Introduction The management of coeliac disease (CD) is clear, however agreement on paediatric diagnosis is debated. NICE dictates that TTG testing should be used front line, with EMA added if TTG is borderline, and referral to a specialist for a final diagnosis. ESPGHAN states that symptomatic patients with TTG > 10 times the upper limit (ULN) will most likely have villous atrophy and recommends the use of HLA DQ2/DQ8 as a rule in test to obviate the need for a biopsy. This audit reviewed our adherence to these guidelines over 4 years and investigated the reliability of serological and genetic testing as indicators of CD.
Methods TTG positive data (>7.0 kU/L) in those <16 years was collected from the Telepath Database System, from 02/11/11 to 11/11/15. Only data on newly suspected CD patients was used, n = 34. Monitored CD patients or those managed elsewhere were excluded. TTG testing was carried out on the Thermo Fisher ImmunoCAP 250. HLA results, biopsy results, and referral times were collated from the Advantis Document System.
Results Of the 34 patients, 28 were diagnosed with CD. 13 underwent a biopsy; 12 were positive and 1 was negative, most likely due to a GFD. 11 nonbiopsied patients underwent HLA testing; all 11 were positive. 4 had neither biopsy or HLA testing; 2 were diagnosed on positive TTG and EMA results, 1 was diagnosed on symptoms and a high TTG, and 1 was diagnosed on TTG alone, due to a biopsy refusal. The average dietician referral time post initial TTG was 164 days; 122 days for those undergoing HLA testing and 220 days for those undergoing a biopsy. Of the remaining patients, 4 were not diagnosed with CD and their average TTG = 13.4 kU/L; 2 had normal EMA results, 1 had a negative biopsy, and 1 had a normal repeat TTG. Of all patients, 24 had TTG > 10 ULN; 22 were diagnosed with CD, and 2 had early CD, but a GFD was not instigated. 1 was asymptomatic and did not consent to a biopsy, and 1 had a positive EMA and was awaiting HLA testing. 10 patients had TTG < 10 ULN; 2 were tested for EMA, 1 tested for HLA, and 5 had a biopsy.
Conclusion TTG was always used front line, but EMA was not assessed in all borderline cases. Symptomatic patients with TTG > 10 ULN, regardless of biopsy or HLA testing, were diagnosed with CD or early CD. HLA testing was not always utilised, with 46% of cases having a biopsy, however in all instances of HLA testing this occurred to obviate a biopsy. There is no indication of a minimum referral time to a dietician in the guidelines, but referral times are longer in those who underwent a biopsy, with the need to maintain a normal diet. The diagnostic process of CD is becoming streamlined as more consultants opt for serological and genetic testing, allowing for quicker management.
Disclosure of Interest None Declared
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