Celiac disease with mild to moderate histologic changes is a common cause of chronic diarrhea in Indian children.
OBJECTIVE
In developed countries, small bowel histology in coeliac disease is a spectrum, ranging from normal with increased intraepithelial lymphocytes to the classic flat mucosa. In developing countries, mild to moderate enteropathies in children with chronic diarrhea and growth failure are assumed to be caused by tropical sprue, persistent infections, or malnutrition with bacterial overgrowth. We report the prevalence and histology of coeliac disease in children with chronic diarrhea at a tertiary referral hospital in North India.


METHODS
Two hundred fifty-nine children with symptoms indicating coeliac disease attended the All India Institute of Medical Sciences. Histology was graded after a modified Marsh classification. Serum immunoglobulin A anti-endomysial antibodies (AEA) were assayed using indirect immunofluorescence. Subjects with abnormal histology and positive AEA were put on a gluten free diet (GFD). Coeliac disease was diagnosed on small intestinal biopsy changes and a clinical response to a GFD.


RESULTS
Severe enteropathies were present in 63 (24%) subjects, and 58 (92%) responded to a GFD. Sixty-six (25%) had moderate histologic changes, 61 responding to a GFD. AEA was positive in 56 of 63 patients with severe and 65 of 66 with moderate enteropathies. Fifty-seven children had mild enteropathies, and 19 of 20 with positive AEA responded clinically to a GFD.


CONCLUSIONS
Coeliac disease is more common than previously believed. It presents a variable histology, and diagnoses may be missed or delayed if based only on severe enteropathies. Serology is a useful adjunct to diagnosis, and diagnostic criteria need to be developed appropriately for coeliac disease in developing countries despite limited facilities.
Bhatnagar
Shinjini
S
Centre for Diarrhoeal Diseases and Nutrition Research, Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. shinjini_bhatnagar@rediffmail.com
Gupta
Sidhartha Datta
SD
Mathur
Meera
M
Phillips
Alan D
AD
Kumar
Ramesh
R
Knutton
Stuart
S
Unsworth
David J
DJ
Unsworth
Joe
J
Lock
Robert J
RJ
Lock
Bob
B
Natchu
Uma C M
UC
Mukhopadhyaya
Sanjay
S
Saini
Savita
S
Bhan
Maharaj K
MK
D000293:Adolescent; D001323:Autoantibodies / Q000097:blood*; D002446:Celiac Disease / Q000150:complications* / Q000175:diagnosis / Q000178:diet therapy / Q000473:pathology; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease; D003967:Diarrhea / Q000175:diagnosis / Q000178:diet therapy / Q000209:etiology* / Q000473:pathology; D005260:Female; D019084:Fluorescent Antibody Technique, Indirect; D005983:Glutens / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D007413:Intestinal Mucosa / Q000473:pathology; D008297:Male; D012720:Severity of Illness Index; D016896:Treatment Outcome
D001323:Autoantibodies; D005983:Glutens