Opinion Review
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 14, 2021; 27(42): 7233-7239
Published online Nov 14, 2021. doi: 10.3748/wjg.v27.i42.7233
Serologic diagnosis of celiac disease: May it be suitable for adults?
Giuseppe Losurdo, Milena Di Leo, Edoardo Santamato, Monica Arena, Maria Rendina, Carmelo Luigiano, Enzo Ierardi, Alfredo Di Leo
Giuseppe Losurdo, Edoardo Santamato, Maria Rendina, Enzo Ierardi, Alfredo Di Leo, Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari 70124, Italy
Milena Di Leo, Monica Arena, Carmelo Luigiano, Unit of Digestive Endoscopy, San Paolo Hospital, Milan 20090, Italy
Author contributions: Losurdo G, Luigiano C, Ierardi E, and Di Leo A planned the study; Di Leo M, Arena M, Rendina M, and Ierardi E searched for the data; Losurdo G, Di Leo M, Santamato E, and Ierardi E wrote the paper; Luigiano C and Di Leo A critically revised the paper; all authors read and approved the final version of the manuscript.
Conflict-of-interest statement: The authors declare no conflict of interest for this manuscript.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Giuseppe Losurdo, MD, Academic Fellow, Doctor, Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Piazza Giulio Cesare, Bari 70124, Italy. giuseppelos@alice.it
Received: March 21, 2021
Peer-review started: March 21, 2021
First decision: April 29, 2021
Revised: May 2, 2021
Accepted: October 25, 2021
Article in press: October 25, 2021
Published online: November 14, 2021

The diagnosis of coeliac disease (CD) in adult patients requires the simultaneous assessment of clinical presentation, serology, and typical histological picture of villous atrophy. However, several years ago, the European Society of Pediatric Gastroenterology, Hepatology, and Nutrition guidelines approved new criteria for the diagnosis in children: Biopsy could be avoided when anti-transglutaminase antibody (TGA) values exceed the cut-off of × 10 upper limit of normal (ULN) and anti-endomysium antibodies are positive, independently from value. This “no biopsy” approach is a decisive need for pediatric population, allowing to avoid stressful endoscopic procedures in children, if unnecessary. This approach relies on the correlation existing in children between TGA levels and assessment of mucosal atrophy according to Marsh’s classification. Several lines of evidence have shown that patients with villous atrophy have markedly elevated TGA levels. Therefore, we aim to perform a narrative review on the topic in adults. Despite that some studies confirmed that the × 10 ULN threshold value has a very good diagnostic performance, several lines of evidence in adults suggest that TGA cut off should be different from that of pediatric population for reaching a good correlation with histological picture. In conclusion, the heterogeneity of study reports as well as some conditions, which may hamper the serological diagnosis of CD (such as seronegative CD and non-celiac villous atrophy) and are much more common in adults than in children, could represent a limitation for the “no biopsy” approach to CD diagnosis in patients outside the pediatric age.

Keywords: Celiac disease, Villous atrophy, Serology, Biopsy, Anti-transglutaminase antibody

Core Tip: A “no biopsy” approach to celiac disease diagnosis, based only on anti-transglutaminase antibody titer, is a well-established strategy in children and an appealing matter of debate in adults. Indeed, the same strategy is recommended by pediatric guidelines, since it allows to avoid about one third of upper endoscopy procedures. In adults, literature on the topic is flourishing even if the topic is still under-investigated, results are heterogeneous, and some conditions may be relevant limiting factors.