title: Are ESPGHAN "biopsy-sparing" guidelines for celiac disease also suitable for asymptomatic patients?
abstract: OBJECTIVE
  In 2012, European Society of Pediatric Gastroenterology, Hepatology, and Nutrition published novel guidelines on celiac disease (CD) diagnosis. Symptomatic children with serum anti-transglutaminase (anti-tTG) antibody levels ≥10 times upper limit of normal (ULN) could avoid duodenal biopsies after positive HLA test and serum anti-endomysial antibodies (EMAs). So far, both asymptomatic and symptomatic patients with anti-tTG titer <10 times ULN should undergo upper endoscopy with duodenal biopsies to confirm diagnosis. The aim of this study was to assess the accuracy of serological tests to diagnose CD in asymptomatic patients.
  
  
  METHODS
  We retrospectively reviewed data of 286 patients (age range: 10 months to 17 years) with CD diagnosis based on elevated titer of anti-tTG, EMA positivity, and histology. All patients were distinguished between symptomatic and asymptomatic; histological lesions were graded according to the Marsh-Oberhuber (MO) criteria. Fisher exact test was applied to analyze both groups in terms of diagnostic reliability of serological markers.
  
  
  RESULTS
  A total of 196 patients (68.53%) had anti-tTG titers ≥10 times ULN. Among them, a group of 156 patients (79.59%) also had symptoms suggestive of CD ("high-titer" symptomatic); of these, 142 patients (91.02%) showed severe lesion degree (3a, 3b, 3c MO). Conversely, 40 out of 196 patients (20.40%) were asymptomatic ("high-titer" asymptomatic) and 37 patients (92.5%) of them showed severe lesion degree (3a, 3b, 3c MO). No difference in histological damage was found between "high-titer" symptomatic and "high-titer" asymptomatic children (Fisher exact test, P=1.000).
  
  
  CONCLUSIONS
  If confirmed in large multicenter prospective studies, the "biopsy-sparing" protocol seems to be applicable to both symptomatic and asymptomatic patients with anti-tTG titer ≥10 times ULN, positive EMA, and HLA-DQ2/DQ8.
authors.affiliation: Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Chiara Maria
authors.initials: CM
authors.lastname: Trovato
authors.affiliation: Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Monica
authors.initials: M
authors.lastname: Montuori
authors.affiliation: Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Caterina
authors.initials: C
authors.lastname: Anania
authors.affiliation: Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Barbato
authors.affiliation: Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy.
authors.forename: Anna Rita
authors.initials: AR
authors.lastname: Vestri
authors.affiliation: Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
authors.forename: Sofia
authors.initials: S
authors.lastname: Guida
authors.affiliation: Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Oliva
authors.affiliation: Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Mainiero
authors.affiliation: Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Cucchiara
authors.affiliation: Department of Pediatrics, Pediatric Gastroenterology and Liver Unit, Sapienza University of Rome, Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Valitutti
mesh_terms: D000293:Adolescent; D058070:Asymptomatic Diseases; D001323:Autoantibodies / Q000276:immunology*; D015415:Biomarkers; D001706:Biopsy / Q000379:methods; D002446:Celiac Disease / Q000175:diagnosis* / Q000235:genetics / Q000276:immunology; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004386:Duodenum / Q000473:pathology*; D016145:Endoscopy, Digestive System; D005260:Female; D019204:GTP-Binding Proteins / Q000276:immunology; D006683:HLA-DQ Antigens / Q000235:genetics; D006239:Haplotypes; D006801:Humans; D007223:Infant; D008297:Male; D017410:Practice Guidelines as Topic; D000091345:Protein Glutamine gamma Glutamyltransferase 2; D015203:Reproducibility of Results; D012189:Retrospective Studies; D011503:Transglutaminases / Q000276:immunology
chemical_list: D001323:Autoantibodies; D015415:Biomarkers; D006683:HLA-DQ Antigens; C053186:HLA-DQ2 antigen; C109756:HLA-DQ8 antigen; D000091345:Protein Glutamine gamma Glutamyltransferase 2; D011503:Transglutaminases; D019204:GTP-Binding Proteins