Introduction Therapeutic goals in coeliac disease (CD) are poorly defined. Emerging evidence reports worse outcomes with lack of mucosal recovery, suggesting histological normalisation as the aim of treatment. However, few centres routinely re-biopsy and many clinicians depend on serology or symptoms for follow-up. This retrospective study evaluates the role of the follow-up biopsy compared to serology in treated coeliacs and is the largest study of paired biopsies reported.
Methods Details of patients attending the Addenbrookes Adult CD Clinic are entered onto a database. Patients undergo repeat duodenal biopsy 9–12 months after commencing dietary therapy. Serum Anti-TTG antibodies and total IgA are measured at clinic visits. From the database of around 600 adult patients (30% male, 70% female, average age at diagnosis 48 and 44 yrs respectively) follow-up biopsy results were available for 433 patients and compared using a paired t-test.
Results Paired initial and follow-up biopsies were available for 368/433 patients (no information about index biopsy in 65). 239 (65%) were re-biopsied within 12 months, 311 (85%) within 24 months. The proportion achieving normalisation of duodenal mucosa (Marsh 0) at 12 months, 12–24 months or after 24 months is 27%, 25% (p=0.61) and 25% (p=0.1) respectively. Those without villous atrophy (VA) (Marsh 0, 1 or 2) is 58%, 58% (p=0.98) and 52% (p=0.24) respectively. Excluding the 2.5% of patients with IgA deficiency, 13% of patients had negative anti-TTG antibody titres at the time of diagnostic biopsy. In the group of patients with positive serology at first biopsy, only 43% with VA on follow-up biopsy were positive for anti-TTG antibodies. Conversely, 13% without VA on follow-up had positive serology. The sensitivity, positive predictive and negative predictive values for serology compared to biopsy at follow-up are 43.4%, 68.8% and 70.5% respectively.
Conclusion Response to diet in CD might be monitored by symptoms, serology or histology. Many patients diagnosed in adulthood report minimal or no symptoms at diagnosis and this is therefore not a credible marker of response. Here we show that:
Anti-TTG antibody serology has a sensitivity of 87% at diagnosis
Anti-TTG serology has a poor sensitivity (43%) on follow-up and is therefore unreliable
Histological response rates are not increased after 1 year on diet
Approximately 28% of patients achieve normal duodenal mucosa, 58% show no or minimal signs of coeliac disease on follow-up biopsy.
We suggest that follow-up biopsy on diet is the only reliable form of assessing response to treatment, and that the proportion of patients achieving histological response could be used as a means of auditing quality of care in coeliac clinics.
Competing interests None declared.
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