Screening for coeliac disease still off the menu

Despite the high accuracy of IgA tissue transglutaminase as a diagnostic test for coeliac disease, there is little or no evidence to recommend screening for the disease in asymptomatic individuals.

A systematic review found no evidence on the effects of screening versus no screening or targeted versus universal screening on morbidity, mortality, quality of life or harms in asymptomatic adults or children.

Similarly there was a lack of evidence that treatment of screen-detected coeliac disease lead to improved outcomes over no treatment.

The authors concluded much more research was required regarding the effectiveness of screening and treatment for coeliac disease including potential harms of a gluten-free diet.

“Although there continues to be research on pharmacological treatments for coeliac disease, such treatments are considered an adjunct to a gluten-free diet, which remains the mainstay of therapy,” they said.

An accompanying editorial said that increasing adoption of a gluten-free diet in the general population may be ‘filling the vacuum’ created by a lack of evidence guiding screening protocols for coeliac disease.

“As the trend towards less invasive testing and more ready access to a gluten-free diet reduces the burden of diagnosis and treatment, it behooves the medical research community to provide the data to determine who should be screened and treated for coeliac disease, and when and how.”

In a related editorial in JAMA Internal Medicine, Professor Nicholas Talley extended the discussion to the overlap between coeliac disease, non-coeliac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS).

Professor Talley, from the University of Newcastle, said low FODMAP diets have been shown to reduce symptoms in patients who believed they had NCGS or IBS.

“It is also notable that a gluten-free diet alters the microbiome, which may have direct benefits independent of abolishing gluten sensitivity,” he wrote.

Professor Talley told the limbic that teasing out the underlying pathologies behind gastrointestinal symptoms probably required more use of duodenal biopsies.

He said there was emerging evidence that the presence of intraepithelial lymphocytes was a marker of other processes as well as coeliac disease, while duodenal eosinophils indicated NCGS or functional dyspepsia.

“A lot of people sent for gastroscopy do not have a biopsy taken and in those that do, the relevance outside coeliac disease may not be recognised.”

“We need to redefine these conditions and then we may be able to more accurately direct treatment in the near future.”

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