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CAN ATTG REPLACE INTESTINAL BIOPSY IN DIAGNOSIS OF PEDIATRIC CELIAC DISEASE?
F Alrefaee1, S Girgis3, D Spady2, H Huynh4, J Turner5 1Stollery Children's Hospital, Pediatric Gastroenterology and Nutrition Division; 2Stollery Children's Hospital, Department of Pediatrics; 3Department of Pathology, University of Alberta Hospital; 4Stollery Children's Hospital, Pediatric Gastroenterology and Nutrition Division; 5Stollery Children's Hospital, Pediatric Gastroenterology and Nutrition Division, University of Alberta, Edmonton, Alberta
AIMS: Celiac disease is the most common autoimmune gastrointestinal disorder diagnosed in children. This aim of this study was to examine the relationship between elevated ATTG titer and histological diagnosis of celiac disease to determine if a sensitive and specific cut-off for ATTG could replace the need for biopsy.
METHODS: A retrospective review of an existing database, 2005-2008, of patients referred to the Department of Pediatric Gastroenterology for possible diagnosis celiac disease was undertaken. Information included patient demographics, symptoms, risk factors for screening, ATTG titer, anthropometrics, gross endoscopy findings and histological diagnosis. Patients with low IgA levels were excluded. A positive diagnosis of celiac disease was assumed given Marsh 3 histology. Sensitivity, specificity and positive and negative likelihood ratios (LR) were calculated for ATTG level >=100 or 200.
RESULTS: 198 patients were identified, 15 were excluded and of the remaining, 94 had a positive diagnosis of celiac disease according to histological criteria. In patients with positive diagnosis mean ATTG was 383.1, range 0.5-3402. In patients without diagnosis mean ATTG was 284.46, range 4.2-4930. At the ATTG cut-offs tested the following results were obtained:
CONCLUSIONS: At the current time a combination of screening ATTG, diagnostic intestinal biopsy and clinical acumen is required to diagnose celiac disease in children. Screening alone has poor sensitivity and a diagnosis of celiac disease may be pursued given a low or normal screening test. Furthermore complex clinical considerations include latent celiac disease and negative biopsies in the presence of true disease.
Further we evaluated any Marsh diagnosis (1-3) as disease positive, this improved specificity to 100%, at both cut-offs, however sensitivity remained low at 52.2% and 46.3% respectively.