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Our aim was to assess differences in the sensitivities of serologic tests used for the diagnosis of celiac disease among patients with varying degrees of villous atrophy. Among 115 adults with biopsy-proven celiac disease who fulfilled strict criteria, including serologic testing at the time of diagnosis and response to a gluten-free diet, 71% had total villous atrophy and 29% partial villous atrophy. Endomysial antibody was positive in 77% of those with total villous atrophy, compared to 33% with partial villous atrophy (P < 0.001). There was no difference in sensitivity when the type of presentation (classical vs. silent) was compared. Endomysial antibody-positive and negative patients did not differ with respect to age at diagnosis, duration of symptoms, mode of presentation, or family history of celiac disease. All anti-tissue transglutaminase-positive patients had TVA on biopsy. Seronegative celiac disease occurs. Endomysial antibody positivity correlates with more severe villous atrophy and not mode of presentation of celiac disease. Serologic tests, in clinical practice, lack the sensitivity reported in the literature.
KEY WORDS: Celiac disease; serology; villous atrophy; endomysial antibody.
Patients with celiac disease may present with a classical diarrhea-prominent illness or with milder irritable bowel symptoms (1). However, recently nongastrointestinal presentations have become more prominent (2); these include neurological presentations (3, 4), anemia (5), and osteoporosis (6).
The diagnosis of celiac disease requires the recognition of characteristic pathologic changes in an intestinal biopsy, accompanied by clinical and/or histological improvement on a gluten-free diet (7). Positive serologic tests are supportive of the diagnosis but not necessary (7). However, serologic testing has become important in triaging patients for biopsy (8). The serologic tests performed in celiac disease include antigliadin antibodies, endomysial antibodies, and antibodies to tissue transglutaminase. The endomysial antibody is a connective tissue antibody directed against the endomysium or the loose connective tissue around smooth muscle and is detected by immunoflourescence using either monkey esophagus or human umbilical cord as the substrate. Recently, the autoantigen to the endomysial antibody has been identified as the enzyme tissue transglutaminase (9), and an assay detecting anti-tissue transglutaminase antibodies has been developed.
The endomysial and anti-tissue transglutaminase antibodies are considered to be highly sensitive and specific for celiac disease, approaching 100% (10). However, several recent studies (11-15) have questioned the reportedly...