A recent study (F Fernandez-Banares et al. Am J Gastroenterol 2021; 116: 1036-1043. Persistent Villous Atrophy in De Novo Adult Patients With Celiac Disease and Strict Control of Gluten-Free Diet Adherence: A Multicenter Prospective Study (CADER Study) shows that there is a high likelihood of persistent villous atrophy among adults with celiac disease (CD) despite adherence with a gluten-free diet (GFD). Thanks to Ben Gold for showing me this paper.
- Among 76 patients (median age 36.5 years) who were prospectively followed for 2 years, persistent villous atrophy was observed in 40 (53%). In this group, 72.5% were asymptomatic (based on Likert scales) and 75% had negative serology
- Detectable fecal gluten immunogenic peptides (f-GIPs) were present in at least one sample in 69% of patients. (Two samples obtained at f/u visits which were ~every 6 months during study)
- Excellent or good adherence to GFD was demonstrated in 68.4% of patients based on dietetic evaluations. Only 6 (8%) were clearly nonadherent
- “There were no significant differences in the rate of clinical and serological remission between patients with villous atrophy and those with mucosal recovery”
- The authors did not find potentially modifiable predictive factors
- The authors note that serology is “not useful for monitoring patients on a GFD.” Anti-TTG2 and EMA, in a recent meta-analysis, had a pooled sensitivity of around 50%.
- “Adults are significantly less likely than children to normalize their duodenal histology.”
- The associated editorial by Rej et al (pg 946-948) outline a personalized approach for dealing with persistent villous atrophy:
- In those with persistent symptoms/positive GIPs/elevated serology/micronutrient deficiency, the first step is careful dietetic assessment. After this, endoscopy could be considered to confirm presence or absence of mucosal healing.
- In those with no symptoms and no abnormalities, use of monitoring endoscopy needs to be weighed against the costs as well as potential complications.
- Other points in the editorial: 1. GIPs have poor concordance with mucosal healing and 2. causes of poor mucosal healing include the following: natural slow healing process, super sensitive to gluten, ongoing gluten exposure, and refractory celiac disease.
My take: This study shows that there is ongoing gluten exposure in the majority of patients even in those with excellent or good adherence to a GFD; in addition, it shows that clinical/serological markers are NOT effective in predicting mucosal healing in adults. Nevertheless, it is not clear that followup endoscopy is beneficial.
Related blog posts:
- Real-World = Partially-Treated Celiac Disease
- Is a Gluten-Free Diet Possible? DOGGIE BAG Study
- #NASPGHAN19 Postgraduate Course (part 2)
- Celiac Disease: “”80 percent of success is just showing up”
- Improving Care Process in Celiac Disease
- How Slow Do Objective Markers of Celiac Disease Improve
- How Accurate is Serology at Predicting Mucosal Healing in Pediatric Patients with Celiac Disease
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