活检 sparing ESPGHAN 成人乳糜泻诊断指南的应用：一项真实生活研究。
Application of the Biopsy-Sparing ESPGHAN Guidelines for Celiac Disease Diagnosis in Adults: A Real-Life Study.
作者信息
Efthymakis Konstantinos, Serio Mariaelena, Milano Angelo, Laterza Francesco, Bonitatibus Antonella, Di Nicola Marta, Neri Matteo
机构信息
Department of Medicine and Ageing Sciences and Center for Excellence On Ageing and Translational Medicine (CeSI-MeT), "G. D'Annunzio" University and Foundation, Chieti, Italy.
Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University and Foundation, Chieti, Italy.
出版信息
Dig Dis Sci. 2017 Sep;62(9):2433-2439. doi: 10.1007/s10620-017-4672-1. Epub 2017 Jul 17.
BACKGROUND
Current adult celiac disease diagnosis requires histological confirmation. However, pediatric guidelines have proposed biopsy-sparing algorithms.
AIMS
To explore the applicability of the ESPGHAN criteria and assess the accuracy of serology in predicting disease in adults.
METHODS
We evaluated 234 consecutive adults showing elevated anti-tTG titers, EMA-positivity, and genetic susceptibility. Patients underwent upper endoscopy with duodenal biopsy. We determined optimal anti-tTG cutoff levels using ROC curves.
RESULTS
Mean anti-tTG levels were 71.1 ± 66.5 U/ml; mean normalized levels were 14.8 ± 14.1 × ULN (mean ± SD). Partial/total villous atrophy was present in 36%/55% of cases, respectively. Anti-tTG levels correlated with histology (r = 0.397, p < 0.001). AUC was similar before and after normalization (0.803 vs 0.807). Applying the ESPGHAN criterion (≥10 × ULN), we calculated a 97.66% PPV. ROC curve analysis showed an optimal cutoff of ≥16 × ULN, with a PPV of 98.86%. Eleven different assays were used for anti-tTG titer determination: Two were prevalent, labeled A (n = 141) and B (n = 59). They performed differently regarding disease prediction (AUC = 0.689 vs 0.925, p < 0.01), showing distinct optimal cutoff values (14.3 × ULN vs 3.7 × ULN), even after standardization (-0.14 vs -1.2).
CONCLUSION
In adult symptomatic patients showing EMA-positivity and genetic susceptibility, anti-tTG titers correlated with histology. ESPGHAN criteria performed similarly to previous studies. However, a calculated 16 × ULN cutoff showed an improved PPV. Among prevalent assays, PPV peaked differently both after normalization and standardization, indicating intrinsic differences in performance, thus preventing uniform prediction of disease in a real-life setting. Assay-specific optimal cutoffs seem possible, but would complicate diagnostic criteria. However, biopsy-sparing strategies in adults could prove useful in challenging patients.
背景
目前成人乳糜泻的诊断需要组织学确认。然而，儿科指南提出了避免活检的算法。
目的
探讨欧洲儿科胃肠病、肝病和营养学会（ESPGHAN）标准的适用性，并评估血清学在预测成人疾病中的准确性。
方法
我们评估了234例连续的成人患者，这些患者抗组织转谷氨酰胺酶（anti-tTG）滴度升高、肌内膜抗体（EMA）呈阳性且具有遗传易感性。患者接受了十二指肠活检的上消化道内镜检查。我们使用ROC曲线确定最佳的anti-tTG临界值水平。
结果
平均anti-tTG水平为71.1±66.5 U/ml；平均标准化水平为14.8±14.1×ULN（平均值±标准差）。分别有36%/55%的病例存在部分/完全绒毛萎缩。anti-tTG水平与组织学相关（r = 0.397，p < 0.001）。标准化前后曲线下面积（AUC）相似（0.803对0.807）。应用ESPGHAN标准（≥10×ULN），我们计算出阳性预测值（PPV）为97.66%。ROC曲线分析显示最佳临界值为≥16×ULN，PPV为98.86%。使用了11种不同的检测方法来测定anti-tTG滴度：两种方法使用较为普遍，分别标记为A（n = 141）和B（n = 59）。它们在疾病预测方面表现不同（AUC = 0.689对0.925，p < 0.01），即使在标准化后也显示出不同的最佳临界值（14.3×ULN对3.7×ULN）（-0.14对-1.2）。
结论
在有症状且EMA呈阳性和具有遗传易感性的成人患者中，anti-tTG滴度与组织学相关。ESPGHAN标准的表现与先前研究相似。然而，计算得出的16×ULN临界值显示PPV有所提高。在使用较为普遍的检测方法中，标准化前后PPV达到峰值的情况不同，表明检测性能存在内在差异，因此在实际临床环境中难以进行统一的疾病预测。特定检测方法的最佳临界值似乎可行，但会使诊断标准复杂化。然而，成人避免活检的策略在具有挑战性的患者中可能证明是有用的。
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