Head To Head

Should we screen for coeliac disease? No

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b3674 (Published 17 September 2009) Cite this as: BMJ 2009;339:b3674
  1. Kate E Evans, clinical research fellow,
  2. Ruth McAllister, health economist,
  3. David S Sanders, consultant gastroenterologist
  1. 1Department of Gastroenterology, Sheffield Teaching Hospitals Trust, Sheffield S10 2JF
  1. Correspondence to: D S Sanders david.sanders{at}sth.nhs.uk

    Coeliac disease often goes undiagnosed. Alessio Fasano (doi:10.1136/bmj.b3592) argues that screening would prevent considerable morbidity, but Kate Evans and colleagues think we do not know enough about the effects on people without symptoms

    Coeliac disease is common, can be detected by a cheap accurate test, and there is an effective treatment that can reduce morbidity and severe complications. So of course we should screen for it. Or should we? Controversies of diagnosis, a poor understanding of the natural course of coeliac disease, difficulties with adherence to a gluten-free diet, and a lack of cost effectiveness all suggest caution before we implement population screening.

    Diagnosis

    Coeliac disease is detected using tests for tissue transglutaminase or endomysial antibodies. In combination these antibodies have a positive predictive value above 90% in selected groups,1 2 although it falls to around 70% in the general population.3 Furthermore, serological positivity can be transient or fluctuating. Simell and colleagues showed that seropositive children carrying the genetic risk of coeliac disease could become seronegative spontaneously—a concept labelled as immune tolerance.4

    Additional logistical problems were highlighted in a recent screening study …

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