Letter to the Editor
Potential celiac disease in Indian patients Marleena Repo and Kalle Kurppa
Dear Editor, We congratulate Dr. Kondala and colleagues for their excellent study investigating the natural history of potential celiac disease (PCD) in India.1 This is a very timely and important issue as the number of these cases is constantly increasing due to active casefinding and screening. The authors note that there are major variations between studies in the natural history of PCD, these likely being at least partly explained by different study designs and selection on patients.2,3 Based on the low rate of histological progression they conclude that starting a gluten-free diet is not justified in all cases with PCD, but it is not specified in whom it might be considered. Intriguingly, despite the morphologically normal intestinal mucosa, approximately half of the PCD patients presented either with clinical symptoms or iron-deficiency anemia. Accordingly, we have recently shown that children with PCD often suffer from anemia or iron deficiency even before the development of the mucosal lesion.4 Moreover, there is mounting evidence that such patients may benefit clinically, histologically and serologically to gluten withdrawal.5,6 It is also well known that tissue transglutaminase antibodies, particularly if measured with a reliable assay or combined with positive endomysial antibodies, elicit excellent specificity for celiac disease. Therefore, why should we delay the dietary treatment
United European Gastroenterology Journal 2017, Vol. 5(1) 139 ! Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2050640616655931 journals.sagepub.com/home/ueg
until mucosal atrophy (the end stage of the disease) develops in subjects with clear clinical symptoms or anemia? Evidently more prospective studies are needed, but at this point we would recommend that a trial with a gluten-free diet should be considered with a low threshold in PCD patients with no other obvious reason for the symptoms or anemia. References 1. Kondala R, Puri AS, Banka AK, et al. Short-term prognosis of potential celiac disease in Indian patients. United European Gastroenterol J 2016; 4: 275–280. 2. Kurppa K, Ashorn M, Iltanen S, et al. Celiac disease without villous atrophy in children: A prospective study. J Pediatr 2010; 157: 373–380. 3. Auricchio R, Tosco A, Piccolo E, et al. Potential celiac children: 9-year follow-up on a gluten-containing diet. Am J Gastroenterol 2014; 109: 913–921. 4. Repo M, Lindfors K, Ma¨ki M, et al. Anemia and iron deficiency in children with potential celiac disease. J Ped Gastroenterol Nutr 2016; doi:10.1097/MPG.000000000000 1234 [epub ahead of print]. 5. Kurppa K, Collin P, Viljamaa M, et al. Diagnosing mild enteropathy celiac disease: A randomized, controlled clinical study. Gastroenterology 2009; 136: 816–823. 6. Volta U, Caio G, Giancola F, et al. Features and progression of potential celiac disease in adults. Clin Gastroenterol Hepatol 2016; 14: 686–693.
Tampere Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland Corresponding author: Kalle Kurppa MD, PhD, Tampere Centre for Child Health Research, University of Tampere, Finn Medi 3, 33520 Tampere, Finland. Email: [email protected]
Potential celiac disease in Indian patients Marleena Repo and Kalle Kurppa
Dear Editor, We congratulate Dr. Kondala and colleagues for their excellent study investigating the natural history of potential celiac disease (PCD) in India.1 This is a very timely and important issue as the number of these cases is constantly increasing due to active casefinding and screening. The authors note that there are major variations between studies in the natural history of PCD, these likely being at least partly explained by different study designs and selection on patients.2,3 Based on the low rate of histological progression they conclude that starting a gluten-free diet is not justified in all cases with PCD, but it is not specified in whom it might be considered. Intriguingly, despite the morphologically normal intestinal mucosa, approximately half of the PCD patients presented either with clinical symptoms or iron-deficiency anemia. Accordingly, we have recently shown that children with PCD often suffer from anemia or iron deficiency even before the development of the mucosal lesion.4 Moreover, there is mounting evidence that such patients may benefit clinically, histologically and serologically to gluten withdrawal.5,6 It is also well known that tissue transglutaminase antibodies, particularly if measured with a reliable assay or combined with positive endomysial antibodies, elicit excellent specificity for celiac disease. Therefore, why should we delay the dietary treatment
United European Gastroenterology Journal 2017, Vol. 5(1) 139 ! Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2050640616655931 journals.sagepub.com/home/ueg
until mucosal atrophy (the end stage of the disease) develops in subjects with clear clinical symptoms or anemia? Evidently more prospective studies are needed, but at this point we would recommend that a trial with a gluten-free diet should be considered with a low threshold in PCD patients with no other obvious reason for the symptoms or anemia. References 1. Kondala R, Puri AS, Banka AK, et al. Short-term prognosis of potential celiac disease in Indian patients. United European Gastroenterol J 2016; 4: 275–280. 2. Kurppa K, Ashorn M, Iltanen S, et al. Celiac disease without villous atrophy in children: A prospective study. J Pediatr 2010; 157: 373–380. 3. Auricchio R, Tosco A, Piccolo E, et al. Potential celiac children: 9-year follow-up on a gluten-containing diet. Am J Gastroenterol 2014; 109: 913–921. 4. Repo M, Lindfors K, Ma¨ki M, et al. Anemia and iron deficiency in children with potential celiac disease. J Ped Gastroenterol Nutr 2016; doi:10.1097/MPG.000000000000 1234 [epub ahead of print]. 5. Kurppa K, Collin P, Viljamaa M, et al. Diagnosing mild enteropathy celiac disease: A randomized, controlled clinical study. Gastroenterology 2009; 136: 816–823. 6. Volta U, Caio G, Giancola F, et al. Features and progression of potential celiac disease in adults. Clin Gastroenterol Hepatol 2016; 14: 686–693.
Tampere Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland Corresponding author: Kalle Kurppa MD, PhD, Tampere Centre for Child Health Research, University of Tampere, Finn Medi 3, 33520 Tampere, Finland. Email: [email protected]
