Alharbi Ibrahim S, Sweid Abdul Monem, Memon Muhammad Yousuf, Alshieban Saeed, Alanazi Ameirah
King Abdul Aziz Medical city-National Guard Health Affairs (NGHA), King Abdullah Internaltinal Medical Research Center (KAIMAC), King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Riyadh Saudi Arabia.
Deprtment of Gastroenterology, King Abdul Aziz Medical city-National Guard Health Affairs (NGHA), King Abdullah Internaltinal Medical Research Center (KAIMAC), King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), Riyadh Saudi Arabia.
J Transl Int Med. 2020 May 9;8(1):48-53. doi: 10.2478/jtim-2020-0008. eCollection 2020 Mar.
According to recent guidelines, a diagnosis of celiac disease (CD) can be made without a biopsy, especially in children. There are no enough studies despite high prevalence and differences in genetic, race, and cultures. Therefore, we examined the correlation between tissue transglutaminase (TTG) and duodenal biopsy changes in our region because we are identical and different from others in culture, environment, and habits, and the correlation is same as that in different regions.
A retrospective cohort study at the Ministry of National Guard Health Affaires (NGHA) health care facilities that are distributed throughout kingdom of Saudi Arabia from April 19, 2015, till March 29, 2018. This study used the BESTCARE system that includes data from all NGHA facilities; data from 513 patients with CD were collected. All patients diagnosed with celiac disease aged 15 years or more, confirmed by improvement on gluten-free diet (GFD), and were not on GFD before endoscopy or serology test or both of them were included in the study, and the TTG IgA level was measured at the same time or within 2-3 months of biopsy date. The exclusion criteria were negative duodenal biopsy, which is less than 2; patients with negative biopsy and negative serology; patients who were on GFD before testing, and any patients known to have immunity diseases or illness causing mucosal changes. The TTG IgA level was measured in IU/ mL and was labeled as negative (<20 IU/mL) and positive (≥ 20 IU/mL) based on the cutoff value. However, Intestinal biopsy findings were identified as Marsh classification groups.
One hundred thirty-four patients who met the inclusion criteria were included in the study. Median age of our sample was 24 years (16-37 years). Among these, 99 (73.88%) were female patients, whereas male patients were only 35 (26.12%). Histopathologic investigation of intestinal biopsy were Marsh 0 group was 16 cases (11.9%), Marsh 1 group was 8 cases (6%), Marsh 2 group was 4 cases (3%), Marsh 3a group was 32 cases (23.9%), Marsh 3b group was 64 cases (47.8%), and Marsh 3c group was 10 cases (7.5%). The TTG IgA antibody serology groups were <20 IU/mL in 13 cases (9.7%) and ≥20 IU/mL in 121 cases (90.3%). Among all patients with CD who had negative biopsy (Marsh 0 group), 16 (100%) of them had positive TTG IgA antibody. However, among patients with Marsh 1 group biopsy, 5 (62.5%) cases had negative TTG IgA antibody compared with 3 (37.5%) positive cases. Of the four cases (100%) with Marsh 2 group, all of them had positive TTG IgA antibody. However, in Marsh 3a group biopsy, 3 (9.4%) cases had negative TTG IgA antibody compared with 29 (90.6%) cases with positive TTG IgA antibody. Furthermore, among the patients with Marsh 3b group biopsy, 5 (7.8%) had negative antibody and 59 (92.2%) had positive serology. Of all biopsies of Marsh 3c group, 10 (100 %) had positive TTG IgA antibody.
In perspective of high prevalence of CD in KSA, even more than western countries, we can pretend that positive TTG antibody tests can be applied for the diagnosis of CD without biopsy, particularly in symptomatic patients along with high titer, that is, 5-10 times the upper limit of normal (ULN). However, to validate it further, we need larger prospective studies in which duodenal biopsies should be taken according to recommended protocol and should be interpreted by experienced pathologist. Furthermore, biopsy is still needed in patients who do not show clinical improvement on a gluten-free diet and in cases with mildly or moderately elevated TTG IgA.
根据最近的指南，乳糜泻（CD）的诊断可不进行活检，尤其是在儿童中。尽管患病率高且存在遗传、种族和文化差异，但相关研究仍不足。因此，我们研究了组织转谷氨酰胺酶（TTG）与我们所在地区十二指肠活检变化之间的相关性，因为我们在文化、环境和生活习惯方面与其他地区既有相同之处也有不同之处，而这种相关性与不同地区相同。
在沙特阿拉伯王国各地的国民警卫队卫生部（NGHA）医疗机构进行一项回顾性队列研究，时间从2015年4月19日至2018年3月29日。本研究使用了BESTCARE系统，该系统包含所有NGHA机构的数据；收集了513例CD患者的数据。所有确诊为乳糜泻且年龄在15岁及以上、经无麸质饮食（GFD）改善得到证实、在内镜检查或血清学检测前未采用GFD或两者均未采用的患者纳入研究，并在活检日期的同时或2 - 3个月内测量TTG IgA水平。排除标准为十二指肠活检阴性（小于2次）；活检阴性且血清学阴性的患者；检测前采用GFD的患者，以及任何已知患有免疫疾病或导致黏膜改变疾病的患者。TTG IgA水平以IU/mL为单位测量，并根据临界值标记为阴性（<20 IU/mL）和阳性（≥20 IU/mL）。然而，肠道活检结果按照马什分类法进行分组。
134例符合纳入标准的患者被纳入研究。我们样本的中位年龄为24岁（16 - 37岁）。其中，99例（73.88%）为女性患者，而男性患者仅35例（26.12%）。肠道活检的组织病理学检查中，马什0组16例（11.9%），马什1组8例（6%），马什2组4例（3%），马什3a组32例（23.9%），马什3b组64例（47.8%），马什3c组10例（7.5%）。TTG IgA抗体血清学分组中，13例（9.7%）<20 IU/mL，121例（90.3%）≥20 IU/mL。在所有活检阴性（马什0组）的CD患者中，16例（100%）TTG IgA抗体呈阳性。然而，在马什1组活检的患者中，5例（62.5%）TTG IgA抗体呈阴性，3例（37.5%）呈阳性。马什2组的4例（100%）患者TTG IgA抗体均呈阳性。然而，在马什3a组活检中，3例（9.4%）TTG IgA抗体呈阴性，29例（90.6%）呈阳性。此外，在马什3b组活检的患者中，5例（7.8%）抗体呈阴性，59例（92.2%）血清学呈阳性。在马什3c组的所有活检中，10例（100%）TTG IgA抗体呈阳性。
鉴于沙特阿拉伯王国CD的高患病率，甚至高于西方国家，我们可以认为TTG抗体检测呈阳性可用于CD的诊断而无需活检，特别是对于有症状且滴度高的患者，即正常上限（ULN）的5 - 10倍。然而，为了进一步验证，我们需要更大规模的前瞻性研究，其中应按照推荐方案进行十二指肠活检，并由经验丰富的病理学家进行解读。此外，对于无麸质饮食后未显示临床改善的患者以及TTG IgA轻度或中度升高的病例，仍需要进行活检。
