Reply to K. Rostami et al.

We would like to thank Dr. Rostami and Dr. Danciu for giving us the opportunity to clarify some conceptual points about the role of endoscopy in monitoring patients with celiac disease who are on a gluten-free diet (GFD).

The 2001 American Gastroenterological Association (AGA) medical position statement recommended a repeat biopsy as early as 4 - 6 months after starting a gluten-free diet in order to assess improvement [1]. The more recent AGA position statement is elusive on this issue [2], admitting that ”there are no clear guidelines as to the optimal means to monitor adherence to a GFD.” In the AGA Institute Technical Review [3] it was recognized that ”symptom improvement alone may not offer an accurate assessment of adherence to GFD as judged by interview or by biopsy.”

In general, monitoring adherence to a gluten-free diet with serology (i. e. with tissue transglutaminase antibodies [tTGA] or endosmysial antibodies [EMA]) after 6 months or more on a gluten-free diet can be helpful for assessing histological improvement and compliance with the diet. However, the sensitivity of the serological tests decreases at the lower Marsh grades of histological severity. The serology results therefore tend to become negative as the histological findings improve and they might not therefore reflect a return to normal histology [4] [5] [6] [7]. In addition, the serological test cannot be used in patients with a previously negative test or in patients with selective IgA deficiency [8].

In children on a gluten-free diet, histological improvement appears to occur relatively quickly and more completely [9]. In adults this improvement is slow, often taking more than 2 years [10], and is often incomplete, making the dietary control of the disease difficult [11] [12]. Serological testing in children might therefore reflect the mucosal state better than it does in adults. The 2006 AGA statement recommended that monitoring adherence to a gluten-free diet by clinic visits and serological testing appears to be a reasonable approach in children. In adults this approach would be also reasonable, but with the understanding that negative serology results do not necessarily guarantee improvement beyond severe subtotal or total villous atrophy [2] [5] [6] [7] [13].

Finally, we agree with Dr. Rostami and Dr. Danciu that the currently accepted strategies regarding the diagnosis and management of celiac disease are out of date and will have to be revised in the light of the advances that have been made in the technological field and in our knowledge of the disease. Our studies are going in this direction, showing that new-generation, high-resolution video endoscopy could play a more incisive role in this context than that of merely obtaining biopsy specimens for histological analysis [14] [15] [16].

Competing interests: None

References

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