European Society Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for Diagnosing Coeliac Disease 2020

Risk of celiac disease, type 1 diabetes, and thyroid disease autoimmunity during the SARS-CoV-2 pandemic in South of Sweden: insights from the TRIAD study

Recent studies have implied an increased incidence of autoimmune diseases following the SARS-CoV-2 pandemic. The objective was to determine if SARS-CoV-2 infections were associated with celiac disease (CD), type 1 diabetes (T1D), and autoimmune thyroid disease (AITD) autoantibodies in a population-based screening when the pandemic hit the South of Sweden during 2021 and 2022. Between August 2021 and June 2022 self-obtained capillary plasma samples were collected from 1088 children at 6-9 years of age and 1185 adolescents at 13-16 years of age, who were randomly invited from the general population to a screening for CD, T1D, AITD, and SARS-CoV-2 antibodies. Among children and adolescents screened for autoantibodies associated with CD, T1D and AITD, the SARS-CoV-2 infection rate was increased in tissue transglutaminase autoantibody (tTGA) positive (13/17; 76.5%) compared with tTGA negative (492/1168; 42.1%) 13-16-year-old individuals (p = 0.0057). There was no association between SARS-CoV-2 infection rate and AITD- or T1D autoantibodies. Our findings indicate a potential association between prior SARS-CoV-2 infection and screening-detected CD autoimmunity in adolescents aged 13-16 years. Further research is needed to elucidate whether ongoing CD autoimmunity increases susceptibility to infection or if SARS-CoV-2 may act as a trigger for CD autoimmunity in genetically and environmentally predisposed individuals.

Importance of celiac disease oral manifestations in pediatric patients: A systematic review

BACKGROUND

Celiac disease (CD) is an autoimmune disease triggered by the ingestion of gluten in genetically predisposed individuals. It is more commonly diagnosed in children presenting typical clinical signs and symptoms but most of the CD patients diagnosed in the developed world are silent cases with no prominent gastrointestinal features. Thus, there are silent forms of the disease in which oral manifestations are the first sign. In the pediatric population oral health can affect growth and self-esteem and have a negative impact in their life quality.

AIM

To assess the prevalence and types of oral manifestations in pediatric patients with CD.

METHODS

We performed a comprehensive literature search in PubMed, Scielo, Cochrane Library and Lilacs databases from 2014-2024. Three independent researchers screened and extracted the information, applying the eligibility criteria and bias was assessed using Joanna Briggs Institute tools.

RESULTS

Of the initial 241 articles, 14 studies fulfilled the proposed objectives and were included in the review. The main oral manifestations found were recurrent aphthous stomatitis and enamel defects. Additionally, delayed tooth eruption, angular cheilitis, glossodynia and xerostomia were also reported.

CONCLUSION

Assessing oral manifestations is crucial, especially in underdiagnosed cases of children with CD. Recognizing these signs helps pediatricians or general practitioners identify them during routine exams, enabling early diagnosis and treatment to prevent negative impacts on the child’s and family’s quality of life.

Pediatric autoimmune diseases in the light of COVID-19 pandemic, A retrospective observational big data study

Background

The COVID-19 pandemic has raised concerns about potential links between SARS-CoV-2 infection and autoimmune diseases. This study investigated changes in the incidence rate (IR) of autoimmune diseases among children following the pandemic's onset.

Methods

A retrospective cross-sectional study analyzed data from Clalit Health Services, Israel's largest healthcare provider, examining the IR of different autoimmune diseases in children aged 0-18. The study compared pre-pandemic (2019) with pandemic/post-pandemic periods (2020-2023), encompassing a cohort of over 1.5 million children.

Results

Significant IR increases were observed across multiple autoimmune diseases. Rheumatic diseases (Juvenile Idiopathic Arthritis, Systemic Lupus Erythematosus, Henoch Schoenlein Purpura (HSP)) showed consistent increases, with HSP demonstrating the most pronounced trend. Endocrine disorders exhibited diverse patterns, with autoimmune thyroid diseases and Type 1 diabetes showing overall increases, while diabetic ketoacidosis exhibited an initial spike followed by a decline. Gastrointestinal diseases displayed heterogeneous patterns; Celiac disease and Ulcerative colitis showed general increases, Crohn's disease showed a downward trend, and autoimmune hepatitis exhibited an initial significant decrease followed by a significant increase. Dermatological conditions, including Psoriasis and Vitiligo, demonstrated consistent elevations throughout 2020-2023. Immune Thrombocytopenia Purpura showed initial decreases followed by significant increases in 2022-2023.

Conclusions

This comprehensive analysis reveals significant changes in pediatric autoimmune disease incidence following the COVID-19 pandemic, suggesting potential associations between SARS-CoV-2 infection and autoimmune dysregulation. The diverse patterns observed across different conditions highlight the complex interplay between viral infection and autoimmunity, emphasizing the need for continued surveillance and investigation of long-term immunological consequences of COVID-19 in pediatric populations.

Potential coeliac disease in children: a single-center experience

OBJECTIVES

Potential coeliac disease (PCD) is defined by the presence of positive CD-specific autoantibodies with a normal/extremely mildly damaged intestinal mucosa. This study sought to examine the progression of PCD in children maintaining a gluten-containing diet and to identify risk factors associated with the onset of CD. A comparative literature review was conducted to assess the results in the context of existing evidence.

METHODS

A retrospective cohort study was performed on 67 children diagnosed with PCD between January 2005 and January 2022, with a maximum follow up of 53 months. The associations between baseline clinical characteristics and the development of CD were assessed using hazard ratios (HR).

RESULTS

Nineteen percent (19 %) (12/67, cumulative incidence) of PCD children, with a median age of 4.3 years, progressed to CD during a median follow up period of 30 months. A fluctuating trend in tissue transglutaminase IgA (tTG-IgA) levels was observed in 35.8 % (24/67) of the children, while 46.2 % (31/67) showed tTG-IgA negativization. In univariable analysis, the presence of autoimmune disease and one-year increase in age at diagnosis were significantly associated with CD progression [HR=17.7 (95%CI: 3.0-106.8; p=0.0017) and HR=1.3 (95%CI: 1.1-1.5; p=0.0125), respectively].

CONCLUSIONS

Our study confirms that only a small proportion of PCD children progress to CD. It also highlights that advancing age and the presence of autoimmune disease are the main risk factors for the development of villous atrophy. A better understanding of tTG-IgA trend during follow up could help in the management of PCD children.

ICD-10-CM coding uncovers the gap between serological and clinically identified coeliac disease prevalence: A population-based study

BACKGROUND

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a global health coding system that provides a standardised language for recording, reporting and monitoring diseases. However, epidemiological studies using real-world data on clinically diagnosed coeliac disease (CD) based on the ICD-10-CM remain limited.

AIMS

To evaluate in primary care: (1) the diagnostic adequacy of CD; (2) the accuracy of the ICD-10-CM code K90.0 for identifying CD; and (3) the prevalence of clinically diagnosed CD compared with the known CD seroprevalence in the same geographical area (5‰).

METHODS

This was a population-based, cross-sectional study in the city of L'Hospitalet de Llobregat (269,382 inhabitants), Catalonia, from 2005 to 2020. The data retrieved with the K90.0 code from electronic medical records were cross-checked against laboratory and pathology registries. The CD diagnostic criteria were validated on a case-by-case basis. To calculate the accuracy of the K90.0 code for identifying CD, patients were classified into confirmed versus uncertain/misdiagnosed CD.

RESULTS

Overall, 536/737 patients (73 %) had confirmed CD, and 201/737 (27 %) were misdiagnosed. The accuracy of the K90.0 code for identifying CD was as follows: sensitivity, 91.63 %; specificity, 99.95 %; positive predictive value, 63.85 %; and negative predictive value, 99.99 %. The prevalence of clinically diagnosed CD was 1.99‰, with a decreasing age-related trend of -7.5 %.

CONCLUSIONS

The ICD-10-CM code K90.0 is accurate for identifying clinically diagnosed CD and is thus a great tool for epidemiological disease surveillance. The gap between CD seroprevalence and the prevalence of clinically diagnosed CD (5‰ vs. 1.99‰) calls for the implementation of case-finding programmes to reduce underdiagnosis.

Gliadin-dependent UPR induction directly triggers the expression of TG2 and pro-inflammatory cytokines, dysregulates intestinal permeability, and reduces CFTR expression in intestinal epithelial cells of celiac disease patients

BACKGROUND

Celiac disease (CD) is an autoimmune disorder that primarily affects the gut of genetically predisposed individuals and is triggered by gliadin peptides (PT) produced by the digestion of gluten. Although inappropriate activation of the immune system is thought to be the main trigger of CD, the interaction between PT and intestinal epithelial cells (IECs) remains a key step. Recently, the possible involvement of ER stress in the pathogenesis of CD has been pointed out, although its role is still largely unclear. Therefore, discovering the molecular mechanism(s) activated in IECs exposed to PT represents a unique opportunity to better understand the disease and define new potential therapeutic targets.

METHODS

In this study we used three different experimental set-ups: intestinal biopsies from CD patients and non-CD control subjects, an in vitro model, based on human CaCo-2 cells, and an ex vivo model, based on our recently described mouse gut-ex-vivo system (GEVS), with the latter two systems were studied after stimulation with gliadin peptides (PT). To understand the signaling pathways involved we monitor the expression of a number of proteins by qPCR, Western blotting, IF, ELISA or a combination of tests. Specifically, we have analyzed the level of CD, ER stress, tissue permeability, and inflammation markers.

RESULTS

Indeed, our study demonstrated a prompt induction of the transcription factors ATF4, ATF6 and XBP1 in IECs upon PT exposure. Thus, the upregulation of TG2 and downregulation of CFTR were prevented by ER stress inhibition/buffering by a pharmacological chaperone, also leading to restored physiological expression of OCL, CLD-2 and CLD-15, while preventing the expression of IFNγ, IL-15 and IL-17 A.

CONCLUSION

Overall, our analysis has highlighted the key role of ER stress in the pathogenesis of CD and identified the chemical chaperones as a new potential valuable therapeutic treatment for CD patients.

Clinical settings in which human leukocyte antigen typing is still useful in the diagnosis of celiac disease

Celiac disease (CD) is a systemic autoimmune disorder triggered by gluten ingestion ingenetically predisposed individuals. It is characterized by intestinal histological damage and the production of specific autoantibodies. The latest European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) 2020 guidelines have excluded human leukocyte antigen (HLA) genotyping from the no-biopsy diagnostic approach due to its weak positive predictive value, limited availability, and high cost in some countries. However, HLA genetic testing remains valuable in certain clinical contexts. This study provided practical indications for when to request and how to interpret HLA genotyping, emphasizing its continued relevance for CD diagnosis in specific cases. We also proposed a strategy for monitoring the risk of developing type 1 diabetes (T1D) in patients with CD, based on the risk stratification carried by different HLA genotypes. A retrospective analysis of 746 patients with CD and 627 controls was conducted at our hospital starting in 2012, when HLA genotyping became mandatory for the diagnosis of CD. We identified key clinical scenarios where HLA testing remains useful. Several high risk HLA-DQ genotypes strongly associated with CD were highlighted, including HLA-DQ2.5/HLA-DQ2.2 and HLA-DQ2.5/HLA-DQ2.5. Notably, while the HLA-DQ2.5/HLA-DQ2.2 genotype is linked to CD, it appears to confer protection against T1D. To support clinical practice, we presented a table clarifying commonly used HLA terminology, and another summarized the main clinical situations in which HLA genotyping should still be considered. These findings underscore the dual role of HLA testing: Not only can it help rule out CD in selected cases, but it also identifies patients with CD at risk for T1D, guiding personalized monitoring strategies.

Allergic and immunologic evaluation of children with celiac disease

Introduction

Celiac disease (CD) and allergic diseases are immune-mediated disorders with overlapping clinical and immunologic features. The association between CD and selective immunoglobulin (Ig) A deficiency (sIgAD) is well-established, but limited data exist on the relationship between CD, other antibody deficiencies, and allergic diseases in children. This study aimed to evaluate the prevalence of allergic manifestations and immunologic abnormalities in children with CD.

Methods

This prospective study included children with biopsy-confirmed CD, followed at a gastroenterology clinic from August 2022 to February 2023. Participants underwent comprehensive immunologic and allergic evaluation, including serum immunoglobulin levels, vaccine antibody responses, lymphocyte subgroup analysis, and allergy testing as clinically indicated.

Results

The cohort included 76 patients with a median age of 11 years and a median age at CD diagnosis of 5.8 years. Allergic manifestations included aeroallergen sensitivity (22.4%), allergic rhinitis (15.8%), allergic conjunctivitis (13.2%), food allergy (5.3%), and asthma and eczema (3.9% each). Immunologic evaluations revealed normal profiles in 69.7% of patients, while abnormalities included partial IgM deficiency (6.6%), unclassified hypogammaglobulinemia (5.3%), sIgAD (2.6%), and transient hypogammaglobulinemia of infancy (2.6%). Elevated IgE levels were observed in 13.2% of patients.

Conclusion

This study highlighted a significant prevalence of allergic diseases and immunologic abnormalities in children with CD, extending beyond the commonly recognized association with sIgAD. These findings underscore the importance of comprehensive immunologic and allergic evaluation in children with CD.

Bridging the Gap: Awareness, Knowledge, and Challenges of Living with Celiac Disease in Bulgaria

Background: Celiac disease (CD) is a chronic immune-mediated systemic disorder induced by gluten in genetically predisposed individuals, requiring lifelong management through a strict gluten-free diet (GFD). Although its global prevalence is around 1%, awareness and diagnosis remain suboptimal, contributing to challenges in disease management. Objectives: To assess the awareness, knowledge, and experiences of Bulgarian CD patients and caregivers regarding CD, diagnosis, and dietary adherence. Methods: A structured survey was conducted to evaluate patient and caregiver knowledge, awareness, and experiences with CD, focusing on the diagnostic process and dietary practices. Data were collected from a sample of Bulgarian CD patients and their caregivers. Results: The majority of the 191 respondents (94%) recognized CD as a lifelong condition, but only 26.7% correctly identified its autoimmune, systemic nature. The average diagnostic delay was 8.1 months, with over 50% of patients relying on serological tests alone, consistent with recent non-biopsy guidelines. Dietary adherence was significantly hindered by misconceptions about gluten-containing grains and societal barriers. Notably, 83.6% of participants reported bringing their own food when eating outside. Conclusions: The findings underscore the need for targeted public health initiatives, enhanced healthcare provider training, and improved dietary education to address knowledge gaps, expedite diagnosis, and improve dietary adherence. Such interventions could help reduce the psychosocial burden of CD and enhance the quality of life for affected individuals.

Celiac disease screening in children: evaluating the evidence, benefits, and challenges

Comprehensive screening of the general population is the only approach capable of identifying the majority of cases with celiac disease. In 2023, the Italian Parliament enacted a law to implement nationwide screening for celiac disease and type 1 diabetes. However, critical decisions regarding the target population, optimal timing, and screening methods remain unresolved. Previous observational studies on birth cohorts of children with genetic risk for these conditions have demonstrated that the incidence peaks early in life and is influenced by HLA risk genotypes. This mini-review explores different aspects of screening for celiac disease, presenting the advantages and challenges of identifying children before onset of symptoms. In addition, we summarize the current knowledge and gaps in understanding related to screening programs for celiac disease in children and adolescents and discuss health benefits, psychosocial aspects and cost-effectiveness, and their potential implications for future public health strategies.

Predictive factors of health related quality of life in children and adolescents with celiac disease: An Italian multicenter study on behalf of the SIGENP

BACKGROUND

In pediatric patients, celiac disease (CD) may influence the health-related quality of life (HRQoL).

AIMS

The study aimed to assess HRQoL and further characterise the clinical factors associated with reduced HRQoL, in a large multicenter pediatric cohort with CD.

METHODS

The disease-specific questionnaire CD Dutch Questionnaire (CDDUX) and the generic questionnaire Paediatric Quality of Life Inventory (PedsQL) were used to assess the HRQoL. Clinical and sociodemographic characteristics were analyzed, univariate and multivariate analysis were conducted.

RESULTS

Eleven different Italian pediatric centers and 871 families were involved. Mean age at interview was 12.9 ± 2.9 years. The mean total CDDUX score of CD patients was 47.1 ± 18.8, revealing a neutral HRQoL (47.1 ± 18.8), and a good to very good HRQoL according to the PedsQL (81.4 ± 12.6), parents indicated lower scores (p = 0.03) with both questionnaires (CDDUX 45.1 ± 18.6 and PedsQL 79.9 ± 14.5). Patients with lower HRQoL were mainly female, living in Northern Italy, with lower parent's education level and non-biopsy diagnosis of CD. In multivariate analysis, the main predictor of lower CDDUX score was non-biopsy diagnosis.

CONCLUSIONS

The HRQoL in a large cohort of Italian children is reported as neutral-good. This indicates a high level of adaptive behaviors in response to the daily challenges of CD. Parents tend to underestimate their children's HRQoL. Specific clinical factors, including non-biopsy diagnosis, may be associated to lower HRQoL.

Patient preferences for the diagnosis of coeliac disease: A discrete choice experiment

BACKGROUND

There is potential for a paradigm shift from a biopsy-to a serology-based diagnosis of coeliac disease in selected adult patients. However, it remains unknown if this approach would be acceptable to patients. We aimed to explore patients' preferences regarding the no-biopsy approach for coeliac disease diagnosis.

METHODS

We developed a discrete choice experiment survey containing 12 different scenarios with two possible alternatives (endoscopy & biopsy or serology) to estimate patient preferences. The scenarios were based on 5 attributes: risk of false positive results, risk of missed diagnosis, waiting time to start treatment, risk of complications, discomfort, or pain. Patient preferences and the relative importance of the attributes were estimated using a mixed logit model.

RESULTS

In total, 385 people (70.6% female, 98.2% white) across the four nations of the United Kingdom completed the survey. Respondents preferred a serology-based diagnosis over endoscopy and duodenal biopsies (59% vs. 41%, β coefficient 1.54, p < 0.001). Diagnostic test accuracy (p < 0.001), shorter waiting time to start treatment (p < 0.001), and discomfort levels during the procedure (p < 0.001) were the most important attributes to respondents. The risk of complications, including perforation and bleeding, did not significantly influence respondents' choices. Respondents with previous endoscopy experience were more willing to undergo endoscopy compared with those who never had one.

CONCLUSION

The no-biopsy approach to diagnosing coeliac disease is acceptable and preferred by patients over endoscopy and biopsy. Our findings highlight the importance of patient-centred care and shared decision-making in guiding diagnostic strategies for optimal patient outcomes.

Early-Life Exposure to Acid-Suppressive Therapy and the Development of Celiac Disease Autoimmunity

Importance

Early-life use of acid-suppressive therapy has increased over the past 2 decades. Although these medications are widely used, recent studies showed an association between early-life use of acid-suppressive therapy and various long-term outcomes, including celiac disease.

Objective

To assess the association between early-life use of acid-suppressive therapy and the risk of celiac disease autoimmunity using 2 observational approaches on a large population-based database.

Design, Setting, and Participants

The cohort study took place in Israel using Maccabi Healthcare Services data. The data were collected on December 8, 2023, and were initially analyzed from January to May 2024. Analysis of the data continued during the revision rounds that took place from October 2024 to February 2025. Children born between January 1, 2005, and December 31, 2020, were included, grouped based on their exposure to acid-suppressive therapy within the first 6 months after birth and subsequently followed up for outcome development until the age of 10 years or December 8, 2023. A retrospective matched cohort design (N = 79 820) and retrospective matched test-negative case-control design (n = 24 684), including only the population tested for celiac disease autoimmunity, were used separately and compared.

Exposure

Prescription purchase of acid-suppressive therapy, either proton-pump inhibitors or histamine-2 receptor antagonists, during the first 6 months of life.

Main Outcomes and Measures

Celiac disease autoimmunity was defined as a positive anti-transglutaminase 2 enzyme-linked immunosorbent assay test result according to the thresholds of the commercial kits used. Time to first positive result for celiac disease autoimmunity was defined as the outcome in the cohort design, and acid-suppressive therapy use was defined as the outcome in the test-negative design.

Results

The cohort design included 79 820 children (41 319 boys with no acid-suppressive therapy use [51.8%]; median birth year, 2015 [IQR, 2011-2018]), of whom 19 955 (25.0%) used acid-suppressive therapy. The rate of celiac disease autoimmunity was significantly higher among children using acid-suppressive therapy than among those not using acid-suppressive therapy (1.6% [310 of 19 955] vs 1.0% [610 of 59 865]; P < .001). The adjusted hazard ratio of acid-suppressive therapy use for development of celiac disease autoimmunity was 1.52 (95% CI, 1.33-1.74). In the test-negative case-control design, a total of 24 684 children were included (62.2% girls; median birth year, 2012 [IQR, 2009-2016]), of whom 6176 (25.0%) were celiac disease autoimmunity positive. The rate of acid-suppressive therapy users among those who tested positive for celiac disease autoimmunity was not significant compared with those who tested negative (5.0% [309 of 6176] vs 4.6% [858 of 18 508]; P = .25). The adjusted odds ratio of a positive celiac disease autoimmunity test for acid-suppressive therapy use was 1.07 (95% CI, 0.94-1.23), which was nonsignificant compared with the population that tested negative.

Conclusions and Relevance

This retrospective study included both cohort and test-negative case-control designs. In the cohort design, acid-suppressive therapy was significantly associated with celiac disease autoimmunity. In the test-negative case-control design, this association was not significant. These results suggest a residual confounding by health care utilization in cohort designs studying celiac disease and suggest a noncausal association between acid-suppressive therapy and celiac disease autoimmunity.

Diagnostic outcomes after gluten challenge in adult patients with unconfirmed coeliac disease already on a gluten-free diet: A 20-year retrospective cohort study

BACKGROUND

In uncertain cases of coeliac disease (CD), gluten challenge (GC) may be necessary to confirm or exclude the diagnosis. However, data on diagnostic outcomes after GC are limited.

AIMS

We aimed to evaluate outcomes after GC in patients with unconfirmed CD who had already started a gluten-free diet (GFD), and identify predictors of a confirmed diagnosis.

METHODS

Patients with unconfirmed CD already on a GFD, who underwent GC and subsequent testing with endomysial antibodies (EmA) and duodenal biopsy between 06/2000-06/2021 were included. Clinical data, prior test results, and final diagnoses were retrospectively collected and analysed.

RESULTS

158 patients underwent GC (median duration 3 months, IQR 3-6) and CD was confirmed in 47/158 (29.7 %) (41 conventional CD, 1 CD + IgAdeficiency, 5 potential CD), non-coeliac enteropathies (NCEs) were diagnosed in 3 patients, and enteropathy was ruled out in 108. Prior positive serology strongly predicted CD diagnosis after GC (OR 36.8, 95 %CI 13.8-100.0, p < 0.001), whereas prior reported villous atrophy did not (p = 0.83), as this was frequently (35 %) due to incorrect sampling/interpretation of poorly oriented specimens. Duration of GC was also not associated with diagnostic outcomes (p = 0.37).

CONCLUSION

Prior positive serology strongly predicted CD diagnosis after GC, while histological results without positive serology should be interpreted cautiously. Clinicians should consider NCEs in older patients with severe symptoms.

Low TTG-IgA associated with isolated bulb pathology in pediatric celiac disease: Implications in a no-biopsy approach era

OBJECTIVES

Duodenal involvement in celiac disease (CD) can be patchy, with a subset of patients demonstrating histopathological involvement limited to the bulb. This study evaluates whether bulb-restricted CD represents a distinct subgroup associated with lower titers of immunoglobulin A anti-tissue transglutaminase antibody (TTG-IgA) compared to distal duodenal CD in pediatric patients. Additionally, we assess the impact of a no-biopsy approach for pediatric CD with TTG-IgA ≥10 times the upper limit of normal (TTG-IgA ≥10× ULN) on the relative frequency of bulb-restricted CD among biopsied patients.

METHODS

Incident pediatric CD cases were identified retrospectively between 2017 and 2022. A no-biopsy approach for TTG-IgA ≥10× ULN was locally implemented in 2020. Serum TTG-IgA was categorized as negative, equivocal, positive TTG-IgA <10× ULN, and positive TTG-IgA≥ 10× ULN. Biopsies were classified by Marsh score and site of involvement.

RESULTS

Of the 405 cases included (mean age = 9.6 years, female-to-male ratio = 2.1:1), bulb-restricted CD was present in 7.4%. TTG-IgA was negative or equivocal in 60.0% of bulb-restricted CD, compared to 5.3% of distal duodenal CD (odds ratio [OR] = 26.6; 95% confidence interval [CI] = [11.1-63.3], p < 0.001). Notably, no bulb-restricted CD cases attained TTG-IgA ≥10× ULN, compared to 48.5% of distal duodenal CD. Following local implementation of the no-biopsy approach for TTG-IgA ≥10× ULN, the relative percentage of bulb-restricted CD significantly increased from 4.6% to 12.4% (OR = 2.9, 95% CI = [1.4-6.4], p = 0.004).

CONCLUSION

Pediatric CD with isolated bulb pathology presents with lower serum TTG-IgA titers than cases with distal duodenal involvement. Implementation of the no-biopsy approach increased the relative proportion of bulb-limited CD, as these cases were not associated with TTG-IgA ≥10× ULN.

Selective determination of 3,5-dihydroxycinnamic acid in urine samples as gluten intake biomarker: high-performance thin-layer chromatography combined with colorimetric detection

The determination of biomarkers is a significant field of analytical chemistry research under continuous evolution that contributes to enhance diagnostics and enable more personalized medicine. Celiac disease is a systemic autoimmune disorder caused by the ingestion of gluten (Glu) proteins found in various cereals. Currently, the only effective way to prevent and manage potential complications is through a strict gluten-free diet (GFD). However, both intentional and unintentional dietary transgressions can occur, often leading to persistent symptoms and ineffective treatment. In this scenario, the development of analytical strategies to detect biomarkers of gluten intake and monitor adherence to a GFD is of significant interest. Herein, we present an analytical strategy based on high-performance thin-layer chromatography (HPTLC) combined with colorimetric detection to estimate 3,5-dihydroxycinnamic acid (3,5-DHCA) as selective biomarker of Glu intake in urine. The approach combined Fast Blue (FB)-doped polydimethylsiloxane (PDMS) membrane with colorimetric HPTLC (RP-C18) giving rise to a selective method to isolate 3,5-DHCA response in urine samples. Detection by visual inspection, image analysis, and spectroscopic response was evaluated and compared. Analytical parameters were estimated showing a good sensitivity (limit of detection (LOD) ≤ 0.8 mg L-1) and precision, relative standard deviation (RSD) values < 7%. Analysis of urine samples of celiac patients and control patients was performed, and recovery studies showed satisfactory values (R > 80%). The preliminary results indicated correlation between Glu intake and positive 3,5-DHCA responses. This study demonstrated that FB-doped PDMS membranes-HPTLC is a promising tool for detecting dietary transgressions to the GFD by visual inspection, and subsequent quantitative analysis by image analysis and spectroscopic techniques. Hence, the proposed analytical method contributes to the advance of knowledge about celiac disease, which still remains an important challenge to our society.

What is new in the management of coeliac disease?

Coeliac disease is the most common immune-mediated enteropathy, affecting approximately 1 % of the population worldwide. Currently, the vast majority of individuals remain undiagnosed. Coeliac disease is triggered by gluten ingestion in genetically predisposed individuals carrying the human leukocyte antigen (HLA) genes; HLA-DQ2 and HLA-DQ8. Patients with coeliac disease present with a wide spectrum of gastrointestinal and extraintestinal manifestations and, in some cases, without any symptoms. The diagnosis of coeliac disease in adults is based on a combination of clinical suspicion, positive serological markers and histological evidence of small intestinal atrophy on duodenal biopsies. The only effective treatment is a strict, lifelong gluten-free diet. However, up to 20 % of patients report persistent or recurrent symptoms. In this review, we provide a comprehensive update on coeliac disease, focusing on its relevance to the different medical specialities and highlighting the need for a multidisciplinary approach to its diagnosis and management. Clinicians practicing internal medicine have a unique opportunity to diagnose this multisystem autoimmune disease. By doing so, they would avoid delays in diagnosis for these patients. A low threshold for serological testing is recommended.

No-Biopsy Diagnosis of Coeliac Disease in Children Without Anti-Endomysial IgA Antibody Testing: Combining Anti-Tissue Transglutaminase IgA and Anti-Deamidated Gliadin IgG Antibodies

AIM

To determine the utility of anti-tissue transglutaminase IgA antibodies (tTG-IgA) and anti-deaminated gliadin peptide IgG antibodies (DGP-IgG) in detecting coeliac disease (CD) and whether DGP-IgG can replace anti-endomysial IgA antibody in the European Society for Paediatric Gastroenterology Hepatology and Nutrition no-biopsy approach in diagnosing CD.

METHODS

Children aged < 19 years who had paired tTG-IgA and DGP-IgG performed and had a gastroscopy with biopsies between 1 March 2016 and 31 October 2020 were retrospectively reviewed.

RESULTS

Of 1206 patients who fulfilled the study criteria, 298 (24.7%) patients were diagnosed with CD. Fifteen patients with IgA deficiency were excluded from any tTG-IgA analysis. tTG-IgA had sensitivity and specificity of 93.5% and 92.0%, respectively, in detecting CD, while DGP-IgG had sensitivity of 97.0% and specificity of 86.7%. tTG-IgA ≥ 10x upper limit of normal (ULN) alone had a specificity of 99.3% and a positive predictive value (PPV) of 96.8%. An optimal DGP-IgG threshold was identified to be 70 U/mL (3.5x ULN) based on > 99% specificity in detecting CD. When tTG-IgA ≥ 10x ULN was combined with DGP-IgG ≥ 3.5 ULN, the PPV in diagnosing CD was 98.5%. DGP-IgG performed well in detecting CD in 126 children aged < 3 years, with all patients with CD having an elevated DGP-IgG (sensitivity 100%).

CONCLUSIONS

Combined tTG-IgA ≥ 10x ULN and DGP-IgG ≥ 3.5x ULN provided a high PPV (98.5%) in diagnosing CD. DGP-IgG testing can potentially replace EMA testing in those children with tTG-IgA ≥ 10x ULN. Future studies should evaluate DGP-IgG testing as a sequential test.

A systematic review of guidelines on screening for celiac disease in children with thyroid disease and vice versa

Introduction

Autoimmune thyroid diseases (ATD) are the most prevalent autoimmune disorders associated with celiac disease (CD). Both conditions can often be detected through serological screening in asymptomatic patients over several years. Various guidelines for screening thyroid disease (TD) are available in children with CD and vice versa.

Methods

We conducted a systematic review to identify the most recent and relevant guidelines, comparing their recommendations to analyze key differences and suggesting a practical clinical approach.

Results

Out of 1,294 articles reviewed, we identified 20 guidelines published between January 2013 and January 2024. These guidelines, primarily from gastroenterological organizations in Europe and North America, recommend different timings and methods for screening the co-occurrence of these diseases, both at diagnosis and during follow up. Some guidelines recommend only clinical follow-up without routine serological screening. There is limited consensus on screening for TD [using thyroid-stimulating hormone test (TSH)] in asymptomatic children newly diagnosed with CD, and even less agreement on screening for CD [using anti-transglutaminase antibodies (tTG) immunoglobulin A (IgA) test and total IgA] in children newly diagnosed with TD. No standardized procedures exist for managing patients with isolated low tTG and human leukocyte antigen (HLA) genotyping is rarely recommended as a first- line screening method.

Discussion

Over the past decade, there has been a growing recognition of the importance of identifying children with co-occurrence of CD and TD who could benefit from early treatment, even in the absence of symptoms. However, international guidelines still show a lack of consensus regarding screening for these frequently associated autoimmune diseases, with notable differences in the use of HLA testing and follow-up protocols.

A Rare Association of Celiac Disease and Aplastic Anemia

Celiac disease (CD) is a chronic immune-mediated disorder triggered by the ingestion of gluten in genetically predisposed individuals. Association of CD and aplastic anemia (AA) has been reported in the literature, yet this association remains rare in children. The authors report a case of a previously healthy 4-year-old boy with 1-month history of diarrhea, asthenia, loss of appetite, and weight loss. Laboratory evaluation showed bicytopenia with very severe aregenerative anemia and neutropenia. Bone marrow aspirate and biopsy were performed with findings suggestive of bone marrow aplasia. Further etiological research showed IgA deficiency and increased plasma concentrations of anti-tissue transglutaminase IgG antibodies (anti-tTG IgG 336 U/mL). Patient underwent upper digestive endoscopy confirming diagnosis of CD. The child started a gluten-free diet (GFD) with subsequent clinical and serological improvement. At 12-month post-hospitalization follow-up, the child was asymptomatic, with normal growth rate, resolution of bicytopenia, and anti-tTG IgG lower but still positive (151 U/ml) due to partial adhesion to GFD. To the best of author's knowledge, this is the eighth published pediatric case describing the association of CD with AA. The pathogenesis of this association is not yet fully understood. The authors suggest that CD screening should be considered in patients with unexplained hematological abnormalities.

Interpreting positive celiac serology in children with new-onset type 1 diabetes

OBJECTIVES

The association of celiac disease (CD) in type 1 diabetes mellitus (T1DM) is well-established, yet variation exists in screening practices. This study measures the accuracy of early screening with tissue transglutaminase immunoglobulin A (TTG-IgA) and endomysial antibody (EMA) in newly diagnosed T1DM.

METHODS

This is a retrospective study of children with T1DM between 2013 and 2019 with early CD screening and follow-up. Data elements included anthropometrics, serologies, blood pH, bicarbonate, and Hemoglobin A1c. Celiac serologies were analyzed using chi-square and receiver operating characteristic curves to calculate optimal levels for predicting CD.

RESULTS

A total of 1,292 children met inclusion criteria with 142 having positive celiac serologies; 47 (33.1 %) of whom were subsequently diagnosed with CD - an incidence of 3.6 %. All subjects with positive EMA and TTG-IgA ≥8 times upper limit of normal were diagnosed with CD. Gastrointestinal symptoms, BMI, and thyroid disease were not statistically significant variables in this cohort, although there was a trend toward CD in lower BMI patients and higher TTG IgA in those with markedly elevated HgbA1c.

CONCLUSIONS

Early celiac screening in T1DM is reliable and promotes timely CD diagnosis and treatment. Although transient positive celiac serologies were noted, the degree of TTG-IgA elevation and EMA positivity are strong predictors of coexisting CD. Larger prospective studies using these assays will further define the risk stratification algorithm that is needed for our T1DM community.

Diagnosis of celiac disease on a gluten-free diet: a multicenter prospective quasi-experimental clinical study

BACKGROUND

Diagnosing celiac disease (CD) in individuals adhering to a gluten-free diet (GFD) presents significant challenges. Current guidelines recommend a gluten challenge (GC) lasting at least 6-8 weeks, which has several limitations. Our aim was to compare four approaches previously proposed for diagnosing CD on a GFD: IL-2 serum levels, gut-homing CD8+ T cells, % TCRγδ+ intraepithelial lymphocytes (IELs), and UBE2L3 gene expression. Additionally, we evaluated the CD8+ T-cell-based method with a 3-day GC against the standard GC protocol.

METHODS

We conducted a multicenter prospective quasi-experimental clinical study. Two subsets of individuals were considered: (1) 20 patients with CD previously diagnosed and 15 non-CD controls, to evaluate the first aim; (2) 41 individuals with uncertain diagnosis who were on a GFD and required GC following current clinical guidelines, to assess the second aim. All participants underwent a 3-day GC (10 g gluten/day).

RESULTS

Among CD patients and non-CD controls, the sensitivity and specificity of IL-2, gut-homing CD8+ T cells, and UBE2L3 were 82.4% and 83.3%, 88.2% and 100%, and 52.9% and 100%, respectively. The percentage of TCRγδ+ IELs showed 88.2% sensitivity. In the uncertain diagnosis group, a CD8+ T-cell positive response was observed in 8 of the 41 subjects.

CONCLUSIONS

The percentage of TCRγδ+ IELs and the analysis of IL-2 levels and gut-homing CD8+ T cells are promising diagnostic methods for CD on a GFD. Notably, our results suggest that the CD8+ T-cell assay may provide a consistent and reliable alternative to the extended GC, eliminating the need for invasive procedures to obtain duodenal samples and prolonged gluten ingestion. However, further research with larger cohorts are necessary to validate these findings and establish their definitive clinical utility.

Impact of ESPGHAN no-biopsy strategy on the outcome of celiac disease treatment in children

Aim

The European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) allows a no-biopsy diagnostic of celiac disease under certain conditions. We assessed the impact of the diagnostic algorithm on the patient's long-term outcome by comparing the serology-based diagnosed patients to biopsy-proven ones.

Methods

We reviewed the charts of children presenting with antitransglutaminase IgA titers above ten times upper limit of normal and consecutively diagnosed with celiac disease between 2010 and 2014, a time-period overlapping with ESPGHAN diagnostic guideline change in 2012. Outcome measures for no-biopsy vs. biopsy-proven diagnosed patients were clinical and laboratory findings, compliance to gluten-free diet and to regular visits after one, two and 8-10 years of follow-up.

Results

Clinical and laboratory, i.e., serum chemistry and autoantibody outcome measures on gluten-free diet clearly showed worse patient healing in the 33 serology-based diagnosed children compared to the 30 biopsy-proven ones. The attendance of the follow-up visits was also higher in the biopsy group.

Conclusions

Our results indicate that dietary transgressions are common in childhood celiac disease resulting in slow healing. Therefore, there is a need of improvement of the management, with special attention regarding the ESPGHAN no-biopsy criteria diagnosed patients. Our study also indicates that novel treatments adjunctive to diet are warranted in children.

Hub-and-Spoke regional system supported by telehealth for managing coeliac disease in Liguria: a mixed-methods survey followed by an observational pilot study

BACKGROUND

Due to the need to reorganize the care network for the national screening mandated by law, a new healthcare model was required for the management of coeliac disease. The hub-and-spoke model is a new healthcare organizational system, here we describe its application (supported by telehealth), in the management of pediatric coeliac disease (CD) in Liguria. The results of the pilot phase are presented and the system's strengths and weaknesses discussed.

METHODS

A mixed-methods survey followed by an observational pilot study was performed. A multiphase approach was used including preparation setting, operative planning and application. The pilot phase involves a single primary center. The reduction of families' expenditure and environmental impact was assessed using the Viamichelin calculator.

RESULTS

A regional meeting followed by a survey (specifically developed for this study) and a needs analysis highlighted the priority to have an efficient, up to date and homogeneous model of care assistance throughout the network. A diagnostic and therapeutic care pathway (PDTC) was developed by the regional working group. The project involved 986 Ligurian families and allowed a 90% reduction in the distance traveled by families residing within the pilot center's catchment area, saving €177 and 113 kg of CO2 on average per family per year.

CONCLUSIONS

The Gaslini Diffuso hub-and-spoke system for managing CD in Liguria exemplifies a commitment to enhancing healthcare efficiency and patient care, reducing environmental impact and cost for both family and healthcare system.

Analyzing the landscape of coeliac crisis in adult and paediatric populations: A systematic review and meta-analysis

BACKGROUND

Coeliac crisis (CC) is a rare, potentially life-threatening manifestation of coeliac disease (CD).

AIMS

To comprehensively explore the clinical aspects, management strategies, and outcomes related to CC in both adult and paediatric populations.

METHODS

We conducted a comprehensive literature search to identify studies eligible for inclusion up to 28 December 2024. The study protocol was registered in PROSPERO (CRD42024510682).

RESULTS

A total of 46 included articles and 195 patients were analyzed. The median age of presentation was 18 years (range: 8 months to 83 years), predominantly affecting the paediatric population. An overwhelming majority (180 patients, 92.8 %) had CC as their first presentation, whereas the others were previously diagnosed CD cases with poor adherence to gluten-free diet (GFD). Clinically, patients presented with diarrhoea (88.2 %), abdominal pain (72.8 %), vomiting (56.4 %), confusion and lethargy (11.3 %). Electrolyte derangements in the form of hypokalemia (89.7 %) and hyponatremia (64.1 %), along with metabolic acidosis (79.5 %) and hypoalbuminemia (76.9 %), reflected the severity of malabsorption. Treatment with GFD caused clinical improvement in 186 (95.4 %) patients and mostly favourable long-term outcomes.

CONCLUSION

CC is a poorly understood, life-threatening complication of CD. Given its similarity with infectious conditions, clinicians require a high index of suspicion for recognizing CC to diagnose early and provide proper management.

Assessment of Knowledge of Celiac Disease and Associated Conditions Among Dietitians in Jordan

BACKGROUND

Celiac disease (CD) is a type of systemic autoimmune condition triggered by gluten consumption among genetically predisposed individuals.

AIM

To assess the knowledge, awareness, and practices pertaining to CD and associated conditions among dietitians in Jordan.

METHOD

A cross-sectional web-based survey was carried out between April and October 2023. The survey was an internet-based questionnaire with closed-ended questions.

RESULTS

The majority of dietitians answered correctly that CD is caused due to an immunological reaction to gluten, gliadin, and protamine (91.7%); it is an autoimmune disease (71.2%); and the risk of developing an autoimmune disease is higher among CD patients (78.8). The majority of respondents (93.6%) correctly identified that a strict gluten-free diet is the treatment approach for CD patients. However, only (18.9%) of dietitians correctly identified the FDA guidelines for "Gluten Free" food labeling. Approximately 53.4% of respondents identified immunoglobulin (IgA) antibody testing as the most reliable way to diagnose patients with CD.

CONCLUSIONS

The dietitians have a good understanding of CD topics. The development of credentials in CD would ensure that dietitians practicing in CD are skilled.

European Consensus on Malabsorption-UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN: Part 2: Screening, Special Populations, Nutritional Goals, Supportive Care, Primary Care Perspective

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. Patient's medical and pharmacological history are essential for identifying risk factors. Several examinations like endoscopy with small intestinal biopsies, non-invasive functional tests, and radiologic imaging are useful in diagnosing malabsorption. Due to its high prevalence, CD should always be looked for in case of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians have a central role in early detection of malabsorption and should be involved into multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving 10 scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

Celiac Disease-Narrative Review on Progress in Celiac Disease

Celiac disease is defined as a systemic immunological disorder caused by gluten (gliadin and other prolamin) in genetically predisposed individuals, who present with a variety of gluten-dependent symptoms, specific antibodies, the presence of the HLA DQ2 and DQ8 histocompatibility antigen, and enteropathy. Its prevalence, depending on the studied population and methodology, is estimated at 0.75-1.6% of the general population. During the complex immune reaction it induces, most cells involved in inflammatory processes are activated, which leads to the gradual atrophy of intestinal villi and the proliferation of enterocytes within intestinal crypts. The pathogenesis of celiac disease is extremely complicated and is still the subject of research. According to the current diagnostic guidelines, the following criteria should be taken into account: clinical symptoms (intestinal and extraintestinal), the presence of antibodies against tissue transglutaminase in the IgA class, the level of total IgA, and the presence of typical histological changes in duodenal biopsies. Diet-resistant celiac disease is one of the most important clinical challenges, causing serious complications. Currently, the basic method for treating celiac disease is an elimination diet (i.e., the exclusion of products that may contain gluten from the diet), however, new therapeutic strategies are still being sought, mainly based on supplementation with exogenous endopeptidases, modification of the immune response, and the use of zonulin inhibitors and transglutaminase 2 inhibitors. Clinical trials of new drugs are ongoing. The gradually expanding knowledge about the pathogenesis of celiac disease may allow for the development of new therapeutic strategies for both patients with a mild disease course, as well as those that are diet-resistant.

Broadening the clinical spectrum of White-Sutton syndrome, implications for co-morbidity with celiac disease in a patient with a novel likely pathogenic variant in the POGZ gene

White-Sutton syndrome (WHSUS) is a rare neurodevelopmental disorder caused by heterozygous variants in the POGZ gene. With slightly over 100 reported cases, the diagnosis of WHSUS remains challenging due to its variable and non-specific clinical features. We report a novel case of WHSUS carrying a heterozygous de novo variant in the POGZ gene and with characteristic clinical features including global developmental delay, autism spectrum disorder, generalised myoclonic epilepsy, hypotonia and distinct dysmorphic features. Notably, the patient also presented with mild gastrointestinal symptoms and was diagnosed with celiac disease (CD) based on elevated tissue transglutaminase IgA levels, confirmatory duodenal biopsy and HLA typing. Based on the recent evidence implicating chromatin remodelling genes in CD and the known role of the POGZ protein as a regulator of chromatin remodelling, we cautiously propose, for the first time, to our knowledge that the POGZ gene may contribute to the pathogenesis of the celiac disease, providing evidence of a possible association between White-Sutton syndrome and CD. Comprehensive functional, genetic and epidemiological studies are needed to explore further this potential association, which may broaden the clinical spectrum of WHSUS and improve the understanding of CD-related epigenetic factors.

Persistence of anemia in patients with Celiac disease despite a gluten free diet: a retrospective study

BACKGROUND

The main treatment for Celiac Disease (CD) is the gluten-free diet (GFD). However, in some CD patients, iron deficiency anemia can be persistent despite a GFD.

AIM

In this study, we aim to evaluate the prevalence of anemia in both adults and children with CD at the diagnosis and during the GFD.

METHODS

In this cross-sectional study including both adults and children with CD, the demographic characteristics and hemoglobin, iron, folate and vitamin B12 levels were retrospectively retrieved from patients' medical records at the time of diagnosis (T0); after 3-5 years (T1) and after 8-10 years (T2) of GFD.

RESULTS

311 CD patients (184 adults and 127 pediatric patients) were included in the study. No difference was observed in the prevalence of anemia in the overall population after 3-5 years of GFD in both adult and pediatric patients compared to the diagnosis. At 8-10 years, in the adult patient's group, a significant reduction in the prevalence of anemia was observed (24% vs. 17.8% p = 0.043).

CONCLUSIONS

Despite the GFD and a very long observational period the diagnosis of anemia persists in 17.8% and 4.4% of adult and pediatric patients, respectively. The diagnostic delay (longer in adult patients) and a more pronounced ultrastructural mucosal injury could play a role in the persistence of anemia despite the GFD.

Celiac disease, non-celiac wheat sensitivity, wheat allergy - clinical and diagnostic aspects

In recent years, wheat- and gluten-free diets have increased in demand due to reported increases in various conditions reported to be driven by ingredients of these food products. Celiac disease, wheat allergy and non-celiac wheat sensitivity constitute the three main categories of wheat-related disorders. Celiac disease is a well-characterized immune-mediated disease caused by immune reaction against specific gliadin epitopes, the main protein in wheat. Screening studies of samples collected over time bring evidence that there is a true increase in prevalence not only driven by increased testing activity. Clinical presentation of CeD is diverse and there is an increased risk of autoimmune co-morbidities. Wheat allergy consists of IgE- and non-IgE-mediated reactions, driven by Th2-cells directing eosinophil and basophil responses. Rapid IgE-mediated reactions are characterized by specific IgE antibodies in conjunction with symptoms originating especially from the respiratory and gastrointestinal tract. There is an increased risk of other allergies and the majority recover during adolescence. Non-IgE-mediated wheat allergy is a less-well defined condition, which is often diagnostically challenging due to a longer interval between exposure and symptoms and lack of non-invasive biomarkers. In this condition, wheat as a trigger needs to be established by exclusion followed by dietary challenge. Non-celiac wheat sensitivity, despite being the most recently recognized, has the highest reported prevalence among the three wheat-related entities. It remains, however, particularly poorly characterized due to unclear pathophysiology and lack of diagnostic markers. This narrative review will scrutinize the shared and distinct clinical features of the three wheat-related conditions, focusing on epidemiology, clinical presentation, co-morbidities, diagnosis, treatment and prognosis.

Assessment of Intraepithelial Lymphocytes Count in Potential Celiac Disease

Intraepithelial lymphocytes (IELs) count, central for coeliac disease (CD) diagnosis, can be performed either directly on hematoxylin and eosin (H&E)-stained paraffined sections or on optimal-cutting-temperature-compound (OCT)-embedded frozen sections stained by immunohistochemistry (IHC) with anti-CD3. We evaluated the concordance in Marsh grading between these two techniques on a large sample of sections. A total of 280 patients with a normal intestinal architecture, 210 potential celiac disease (PCD) patients, and 70 controls (CTR) were included. At the H&E histological evaluation, 136/280 were classified as Marsh-0 (showing < 25 IELs/100 enterocytes) and 144 Marsh-1, while at the IHC evaluation, 191 were classified as Marsh-0 (showing ≤ 34 CD3+/mm of epithelium) and 89 Marsh-1. The overall concordance was 66.8% (48.6% Marsh-1 and 86% Marsh-0) with a Cohen Kappa value of 0.33. In the PCD group, the overall concordance was 63% (45.6% Marsh-1 and 84% Marsh-0) with a Cohen Kappa value of 0.26, while in the CTR group it was 77% (60% Marsh-1, 90% Marsh-0) with a Cohen Kappa value of 0.54. Differences between the two groups were statistically significant (p < 0.05). In conclusion, the concordance of IELs counts between histological and IHC evaluation is low (Kappa Cohen 0.54) in no-CD and even more in PCD patients (0.26). Caution must be paid when classifying a patient as Marsh-0 or Marsh-1 according to the technique used.

Food protein-induced enterocolitis syndrome after involuntary gluten transgression in celiac children: A new increasingly common complication?

Among the possible adverse reactions to gluten, celiac disease, non-celiac gluten sensitivity, and IgE-mediated wheat allergy have been classically described. A non-IgE-mediated reaction similar to food protein-induced enterocolitis syndrome (FPIES) after inadvertent gluten ingestion in a celiac patient was recently reported. We present three children affected by celiac disease with exquisite control, including appropriate adherence to an exclusion diet, who suffered a severe adverse food reaction after unappreciated outdoor ingestion of gluten, meeting the criteria for a definitive diagnosis of FPIES. The strict and prolonged exclusion of gluten from the diet is postulated as the possible trigger for this serious entity after an involuntary transgression. Although the first published cases are recent, we might be witnessing an increase in the frequency of presentation. Therefore, we believe emergency services must be alert to the possibility of diagnosis of FPIES in celiac patients due to involuntary transgressions. The determination of gluten glycoimmunopeptides in urine or stool samples may be useful for certifying the inadvertent consumption of wheat as the cause of FPIES.

Faecal biomarkers in children with coeliac disease: A way forward?

AIM

Novel markers to reflect the intestinal damage in coeliac disease are needed. We studied the potential of faecal and serum neopterin, and faecal myeloperoxidase, human β-defensin-2, and lipocalin-2 in a case-control study.

METHODS

Data were collected from medical records and a biobank including newly diagnosed coeliac disease patients, potential coeliac disease patients and non-coeliac controls. Commercially available ELISA assays were used for measuring the biomarkers.

RESULTS

Altogether 19 patients with coeliac disease (median age 9.0 years), 8 with potential coeliac disease (4.0 years) and 18 controls (6.5 years) were included. The highest faecal neopterin levels were seen in potential coeliac disease, followed by controls and coeliac disease (median 513 vs. 372 vs. 255 nmol/L, respectively, p = 0.016). Also, serum neopterin was highest in the potential coeliac disease group (9.8 vs. 5.5 vs. 5.9 nmol/L, p = 0.022). After age adjustment and robust variance estimation, only differences in serum neopterin remained significant. Other markers did not differ between the groups. None of the markers were significantly associated with serum transglutaminase-2 antibody levels.

CONCLUSION

Differences in neopterin levels amongst patients with potential coeliac disease, coeliac disease, and controls suggest that neopterin might serve as an early disease marker.

Utility of endoscopy in paediatric gastroenterology and hepatology-Review and updates

Paediatric endoscopy has been an integral part of the diagnostic evaluation and management of gastroenterology and hepatology diseases in children. This area of clinical medicine has made meteoric advancements since it was first introduced conserving it's traditional roles of gastroscopy and colonoscopy but broadening significantly it's clinical utility and diagnostic accuracy with new and emerging technology. This article aims to explore and review the current utility and emerging applications of diagnostic and therapeutic endoscopy for the practicing paediatric gastroenterologist and hepatologist.

Are the ESPGHAN criteria valid with the chemioluminiscence method? Analysis of potential diagnostic errors

OBJECTIVES

To determine how many patients may have received a mistaken diagnosis of coeliac disease using the ESPGHAN 2012 and 2020 criteria without performance of biopsy when using chemiluminescence, and to evaluate possible causes of interference affecting anti-tissue transglutaminase antibody results obtained with this technique.

METHODS

Retrospective and descriptive study of biopsies of patients with elevated tissue transglutaminase antibodies (tTGA) measured by chemiluminescence in a tertiary care hospital.

RESULTS

The sample included 135 patients with a mean age of 7.7 years. The diagnosis of coeliac disease was confirmed in 67 (49.6%) and ruled out in the remaining 68 (50.4%). Subsequently, among those with a non-diagnostic biopsy, we found that 13 (19.1%) would have met the ESPGHAN 2012 criteria and 17 (25%) the ESPGHAN 2020 criteria. The tTG antibody levels were greater than 10 times the upper limit of normal (ULN) in 27.9%. In patients who tested positive for endomysial antibodies (EMA), the cut-off point for tTGA measured by chemiluminescence that achieved the best combined sensitivity and specificity (Youden index) was 849U/mL (42.5×ULN). On the other hand, if EMA levels were not taken into account, the cut-off point was 301U/mL (15×ULN). In addition, 16 patients (23.5%) received a diagnosis of chronic gastritis secondary to Helicobacter pylori (HP) infection, of who 50% fulfilled the ESPGHAN 2012 and 2020 criteria for diagnosis without biopsy.

CONCLUSIONS

Transglutaminase antibody levels measured by chemiluminescence offer a high sensitivity, but there can be artifacts due to situations such as infection by HP. Therefore, the ESPGHAN guidelines must be revised for application in this particular case.

Typing of HLA susceptibility alleles as complementary tool in diagnosis of controversial cases of pediatric celiac disease

Objectives

Diagnosis of celiac disease (CeD), an immune-mediated disorder, is based on clinical presentation, a panel of serological markers, and the histopathological findings in duodenal biopsies. Commonly, pediatric CeD patients fulfill these criteria for diagnosis. However, lack of correlation between serology tests and histology, or no accessible biopsies because of clinical conditions or during the COVID pandemic, are conditions that led to inconclusive diagnoses. Since the majority of CeD patients carry HLA-DQ2 and/or DQ8 alleles, HLA testing is used as a complementary tool in diagnosis though is costly and not broadly available for gastroenterology centers.

Methods

We performed a retrospective study to assess the performance of HLA testing when applied to selected groups of patients who could not be definitely diagnosed following the common algorithm. Eighty patients underwent testing for CeD-related HLA-DQ2 and DQ8 alleles.

Results

HLA typing contributed to diagnosis in 34 patients with positive serology but normal mucosa or those who presented negative serology or slightly positive serology (less than 3 times ULN) and duodenal histopathological changes. In patients with normal histology and negative or slightly positive serology, or those who did not undergo intestinal biopsy (39 in total), HLA typing contributed to CeD diagnosis in 23 cases, only 16 patients were admitted for a clinical follow-up program.

Conclusion

HLA-DQ typing supported the diagnosis in 57 of 80 children (71.2%) with previously inconclusive results, providing a beneficial approach for diagnosing celiac disease (CeD) in selected cases.

Parameters associated with the development of autoimmune diseases in pediatric onset celiac disease

Patients with celiac disease (CeD) have an increased risk of developing other autoimmune diseases (ADs); however, risk factors and predictors for ADs remain unclear. The study objective is to assess predictors for development of ADs among pediatric onset CeD patients. The study included pediatric onset CeD patients, evaluated at Emek Medical Center, and followed for at least 2 years from April 2008 to April 2022. Data were collected from medical records and included baseline and follow-up data of demographics, clinical manifestations, laboratory variables, and subsequent development of ADs. Then, 930 children with CeD were included, and 790 fulfilled inclusion criteria. Patients were followed for a median of 4.9 years (range 2-16 years). During follow-up, 45%, 68%, and 80% normalized their tissue transglutaminase (TTG) levels by 6, 12, and 24 months, respectively. Among the entire cohort, 16 patients (2%) developed type 1 diabetes mellitus, 35 (4.4%) developed Hashimoto's thyroiditis, and 11 (1.3%) developed other ADs. Of 510 patients with sustained serological remission, 39 (7.6%) patients developed ADs compared to 23 (11.5%) of patients without sustained serological remission. In multivariate Cox models, shorter time to TTG normalization (hazard ratio (HR) 0.94 CI 95% 0.88-0.99) and sustained TTG levels less than three times the upper limit of normal (HR 0.87 CI 95% 0.72-0.96) were significantly associated with reduced risk of developing ADs.

CONCLUSION

Effective management of celiac disease, including timely TTG normalization and sustained lower TTG levels, may be important for reducing the risk of subsequent development of ADs in pediatric-onset CeD.

WHAT IS KNOWN

• Pediatric patients with celiac disease (CeD) are at an increased risk of developing autoimmune diseases (ADs). Risk factors contributing to the development of ADs in CeD patients are not well established, particularly in the pediatric population.

WHAT IS NEW

• Timely TTG normalization and sustained low TTG levels (<3 times ULN) during follow-up are associated with a reduced risk of developing additional ADs in pediatric CeD patients.

Paediatric gluten ataxia: a rare neurological presentation of gluten sensitivity in a toddler

A toddler presented with a 6 week history of progressively worsening ataxia, weight loss and loose stool. There was no developmental regression, history of fever or foreign travel. Extensive investigation, including cerebrospinal fluid studies and neuroimaging, were inconclusive. In coeliac screen, the endomysial antibodies were positive with above tenfold elevation of IgA TTG from normal limit, making the diagnosis of coeliac disease (CD). The association of CD with neurological symptoms in our case led to the clinical impression of gluten ataxia. She was started on gluten free diet and had complete symptom resolution in over 4 weeks' time since the start of gluten-free diet. Although common in adults, it has not been reported in toddlers, expanding the differential diagnosis of ataxia.

Long-term laboratory follow-up is essential in pediatric patients with celiac

OBJECTIVES

Celiac disease (CeD) requires long-term follow. The role of laboratory testing other than celiac serology during follow up is unclear. We aimed to determine which laboratory tests are required during follow up based on the prevalence of abnormal tests and timing of abnormalities appearance.

METHODS

Retrospective chart-review of children diagnosed with CeD between 1999 and 2018 was conducted. Demographic, clinical and laboratory data were recorded from diagnosis and during follow-up.

RESULTS

The cohort included 500 children with CeD [59.8% females, median(IQR) age at diagnosis 5.7(3.7-8.9) years]. Mean follow-up time was 5.5 years (range 1.5-16.2). The most frequently abnormal laboratory tests at time of diagnosis were low ferritin (64.3%), vitamin D (33.6%), zinc (29.9%), hemoglobin (29.2%), and folate (14.7%). In 74 (14.8%) patients, anemia developed only during follow up, while in another 46 patients, anemia resolved after diagnosis and reappeared later (after a mean ± SD 2.8 ± 2.1 years from CeD diagnosis, for the entire group). Abnormal values that developed during follow up were low folate in 40 patients (3.9 ± 2.6 years), and abnormal liver enzymes in 18 patients (3.1 ± 2.7 years). Elevated TSH during follow-up was observed in 14/280 (5%) patients, after a mean ± SD of 2.2 ± 1.6 years from diagnosis. Patients diagnosed as teenagers (12-18 years) had shorter intervals to reappearance of anemia and folate deficiency.

CONCLUSIONS

Multiple laboratory abnormalities may occur in pediatric patients with CeD, both at diagnosis and during long-term follow-up. We suggest continued monitoring of hemoglobin, ferritin, folate, liver, and thyroid function in addition to celiac serology during follow-up of CeD.

Patients' and paediatric gastroenterologists' assessments of the follow-up of coeliac disease in Spain

INTRODUCTION

There is high variability in the follow-up of paediatric patients with coeliac disease (CD) in Europe. The aim of this study was to know the current reality of paediatric CD follow-up in Spain through professionals and the patients themselves and their families.

PATIENTS AND METHODS

A cross-sectional descriptive study was conducted using 2 anonymous web surveys, one aimed at paediatric gastroenterologists, and the other at members of CD patients' associations.

RESULTS

A total of 96 responses from paediatricians and 4745 from patients (1362<15 years) were analysed. Among the professionals, 84.4% carry out follow-up only at the hospital level. A percentage of 80.2 lack a joint follow-up protocol with primary health care. The transition after the paediatric age is made to adult gastroenterologists by 56.2% of professionals (only 8.3% in a protocolized manner). A percentage of 58.3 do not have a dietitian and 64.6% do not use quality of life questionnaires. The patients stated that they mainly performed follow-up visits in the hospital (68.8%). Only 15.7% ever consult a dietitian. Scheduled visits were more frequent in paediatric patients than in adults (95.1% vs. 63.5%, p<0.001). The variable most associated with attendance at follow-up visits was that the survey had been answered by the patient's parents (odds ratio 2.6, p<0.001).

CONCLUSIONS

In Spain, there is a lack of follow-up protocols for paediatric CD patients integrating hospitals and primary care, as well as protocols for the transition to adult professionals. The participation of dietitians is very low. Adult patients adhere less to follow-up visits.

Living with Pediatric Coeliac Disease: Lessons for Health Service Delivery

BACKGROUND

Coeliac Disease (CD) affects up to 1.4% of children worldwide, with a rising global incidence. A less typical clinical presentation and the need for a life-long gluten exclusion diet raise challenges for diagnosis, management, and healthcare delivery with considerable impacts for CD patients and families as well as clinical services.

AIMS

To explore the lived experiences of caregivers of children with CD to identify barriers and enablers to diagnosis, referral, and treatment to inform a more streamlined service delivery model.

METHODS

Semi-structured interviews with caregivers of children with CD diagnosed for at least one month with no significant co-morbidities. Interviews were thematically analyzed.

RESULTS

Sixteen participants representing 12 family units were interviewed. Children with CD ranged in age from 3 to 18 years. Time from symptom onset to diagnosis varied from one month to > 10 years and symptoms were mainly atypical and non-specific. Six key themes were identified: the iterative diagnosis journey, restricted choices, child responsibility and autonomy, mental load (encompassing foodwork, emotional rollercoaster, and lack of trust), Google™ reigns for information, and where to from here?

CONCLUSION

There is a need to decentralize CD diagnosis and management to meet the increasing demand created by rising incidence. Participants highlighted the need for a more streamlined diagnosis pathway, increased training of health professionals, and access to age-appropriate resources. Efforts need to be made to advocate for increased community awareness. These insights will be used to reimagine and co-design a decentralized model of care for pediatric CD diagnosis and management in Queensland, Australia.

Utilizing both IgA tissue transglutaminase and IgG-deamidated gliadin peptide antibodies offers accurate celiac disease diagnosis without duodenal biopsy

BACKGROUND

Gastroenterologists still raise concerns about adopting a non-biopsy strategy for diagnosing celiac disease (CeD) in adults.

AIM

To assess the performance of the concurrent detection of two autoantibodies targeting two independent antigens, tissue transglutaminase (tTG) and deamidated gliadin peptides (DGP).

METHODS

This prospective, multicenter, binational study collected consecutive patients with a high pre-test probability for CeD. Between 2018 and 2020, adults were enrolled at four Italian and one Argentinian center. Serology was also blindly analyzed by a central laboratory (Werfen, San Diego, USA) for tTG IgA and DGP IgG by Aptiva Particle-based multi-analyte technology (PMAT) assays. CeD diagnosis required histological confirmation of Marsh 3 damage.

RESULTS

181 adult patients with suspected CeD were enrolled (134 with histological diagnosis of CeD and 47 not histologically confirmed as CeD). Patients positive for both tTG IgA and DGP IgG (double positive) were predictive of CeD in 92.5 % of patients at >1x upper limit of normal (ULN). Double positivity for tTG IgA and DGP IgG, both at >10x ULN, had a 100 % positive predictive value for the presence of Marsh 3 histology.

CONCLUSIONS

Incorporating DGP IgG alongside tTG IgA in a single-step approach can be considered a valid confirmatory strategy for definitive non-biopsy diagnosis of CeD.

A new algorithm for coeliac disease based on the 'long forgotten' TCRγδ+ intra-epithelial lymphocytes detected with an antibody working on FFPE sections

AIMS

Diagnosis of coeliac disease (CD) with mild mucosal changes is difficult for all parties involved. We aimed to determine the power of T cell receptor (TCR)γδ+ intra-epithelial lymphocytes (IELs) in discriminating CD from other causes of intra-epithelial lymphocytosis using a new monoclonal antibody.

METHODS

A total of 167 cases categorised as coeliac (117 untreated CD, classified according to Marsh, updated by Ensari, including 29 type 1, 29 type 2, 39 type 3 and 20 treated CD), and non-coeliac groups (24 controls and 26 non-coeliac IELosis) based on clinical, serological and histological data were studied for IEL counts enumerated per 100 enterocytes using haematoxylin and eosin, CD3, TCR δ-stains.

RESULTS

TCRγδ+ IELs were significantly higher in CD (24.83 ± 16.13) compared to non-CD (6.72 ± 6.32) and were correlated with the degree of mucosal damage. Both γδ+ IEL count and ratio showed higher performance in differentiating untreated coeliacs from controls, with a sensitivity of 83.76; 85.57 and specificity of 95.83; 79.17, respectively. TCRγδ+ IEL counts distinguished type 1 CD (20.41 ± 13.57) from non-coeliac IELosis (9.42 ± 7.28) (p = 0.025). Discriminant analysis revealed that villus/crypt ratio, γδ+ and CD3+ IEL counts, γδ+/CD3+IEL ratio, IEL distribution pattern were potent discriminants and correctly classified 82.3% of cases while the algorithm accurately diagnosed 93.4% of cases.

CONCLUSIONS

The new antibody detecting γδ+ IELs in FFPE sections revealed thresholds of 10.5 for γδ+ IELs and 14% for γδ+/CD3+IEL ratio which distinguished coeliacs from non-coeliacs with high sensitivity and specificity, particularly in cases with normal villus/crypt axis including type 1 CD, non-CD IELosis and controls. A 'coeliac algorithm' based on γδ+ IELs is proposed with the hope that it will be used in the histopathological diagnostic approach by the pathology community.

Prevalence and Predictors of Follow-up Endoscopic Biopsy in Patients With Celiac Disease in the United States

OBJECTIVE

To characterize the frequency and predictors of follow-up endoscopic biopsy in patients with celiac disease.

BACKGROUND

The utility of routine follow-up biopsy in patients after a diagnosis of celiac disease is uncertain, especially in patients whose symptoms resolve on the gluten-free diet.

PATIENTS AND METHODS

Using the Merative MarketScan U.S. commercial insurance and Medicare databases, we identified 30,737 patients with biopsy-diagnosed celiac disease. We followed them until they had a second duodenal biopsy (our primary outcome) or insurance coverage ended.

RESULTS

Among the patients with celiac disease we identified, 5976 (19.4%) underwent a follow-up biopsy. The median time between initial and follow-up biopsies was 16.8 months. Compared with younger patients, those aged 20 years or older had an increased likelihood of undergoing a follow-up biopsy (cumulative incidence rate at 5 y for patients age ≥20 y was 36.0%, 95% CI: 35.0%-37.1% vs 21.9%, 95% CI: 20.5%-23.4% in patients age ≤19 y). Follow-up biopsies occurred less frequently in more recent calendar years. Follow-up biopsy was more common among patients with an Elixhauser Comorbidity Index of 1 (hazard ratio: 1.09; 95% CI: 1.01-1.17) or ≥2 (hazard ratio: 1.28; 95% CI: 1.20-1.37) compared with patients with an index of zero. Among patients who had a follow-up biopsy, 57% had a celiac disease-related symptom recorded in the 30 days before the procedure.

CONCLUSIONS

Follow-up duodenal biopsy is performed in a substantial minority of U.S. patients with celiac disease. Adult age and increased comorbidity burden were associated with a greater likelihood of follow-up biopsy. Just under half of follow-up biopsies are performed for routine surveillance, in the absence of persistent symptoms.

Short- and Long-Term Nutritional Status in Children and Adolescents with Celiac Disease Following a Gluten-Free Diet: A Systematic Review

BACKGROUND/OBJECTIVES

Numerous studies have highlighted the nutritional imbalances that are commonly observed in children and adolescents diagnosed with celiac disease (CD) who follow a gluten-free diet (GFD). However, the development and timeline of these nutritional deficiencies remain unclear. The aim of the present study is to investigate the short-term (≥6 months to <12 months) and long-term (≥12 months) association between adherence to a GFD and nutrient intake as well as micronutrient blood status in children and adolescents aged from 0 to 18 years with CD.

METHODS

A systematic review was conducted in PubMed and Scopus for observational studies published up to June 2024.

RESULTS

A total of 15 studies (case-control, cross-sectional, and prospective studies) with 2004 children and adolescents were included. Their quality was assessed using the ROBINS-E tool. Despite the lack of high-quality data and the heterogeneity of the methods used in the included studies, the results of the cross-sectional/case-control studies show that, in the short term, children and adolescents with CD consumed excessive amounts of protein and carbohydrates compared to controls. After long-term adherence to a GFD, significant changes in the diets of children and adolescents with CD persisted. Fat intake was higher, while protein intake remained excessive compared to controls. Based on prospective studies, vitamin C and iodine intake improved both in the short and long term after adherence to a GFD. However, most other nutrients either remain inadequate or continue to decline, indicating that it is difficult to meet nutrient requirements despite dietary adjustments.

CONCLUSIONS

Gaps in adherence to dietary recommendations appear to be widespread in children and adolescents with CD, emphasizing the need for improved diet quality and regular monitoring.

Phenotypical Characterization of Gastroenterological and Metabolic Manifestations in Patients With Williams-Beuren Syndrome

Gastrointestinal (GI) symptoms are common in patients with Williams-Beuren syndrome (WBS), but their prevalence and possible causes are not yet fully known. This study assessed GI symptoms' prevalence and their possible origin by performing a predefined set of tests in adult WBS patients. Laboratory tests and a questionnaire were administered to assess GI symptoms and dietary habits. All the patients underwent the urea breath test, H2-lactose and H2-glucose breath tests, and intestinal ultrasound (IUS) and vibration-controlled transient elastography for liver stiffness measurement (LSM) and controlled attenuation parameter (CAP, dB/m). Thirty-one patients were enrolled (72% of the whole cohort, 17 males, median age 32 years). Gastroesophageal reflux disease (GERD) symptoms were reported in 29% of the patients, abdominal pain in 26%, and altered bowel habits in 48%. Pathologic signs at (IUS) were present in 60% of the cases. Prevalence was 0.26 (95% CI 0.12-0.44) for Helicobacter pylori infection and 0.61 (95% CI 0.42-0.78) for lactose intolerance. LSM was > 6 kPa (in the range of a fibrosis score > F1) in three patients, and CAP values were > 268 dB/m (corresponding to a steatosis score > S2, e.g., moderate steatosis) in nine. The presence of altered bowel habits was significantly related to chronic abdominal pain (OR 13.1, p = 0.03). Increased BMI (> 28 kg/m2) (OR 10.8, p = 0.04) was associated with the presence of moderate-severe hepatic steatosis. After specific treatment and dietary counseling, most patients reported resolution/improvement of symptoms, whereas a few retained/developed symptoms during follow-up. Chronic abdominal pain, GERD symptoms, and unbalanced metabolic parameters were common in our WBS patients, together with an increased prevalence of lactose intolerance/colonic diverticula. Specific counseling and treatment improved symptoms for most patients.

Development of Cell-Assembled Human Endomysial-Type Biomatrix Substrate for the Detection of Celiac Disease Autoantibodies

The endomysial antibody (EMA) immunofluorescent test is a highly specific method to detect disease-specific autoantibodies in celiac disease (CD) by their binding to natural transglutaminase-2 autoantigen in tissue sections, and it is used as a compulsory confirmatory test in the non-invasive diagnosis of CD. The classical EMA substrates are the monkey esophagus and the human umbilical cord. It is increasingly difficult to use these tissues due to ethical concerns and animal welfare regulations. In this study, we developed, in cell culture, an endomysium-type extracellular biomatrix assembled by human umbilical cord vein-derived endothelial cells which binds CD antibodies in a similar pattern as monkey esophagus and has similar macromolecular composition. Evaluating retrospectively and prospectively tested patient cohorts, including 130 CD cases and 105 non-celiac controls, IgA-class celiac antibody detection on the biomatrix was equally specific (100%) as EMA testing on tissues, and had higher sensitivity (95.6% versus 91.2%). Both EMA tests were less sensitive, but more specific than transglutaminase-based ELISA measurements. The decellularization of the biomatrix improved sensitivity, enabled the detection of IgG-class celiac antibodies, and allowed for simple reading without previous training. This easily available cell-assembled biomatrix substrate may replace substrate tissues in diagnostic EMA testing in the future.