title: Outcome of Referrals for Non-Responsive Celiac Disease in a Tertiary Center: Low Incidence of Refractory Celiac Disease in the Netherlands.
abstract: OBJECTIVE
  Refractory celiac disease (RCD) is a severe cause of non-responsive celiac disease (CD) due to its association with the enteropathy associated T-cell lymphoma (EATL). Conflicting data exist on the prevalence and the clinical manifestations of RCD type I (RCD I) and type II (RCD II). The aim of the current study was to provide insight in the incidence of RCD and in the distinction with other causes of non-responsive CD.
  
  
  METHODS
  A total of 106 CD patients were referred to our tertiary referral center between January 2006 and December 2011 for evaluation of non-responsive CD. In addition, a questionnaire was sent to all 82 gastroenterology departments in the Netherlands to reveal whether a patient with RCD was currently being evaluated or had been treated between 2006 and 2012.
  
  
  RESULTS
  During a 6 year period, a total of 31 patients were diagnosed with RCD (19 RCD I and 12 RCD II). The nationwide survey revealed 5 additional patients with RCD I and one patient with RCD II. This leads to an annual incidence of RCD of 0.83/10.000 CD patients. The remaining patients were diagnosed with involuntary gluten ingestion (21.7%), delayed mucosal recovery (11.3%), enteropathy associated T-cell lymphoma (7.5%) and autoimmune enteropathy (1.8%).
  
  
  CONCLUSIONS
  This nationwide study reveals a low incidence of RCD in the Netherlands. Nevertheless, RCD is a clinically relevant disease entity in CD patients non-responsive to the gluten-free diet.
authors.affiliation: Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: R L J
authors.initials: RL
authors.lastname: van Wanrooij
authors.affiliation: Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: G
authors.initials: G
authors.lastname: Bouma
authors.affiliation: Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: H J
authors.initials: HJ
authors.lastname: Bontkes
authors.affiliation: Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: A
authors.initials: A
authors.lastname: Neefjes-Borst
authors.affiliation: Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: N C
authors.initials: NC
authors.lastname: van Grieken
authors.affiliation: Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: B M E
authors.initials: BM
authors.lastname: von Blomberg
authors.affiliation: Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: C J J
authors.initials: CJ
authors.lastname: Mulder