title: Noncoeliac enteropathy: the differential diagnosis of villous atrophy in contemporary clinical practice.
abstract: BACKGROUND
  Duodenal villous atrophy (DVA) is a key diagnostic finding in coeliac disease (CD). However, the differential diagnosis for this finding is broad.
  
  
  OBJECTIVE
  To identify conditions causing noncoeliac enteropathy (NCE) with villous atrophy and methods to differentiate between CD and NCE in clinical practice.
  
  
  METHODS
  Through record review we identified patients with DVA due to conditions other than CD. Patient demographics, clinical features and relevant investigations were compared with CD patients. Rates of CD misdiagnosis, and response to treatments were recorded.
  
  
  RESULTS
  Thirty cases of NCE were identified with ten different aetiologies. Unspecified immune-mediated enteropathy was the most common aetiology; affecting 10 patients. Gastrointestinal symptoms were more common in NCE than those in CD patients (P < 0.01). Twenty of the 24 NCE patients tested were HLA-DQ2/DQ8 negative. Twenty-six NCE patients were negative for IgA tissue transglutaminase (tTG) (P = 0.0001). Intraepithelial lymphocytosis was absent in 10 (33.3%) patients. Twenty-one NCE patients initially misdiagnosed with CD and one with gluten intolerance were prescribed a gluten free diet (GFD). Fifteen of 22 had repeat biopsy and none showed histological improvement.
  
  
  CONCLUSIONS
  Although coeliac disease is the most common cause of DVA, noncoeliac enteropathy is not rare and may easily be mistaken for coeliac disease. Noncoeliac enteropathy is suggested by a normal initial tTG (87%), lack of intraepithelial lymphocytosis on biopsy, and lack of histological response to a gluten free diet. Subjective response to gluten free diet has poor predictive value for coeliac disease. Noncoeliac enteropathy can often be confirmed by negative HLA-DQ2/DQ8 testing and targeted investigations can ascertain a definitive aetiology in most cases.
authors.affiliation: Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA. kpallav@bidmc.harvard.edu
authors.forename: K
authors.initials: K
authors.lastname: Pallav
authors.forename: D A
authors.initials: DA
authors.lastname: Leffler
authors.forename: S
authors.initials: S
authors.lastname: Tariq
authors.forename: T
authors.initials: T
authors.lastname: Kabbani
authors.forename: J
authors.initials: J
authors.lastname: Hansen
authors.forename: A
authors.initials: A
authors.lastname: Peer
authors.forename: A
authors.initials: A
authors.lastname: Bhansali
authors.forename: R
authors.initials: R
authors.lastname: Najarian
authors.forename: C P
authors.initials: CP
authors.lastname: Kelly
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D001284:Atrophy; D002446:Celiac Disease / Q000175:diagnosis* / Q000178:diet therapy; D003937:Diagnosis, Differential; D055050:Diet, Gluten-Free; D004386:Duodenum / Q000473:pathology*; D005260:Female; D006683:HLA-DQ Antigens / Q000378:metabolism; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D055815:Young Adult
chemical_list: D006683:HLA-DQ Antigens; C053186:HLA-DQ2 antigen; C109756:HLA-DQ8 antigen