Pre-endoscopy serological testing for coeliac disease: evaluation of a clinical decision tool

doi:10.1136/bmj.39133.668681.BE

BMJ 2007;334:729 (7 April), doi:10.1136/bmj.39133.668681.BE (published 23 March 2007)

Research

Pre-endoscopy serological testing for coeliac disease: evaluation of a clinical decision tool

Andrew D Hopper, gastroenterology specialist registrar¹, Simon S Cross, reader in pathology and honorary consultant in pathology³, David P Hurlstone, consultant gastroenterologist¹, Mark E McAlindon, consultant gastroenterologist¹, Alan J Lobo, consultant gastroenterologist¹, Marios Hadjivassiliou, consultant neurologist⁴, Marion E Sloan, general practitioner⁵, Simon Dixon, senior lecturer in health economics², David S Sanders, consultant gastroenterologist¹

¹ Department of Gastroenterology, Royal Hallamshire Hospital, Sheffield, ² Health Economics and Decision Science (HEDS), University of Sheffield, Sheffield, ³ Section of Oncology and Pathology, Division of Genomic Medicine, University of Sheffield Medical School, Sheffield, ⁴ Department of Neurology, Royal Hallamshire Hospital, ⁵ Surgery, 29 Blackstock Road, Sheffield S14 1AB

Correspondence to: A D Hopper, 15 Nairn Street, Sheffield S10 1UL andydhopper{at}aol.com

Objective To determine an effective diagnostic method of detectingall cases of coeliac disease in patients referred for gastroscopywithout performing routine duodenal biopsy.

Design An initial retrospective cohort of patients attendingfor gastroscopy was analysed to derive a clinical decision toolthat could increase the detection of coeliac disease withoutperforming routine duodenal biopsy. The tool incorporated serology(measuring antibodies to tissue transglutaminase) and stratifyingpatients according to their referral symptoms (patients wereclassified as having a "high risk" or "low risk" of coeliacdisease). The decision tool was then tested on a second cohortof patients attending for gastroscopy. In the second cohortall patients had a routine duodenal biopsy and serology performed.

Setting Teaching hospital in Sheffield.

Participants 2000 consecutive adult patients referred for gastroscopyrecruited prospectively.

Main outcome measure Evaluation of a clinical decision toolusing patients' referral symptoms, tissue transglutaminase antibodyresults, and duodenal biopsy results.

Results No cases of coeliac disease were missed by the pre-endoscopytesting algorithm. The prevalence of coeliac disease in patientsattending for endoscopy was 3.9% (77/2000, 95% confidence interval3.1% to 4.8%). The prevalence in the high risk and low riskgroups was 9.6% (71/739, 7.7% to 12.0%) and 0.5% (6/1261, 0.2%to 1.0%). The prevalence of coeliac disease in patients whowere negative for tissue transglutaminase antibody was 0.4%(7/2000). The sensitivity, specificity, positive predictivevalue, and negative predictive value for a positive antibodyresult to diagnose coeliac disease was 90.9%, 90.9%, 28.6%,and 99.6%, respectively. Evaluation of the clinical decisiontool gave a sensitivity, specificity, positive predictive value,and negative predictive value of 100%, 60.8%, 9.3%, and 100%,respectively.

Conclusions Pre-endoscopy serological testing in combinationwith biopsy of high risk cases detected all cases of coeliacdisease. The use of this decision tool may enable the endoscopistto target patients who need a duodenal biopsy.

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