The changing clinical presentation of coeliac disease

Madhur Ravikumara ¹, David P Tuthill ¹ and Huw R Jenkins ^1*

¹ University Hospital of Wales, Cardiff, United Kingdom

^* To whom correspondence should be addressed. E-mail: huw.jenkins{at}cardiffandvale.wales.nhs.uk.

Accepted 26 July 2006

Abstract

Background: There has been a growing recognition that Coeliac disease (CD) is much more common than previously recognised and this has coincided with the increasingly widespread use of serological testing.

Aim: To determine whether the age at presentation and the clinical presentation of CD has changed with the advent of serological testing.

Methods: A 21 year review of prospectively recorded data on the mode of presentation of CD in a single regional centre. Presenting features over the last five years were compared with those of the previous 16 years. Between 1983 and 1989 (inclusive) there was no serological testing undertaken; between 1990-98 anti- gliadin antibody (AGA) was used with occasional use of anti-endomysial (AEA) and anti-reticulin antibody (ARA). From 1999 onwards anti-tissue transglutaminase (ATTG) was used. All cases were biopsy proven according to the European Society of Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) criteria.

Results: 86 cases were diagnosed over the 21 year period: 50 children were diagnosed with CD between 1999 and 2004 compared to 25 children between 1990 and 1998 (serological testing began in 1990) and 11 children between 1983 to 1989 (no serological testing). The median age at presentation has risen over the years. Gastrointestinal manifestations as presenting features have decreased dramatically. In the last 5 years almost one in 4 children with CD were diagnosed by targeted screening.

Conclusion: We report the 21-year experience from a single centre involving 86 biopsy proven cases demonstrating significant changes in the presentation of childhood CD, namely; a decreased proportion presenting with GI manifestations and a rise in the number of asymptomatic cases picked up by targeted screening. Almost one in four children with CD are now diagnosed by targeted screening, a significant proportion of these being relatively asymptomatic. The majority of children with CD remain undiagnosed. Paediatricians and primary care physicians should maintain a high index of suspicion and have a low threshold for testing so that the potential long term problems associated with untreated CD can be prevented.

Keywords: coeliac disease, presenting features, screening

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