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Diagnosis and Management of Celiac Disease

Author/s: 
Kerstin Austin, Nimrod Deiss-Yehiely, Jason T Alexander

Guideline title American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease

Release date January 2023

Prior version May 2013

Developer and funding source American College of Gastroenterology

Target population Children and adults with celiac disease

Selected recommendations

Screening for celiac disease in asymptomatic people in the general population is not recommended (strong recommendation; low quality of evidence).

Upper endoscopy with multiple (≥4) duodenal biopsies is recommended for diagnostic confirmation in both children and adults who have characteristic signs and symptoms of celiac disease (strong recommendation; moderate quality of evidence).

In symptomatic children, a blood test with high-level tissue transglutaminase antibody (tTG) IgA (>10 times the upper limit of normal) and presence of endomysial antibody (EMA) in a second blood sample are suggested for diagnosis of celiac disease. In symptomatic adults who are unwilling or unable to undergo upper endoscopy, high-level tTG IgA and presence of EMA can be used to establish a diagnosis of likely celiac disease (conditional recommendation; moderate quality of evidence).

A gluten-free diet is required (strong recommendation; moderate quality of evidence) to achieve the treatment goal of resolution of histologic mucosal lesions in adults (conditional recommendation; low quality of evidence).

Keywords 
Gastroenterology celiac disease

A “no-biopsy” approach to diagnosing celiac disease

Author/s: 
Mott, T., Gray, C., Storey, J.

PRACTICE CHANGER
CONSIDER A “NO-BIOPSY” APPROACH BY EVALUATING SERUM IMMUNOGLOBULIN (IG) A ANTI-TISSUE TRANSGLUTAMINASE (TTG-IGA) ANTIBODY TITERS IN ADULT PATIENTS WHO PRESENT WITH SYMPTOMS CONCERNING FOR CELIAC DISEASE (CD). AN INCREASE OF ≥ 10 TIMES THE UPPER LIMIT OF NORMAL (ULN) FOR TTG-IGA HAS A POSITIVE PREDICTIVE VALUE (PPV) OF ≥ 95% FOR DIAGNOSING CD WHEN COMPARED WITH ESOPHAGOGASTRODUODENOSCOPY (EGD) WITH DUODENAL BIOPSY—THE CURRENT GOLD STANDARD.

Keywords 
celiac disease Gastroenterology diagnosis Predictive Value of Tests Alternative Approach

Acid Suppression and Antibiotics Administered During Infancy Are Associated with Celiac Disease

Author/s: 
Boechler, M., Susi, A., Hisle-Gorman, E., Rogers, P. L., Nylund, C. M.

Objective
To investigate why certain at-risk individuals develop celiac disease, we examined the association of proton pump inhibitors (PPI), histamine-2 receptor antagonist (H2RA), and antibiotic prescriptions in the first six months of life with an early childhood diagnosis of celiac disease.
Study design
A retrospective cohort study was performed using the Military Healthcare System (MHS) database. Children with a birth record from October 1, 2001- September 30, 2013, were identified. Outpatient prescription records were queried for antibiotic, PPI, and H2RA prescriptions in the first 6 months of life. Cox proportional hazards regression was used to calculate the hazard ratio (HR) of developing CD based on medication exposure. ICD-9 codes identified children with an outpatient visit for celiac disease.
Results
968,524 children met inclusion criteria with 1,704 cases of celiac in this group. Median follow up for the cohort was about 4.5 years. PPI’s (HR, 2.23; 95% CI, 1.76-2.83), H2RA’s (HR, 1.94 95% CI, 1.67-2.26) and antibiotics (HR 1.14 95%CI 1.02-1.28) were all associated with an increased hazard of celiac disease.
Conclusion
There is an increased risk of developing celiac disease if antibiotics, PPI’s and H2RA’s are prescribed in the first 6 months of life. Our study highlights modifiable factors such as medication stewardship that may change the childhood risk of CD.

Keywords 
Infancy Retrospective Studies children prescriptions celiac disease

Diagnosis of Celiac Disease: Current State of the Evidence

Author/s: 
John M. Eisenberg Center for Clinical Decisions and Communications Science

This is a summary of a systematic review evaluating the evidence regarding the comparative accuracy (the balance of sensitivity and specificity) and possible adverse consequences (both direct and indirect) of various methods used to diagnose celiac disease. The systematic review included 60 individual studies and 13 previous systematic reviews published from January 1990 through March 2015. The full report, listing all studies and reviews, is available at www.effectivehealthcare.ahrq.gov/celiac-disease. This summary is provided to assist in informed clinical decisionmaking. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.

Keywords 
celiac disease sensitivity and specificity clinical decision-making
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