Can a case-finding strategy identify more patients with celiac disease?

This study tells us that celiac disease (CD) is relatively common in primary care practice, particularly in patients with gastrointestinal symptoms, chronic fatigue, or thyroid disease. Patients with persistent symptoms should be evaluated for CD using the strategy described in this study, and the diagnosis should be confirmed either by intestinal biopsy or a successful trial of a gluten-free diet. (LOE = 2c)

Catassi C, Kryszak D, Louis-Jacques O, et al. Detection of celiac disease in primary care: a multicenter case-finding study in North America. Am J Gastroenterol 2007;102:1454-1460.  [PMID:17355413]

Cohort (prospective)

Government

Outpatient (primary care)

CD is a relatively common cause of chronic gastrointestinal symptoms and increases the risk of anemia, lymphoma, and osteoporosis. However, it often remains undiagnosed. In this study, the authors approached all adult patients presenting to a group of primary care physicians. Patients with at least one symptom or comorbidity associated with CD (including family history, anemia, recurrent abdominal pain or bloating, irritable bowel syndrome, chronic diarrhea, chronic fatigue, or autoimmune disorder) were asked to participate in the study by completing a more detailed questionnaire and having blood drawn for CD serology. Of 2568 patients who were approached to participate, 33% had none of the qualifying symptoms, 3% refused the questionnaire, and 26% refused the serology, leaving 976 (38%) for the study population. The initial blood test was for IgA anti-tissue transglutaminase (tTG) antibodies. Patients (n=103) with a low value on this test (< 0.5 units) had total IgA evaluated to rule out selective IgA deficiency. All results were normal. Thirty patients had an elevated tTG IgA (> 7.0 units) and underwent testing for IgA endomysial antibodies; 22 had abnormal results on this test as well. Of this final group, 15 underwent small bowel biopsy and 17 adopted a gluten-free diet. We aren't told, however, whether the diet was successful. The most common initial reasons for screening were bloating (12/22 patients), thyroid disease (11/22), irritable bowel (7/22), and chronic diarrhea (6/22). Ultimately, CD was diagnosed in 11.6 per thousand visits, a rate much higher than that seen before the case-finding strategy was adopted.