fusion in Fully Automatized Celiac Disease Diagnosis. LECTURE NOTES IN COMPUTER SCIENCE 2014. [DOI: 10.1007/978-3-319-11752-2_55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Bruins MJ. The clinical response to gluten challenge: a review of the literature. Nutrients 2013; 5:4614-41. [PMID: 24284613 PMCID: PMC3847752 DOI: 10.3390/nu5114614] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 11/01/2013] [Accepted: 11/06/2013] [Indexed: 02/07/2023] Open
Abstract
The aim of this review was to identify, evaluate and summarize all relevant studies reporting on the clinical response to gluten challenge by adult or pediatric patients with suspected or diagnosed coeliac disease (CD) on a gluten-free diet. We evaluated the effect of gluten challenge on changes in symptoms, intestinal mucosa histology, and serum antibodies. A systematic electronic search was performed for studies published as of 1966 using PubMed and Scopus databases. In the reviewed studies, doses ranged from 0.2 to 30 g/day of wheat gluten or comprised a gluten-containing diet. The onset of symptoms upon gluten intake varied largely from days to months and did not parallel serum antibody or histological changes. Within 3 months of gluten challenge, 70%-100% of pediatric CD patients became positive for AGA-IgA and EMA-IgA antibodies and 50%-70% for AGA-IgG. A limited number of trials suggest that no more than half of adult patients developed positive AGA-IgA, EMA-IgA, tTG-IgA or DGP-IgA/IgG titers. Approximately 50%-100% of pediatric and adult patients experienced mucosal relapse of gluten provocation within 3 months, which was preceded by increased mucosal intra-epithelial lymphocytes within several days of challenge. A 3-month high-dose gluten challenge should be suitable to diagnose the majority of CD patients. In some cases prolonged challenge may be needed to verify diagnosis. Combination testing for antibodies and mucosal histology may fasten the diagnosis.
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Affiliation(s)
- Maaike J Bruins
- DSM Biotechnology Center, Alexander Fleminglaan 1, Delft 2613AX, The Netherlands.
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Husby S, Murray JA. New aspects of the diagnosis of celiac disease in children, adolescents, and adults. Mayo Clin Proc 2013; 88:540-3. [PMID: 23660481 DOI: 10.1016/j.mayocp.2013.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 03/29/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Steffen Husby
- Department of Pediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
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Defining thresholds of antibody levels improves diagnosis of celiac disease: replacing the gold standard. Clin Gastroenterol Hepatol 2013; 11:404-5. [PMID: 23333706 DOI: 10.1016/j.cgh.2012.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 12/12/2012] [Accepted: 12/13/2012] [Indexed: 02/07/2023]
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Güreşci S, Hızlı S, Simşek GG. The Value of Ensari's Proposal in Evaluating the Mucosal Pathology of Childhood Celiac Disease: Old Classification versus New Version. Balkan Med J 2012; 29:281-4. [PMID: 25207015 DOI: 10.5152/balkanmedj.2012.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 02/23/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Small intestinal biopsy remains the gold standard in diagnosing celiac disease (CD); however, the wide spectrum of histopathological states and differential diagnosis of CD is still a diagnostic problem for pathologists. Recently, Ensari reviewed the literature and proposed an update of the histopathological diagnosis and classification for CD. MATERIALS AND METHODS In this study, the histopathological materials of 54 children in whom CD was diagnosed at our hospital were reviewed to compare the previous Marsh and Modified Marsh-Oberhuber classifications with this new proposal. RESULTS In this study, we show that the Ensari classification is as accurate as the Marsh and Modified Marsh classifications in describing the consecutive states of mucosal damage seen in CD. CONCLUSIONS Ensari's classification is simple, practical and facilitative in diagnosing and subtyping of mucosal pathology of CD.
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Affiliation(s)
- Servet Güreşci
- Department of Pathology, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Samil Hızlı
- Department of Pediatric Gastroenterology, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Gülçin Güler Simşek
- Department of Pathology, Keçiören Training and Research Hospital, Ankara, Turkey
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Dydensborg S, Toftedal P, Biaggi M, Lillevang ST, Hansen DG, Husby S. Increasing prevalence of coeliac disease in Denmark: a linkage study combining national registries. Acta Paediatr 2012; 101:179-84. [PMID: 21722173 DOI: 10.1111/j.1651-2227.2011.02392.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIM To determine the prevalence and incidence of diagnosed coeliac disease (CD) in Danish children and adolescents and to describe trends over time. METHODS All children with a CD diagnosis registered in the Danish National Patient Registry (DNPR) were included in the study. Data were validated by combining this information with registrations of small-bowel biopsies in the National Registry of Pathology (NRP) and with a selected sample of hospital records. RESULTS Data were obtained from 1996 to 2010. The prevalence of CD registered in DNPR increased from 43.2 [95% CI 39.3-47.1] to 83.6 [95% CI 78.4-88.7] per 100,000, and the incidence increased from 2.8 [95% CI 1.9-3.9] to 10.0 [95% CI 8.4-12.0] per 100,000; 56% of the children had at least one biopsy compatible with CD registered in NRP. The incidence of biopsy-verified CD increased from 0.8 [95% CI 0.3-1.4] to 6.9 [95% CI 5.4-8.4] per 100,000. The mean age at diagnosis increased from 5.1 [95% CI 3.5-6.6] to 8.1 [95% CI 7.2-9.0] years of age. The proportion of children with associated diseases did not change over time. CONCLUSION The prevalence of diagnosed CD in Danish children and adolescents has increased over the last 15 years.
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Affiliation(s)
- Stine Dydensborg
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense C, Denmark
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Mubarak A, Nikkels P, Houwen R, Ten Kate F. Reproducibility of the histological diagnosis of celiac disease. Scand J Gastroenterol 2011; 46:1065-73. [PMID: 21668407 DOI: 10.3109/00365521.2011.589471] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE A small intestinal biopsy is considered to be the gold standard for the diagnosis of celiac disease (CD). However, the assessment of small intestinal histology may vary between pathologists. Our aim was, therefore, to determine the interobserver variability in the histological diagnosis of CD. MATERIAL AND METHODS Biopsy specimens of 297 pediatric patients suspected of having CD were revised by a single experienced pathologist and compared to the original reports. Mucosal changes were scored using the Marsh classification. In patients with a discrepancy in diagnosis, clinical and serological data were used to determine the most probable diagnosis. RESULTS Although the interobserver variability for the Marsh classification was found to be moderate with a Kappa value of 0.486, the Kappa value for the diagnosis reached an almost perfect agreement (0.850). Nevertheless, in 22 patients a different diagnosis was made by the second observer. Interestingly, in this subgroup relatively more biopsies were classified to be of suboptimal quality. Based on clinical presentation, serology and follow-up, 19 of those patients truly had CD. In 14 of them the diagnosis was originally missed by the first observer while five cases were under-diagnosed by the second pathologist. CONCLUSIONS CD can be missed histologically due to assessment variation between pathologists. A final diagnosis of CD should be based on histology, serology as well as response to the diet.
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Affiliation(s)
- Amani Mubarak
- Department of Pediatric Gastroenterology, Wilhelmina Children's hospital/University Medical Center Utrecht, Utrecht, The Netherlands.
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Bragde H, Jansson U, Jarlsfelt I, Söderman J. Gene expression profiling of duodenal biopsies discriminates celiac disease mucosa from normal mucosa. Pediatr Res 2011; 69:530-7. [PMID: 21378598 DOI: 10.1203/pdr.0b013e318217ecec] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Celiac disease (CD) is identified by histopathologic changes in the small intestine which normalize during a gluten-free diet. The histopathologic assessment of duodenal biopsies is usually routine but can be difficult. This study investigated gene expression profiling as a diagnostic tool. A total of 109 genes were selected to reflect alterations in crypt-villi architecture, inflammatory response, and intestinal permeability and were examined for differential expression in normal mucosa compared with CD mucosa in pediatric patients. Biopsies were classified using discriminant analysis of gene expression. Fifty genes were differentially expressed, of which eight (APOC3, CYP3A4, OCLN, MAD2L1, MKI67, CXCL11, IL17A, and CTLA4) discriminated normal mucosa from CD mucosa without classification errors using leave-one-out cross-validation (n = 39) and identified the degree of mucosal damage. Validation using an independent set of biopsies (n = 27) resulted in four discrepant cases. Biopsies from two of these cases showed a patchy distribution of lesions, indicating that discriminant analysis based on single biopsies failed to identify CD mucosa. In the other two cases, serology support class according to discriminant analysis and histologic specimens were judged suboptimal but assessable. Gene expression profiling shows promise as a diagnostic tool and for follow-up of CD, but further evaluation is needed.
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Affiliation(s)
- Hanna Bragde
- Division of Medical Diagnostics, Ryhov County Hospital, Jönköping SE-551 85, Sweden
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Sugai E, Moreno ML, Hwang HJ, Cabanne A, Crivelli A, Nachman F, Vázquez H, Niveloni S, Argonz J, Mazure R, Motta GL, Caniggia ME, Smecuol E, Chopita N, Gómez JC, Mauriño E, Bai JC. Celiac disease serology in patients with different pretest probabilities: Is biopsy avoidable? World J Gastroenterol 2010; 16:3144-52. [PMID: 20593499 PMCID: PMC2896751 DOI: 10.3748/wjg.v16.i25.3144] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To establish the diagnostic performance of several serological tests, individually and in combination, for diagnosing celiac disease (CD) in patients with different pretest probabilities, and to explore potential serological algorithms to reduce the necessity for biopsy.
METHODS: We prospectively performed duodenal biopsy and serology in 679 adults who had either high risk (n = 161) or low risk (n = 518) for CD. Blood samples were tested using six assays (enzyme-linked immunosorbent assay) that detected antibodies to tissue transglutaminase (tTG) and deamidated gliadin peptide (DGP).
RESULTS: CD prevalence was 39.1% in the high-risk population and 3.3% in the low-risk group. In high-risk patients, all individual assays had a high diagnostic efficacy [area under receiving operator characteristic curves (AU ROC): 0.968 to 0.999]. In contrast, assays had a lower diagnostic efficacy (AU ROC: 0.835 to 0.972) in the low-risk group. Using assay combinations, it would be possible to reach or rule out diagnosis of CD without biopsy in 92% of cases in both pretest populations. We observed that the new DGP/tTG Screen assay resulted in a surplus compared to more conventional assays in any clinical situation.
CONCLUSION: The DGP/tTG Screen assay could be considered as the best initial test for CD. Combinations of two tests, including a DGP/tTG Screen, might be able to diagnose CD accurately in different clinical scenarios making biopsy avoidable in a high proportion of subjects.
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Toftedal P, Nielsen C, Madsen JT, Titlestad K, Husby S, Lillevang ST. Positive predictive value of serological diagnostic measures in celiac disease. Clin Chem Lab Med 2010; 48:685-91. [DOI: 10.1515/cclm.2010.136] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
BACKGROUND AND OBJECTIVE Celiac disease (CD) is believed to be a permanent intolerance to gluten. A number of patients, however, discontinue the gluten-free diet (GFD) without developing symptoms or signs. The aim of our study was to investigate whether CD patients are capable of developing tolerance to gluten. METHODS All 77 adult patients from our hospital known to have biopsy-proven CD for more than 10 years were invited to participate. We investigated symptoms, gluten consumption, antibodies for CD and other autoimmunity, human leukocyte antigen (HLA)-typing, bone mineral density, and performed small bowel biopsies. Tolerance was defined as no immunological or histological signs of CD while consuming gluten. RESULTS Sixty-six patients accepted participation, but after review of the diagnostic biopsies 53 were found to have true CD. Twenty-three percent of patients had a gluten-containing diet, 15% admitted gluten transgression and 62% followed the GFD. Patients on a GFD had significantly more osteoporosis. Normal small bowel mucosa was found in four of eight on gluten-containing diet and in four of four with gluten transgression. Two patients were considered to have developed tolerance to gluten. One of them was HLA-DQ2/DQ8 negative. CONCLUSION Development of tolerance to gluten seems possible in some patients with CD. Further follow-up will show whether this tolerance is permanent or only a long-term return to latency. This feature may be associated with genetic characteristics, especially with HLA genotypes that differ from DQ2 or DQ8. More insight into the mechanisms of the development of gluten tolerance may help to distinguish those CD patients that might not require life-long GFD.
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Affiliation(s)
- G R Corazza
- First Department of Medicine, IRCCS Policlinico S. Matteo University of Pavia, Pavia I-27100, Italy
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30
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Affiliation(s)
- G R Corazza
- First Department of Medicine, IRCCS Policlinico S. Matteo University of Pavia, Pavia I-27100, Italy
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