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					                                          Celiac Disease
                                           August 2005

Number of submission:

1

Organisations that submitted:

PCSG

Summary

The advent of serological tests with a high sensitivity and specificity1 has allowed the
demonstration of higher rates of seroprevalence of celiac disease than previously thought2, and
has made this disease suitable for screening. Screening is particularly relevant for this disease as
it is common, has a long latent interval where it could be identified, and is associated with
serious long term sequelae including an increased risk of osteoporosis3,4, infertility and malignant
disease5. Screening by serum endomysial antibody (EMA-IgA) testing should be acceptable to
patients. Complications can be prevented by compliance with a gluten-free diet.

Evidence

A review of studies investigating serological tests for celiac disease1 found that serological tests
for EMA-IgA and tissue transglutaminase (TTG-IgA) had, for the most part, sensitivities and
specificities exceeding 95%

A study of the seroprevalence of celiac disease in England2 demonstrated a prevalence of 1.2%
in a sample of 7527 45-76 year olds. Celiac disease was defined as a positive EMA-IgA test. This
study also highlighted an increased risk of osteoporosis and mild anaemia. Celiac disease is also
associated with an increased rate of development of malignant disease of the intestine5. The rate
of malignant disease can be reduced by compliance with a gluten free diet. Patients with celiac
also have some degree of splenic atrophy11. Calcium and vitamin D absorption can be affected,
especially in the elderly.

A latent interval exists for the identification of celiac disease. Most patients are symptomatic for a
number of years prior to diagnosis. In one case series6, since the introduction of serological tests
in 1993, the mean time to diagnosis from onset of symptoms was 4.4 years. The onset of celiac
disease may be earlier in life, however. A seroprevalence study in 71/2 year old children7 found
that 1% tested positive for EMA-IgA.

Celiac disease is certainly common in the general population, but a higher yield from serological
testing might be expected from targeting specific populations. A UK based case-control study8
found that, in patients meeting the ROME II criteria for irritable bowel syndrome, the odds ratio
for having celiac disease was 7.0. However, this was a study in patients referred to secondary
care who may have a higher prevalence of celiac disease than in the general population. An Irish
case-control study9 compared 150 celiac patients with 162 matched controls and found that
presence of the ROME I criteria had a likelihood ratio of 4.00 for celiac disease. Guidelines from
the Primary Care Society for Gastroenterology10 suggest that celiac should be considered in
patients presenting with iron or folate deficiency anaemia, chronic fatigue, unexplained
diarrhoea, and in those with a family history of celiac, IDDM, autoimmune thyroid disease,
osteoporosis, infertility and neurological disorders.




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                                                      Celiac disease is treated with the introduction of a gluten-free diet; this not only has a dramatic
                                                      effect of symptoms but also reduces the rate of complications such as malignant disease11. The
                                                      level of compliance with gluten-free diets is known to be between 45-87%11. Compliance with a
                                                      gluten-free diet can be assessed by means of serology12, although it should be noted that
                                                      antigliadin antibodies (AGA-IgA) and EMA-IgA are less predictive of the presence of villous
                                                      atrophy than TTG-IgA.

                                                      Suggested indicators with Process/IT group comments

                                                      CURRENT/PROPOSED INDICATOR                                                                  Process group/IT comments

                                                      CEL1: The practice has a register of                                                        Process: Easy to operationalise – to be
                                                      patients with celiac disease.                                                               pedantic it should read with a recorded
                                                                                                                                                  diagnosis of
                                                                                                                                                  Technical: Not possible to interrogate
                                                                                                                                                  reason for referral hence this indicator
                                                                                                                                                  will be vulnerable to contamination by
                                                                                                                                                  other referrals.
                                                      CEL2: Patients with celiac disease have                                                     Process: Once again easy to do – pedantic
                                                      been referred to a                                                                          addition would be offered referral as
                                                      gastroenterologist/dietician to discuss                                                     “Patients with celiac disease have been
                                                      the introduction/compliance with a                                                          offered referral to gastroenterologist/dietician
                                                      gluten-free diet11.                                                                         to discuss the introduction /compliance with
                                                                                                                                                  a gluten-free diet.
                                                                                                                                                  Technical: Not possible to interrogate
                                                                                                                                                  reason for referral hence this indicator will be
                                                                                                                                                  vulnerable to contamination by other
                                                                                                                                                  referrals
                                                      CEL3: All patients with celiac disease                                                      Process: there will be resource implications
                                                      have been offered osteoporosis risk                                                         for this
                                                      assessment (e.g. DEXA scan)11.                                                              Technical: Not possible to reliably identify
                                                                                                                                                  interventions offered as distinct from
                                                                                                                                                  interventions taken up. Needs clear
                                                                                                                                                  definition of evidence required / allowed to
                                                                                                                                                  establish achievement against the indicator
                                                      CEL4:All patients with celiac have been
                                                      offered
                                                              1. influenza vaccination




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Implications for Primary Care

It should be relatively simple to identify patients with celiac disease. Many will already be coded
as such, others can be identified from prescription records of gluten-free foodstuffs. DEXA
scanning of all celiac patients is likely to present significant cost and access problems for GP’s.
GP’s already have systems in place for offering vaccinations to at-risk groups which could be
extended to celiac disease.

Summary of suggested indicators post Process/IT Group

CEL1: The practice has a register of patients with a diagnosis recorded of celiac disease
CEL2: Proportion of patients CEL1 seen by a gastroenterologist or dietician after diagnosis
CEL3: Proportion of patients CEL1 recorded as having had a DEXA scan
CEL4: Proportion of CEL1 Patients over the age of 75 have been prescribed calcium and vitamin
D supplementation
CEL5: Proportion of patients CEL1 who have had an antigliadin antibody test in the past 15
months

Appendix A

Methodology

This report was written by:

    1. Dr. Craig Munro, Clinical Research Fellow, University Of Birmingham
    2. Professor Brendan Delaney, University Of Birmingham




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References

   1. Hill I., What are the sensitivity and specificity of serologic tests for celiac disease? Do
       sensitivity and specificity vary in different populations? Gastroenterology 2005;128:S25-
       S32
   2. West J et al, Seroprevalences, correlates, and characteristics of undetected celiac disease
       in England. Gut 2003;52:960-965
   3. Corazza GR, et al. Influence of pattern of clinical presentation and of gluten-free diet on
       bone mass and metabolism in adult celiac disease. Bone 1996;18:525-30
   4. Mustalahti K, et al. Osteopaenia in patients with clinically silent celiac disease warrants
       screening (letter). Lancet 1999; 354:744-5
   5. Catassi C, et al. Association of celiac disease and intestinal lymphomas and other
       cancers. Gastroenterology 2005; 128:S79-S86
   6. Lo W, et al. Changing patterns of adult celiac disease. Digestive Diseases & Sciences
       2003; 48:395-398
   7. Bingley PJ, et al. Un-diagnosed celiac disease at age 7: Population based prospective
       birth cohort study. BMJ 2004; 328:322-323
   8. Sanders DS, et al. Association of adult celiac disease with irritable bowel syndrome: a
       case-control study in patients fulfilling ROME II criteria referred to secondary care.
       Lancet 2001; 358:1504-08
   9. O’Leary C, et al. Celiac Disease and Irritable Bowel-Type Symptoms. The American
       Journal Of Gastroenterology 2002; 97:1463-7
   10. Primary Care Society for Gastroenterology. Decision points in the management of adult
       celiac disease in primary care. http://www.pcsg.org.uk/ 2000 (accessed 9th August 2005)
   11. Primary Care Society for Gastroenterology. Follow-up care of adult celiac disease.
       http://www.pcsg.org.uk/ 2001 (accessed 9th August 2005)
   12. Pietzak MM. Follow-up of patients with Celiac disease: Achieving compliance with
       treatment. Gastroenterology 2005; 128:S135-S141




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