Dickey, W.

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Serology and endoscopy in coeliac disease: applications and limitations

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UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)UvA-DARE (Digital Academic Repository)Serology and endoscopy in coeliac disease: applications and limitationsDickey, W.Publication date2000Link to publicationCitation for published version (APA):Dickey, W. (2000). Serology and endoscopy in coeliac disease: applications and limitations.General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.Download date:11 Nov 202222 2 ChapterChapter 2 23 3 Chapterr 2 Usee of Endomysial antibody testing by family doctors IDENTIFICATIONN OF COELIAC DISEASE IN PRIMARY CARE WW DICKEY, SA MCMILLAN, DF HUGHES Departmentss of Gastroenterology and Histopathology, Altnagelvin Hospital, Londonderry; Regionall  Immunology Service, Royal Group of Hospitals, Belfast; Northern Ireland, UK Scandinaviann Journal of Gastroenterology 1998; 33: 491-3 24 4 ChapterChapter 2 25 5 UseUse of Endomysial antibody testing by family doctors Abstract t Background Background Coeliacc disease is common yet often undiagnosed because symptoms may be trivial, non-specific,, or non-gastrointestinal, or because of lack of clinician awareness. Serum IgA class endomysiall  antibodies (EmA) have high specificity for coeliac disease and may facilitate case-findingg by clinicians other than gastroenterologists. We assessed the appropriateness andd diagnostic yield of requests for EmA by primary care general practitioners in a defined geographicall  area of Northern Ireland. Methods s Wee identified patients who had EmA requests by their general practitioners during 1994-1996.. Individual patient questionnaires were posted to the general practitioners concerned, seekingg information on indications for testing, management following the result and final diagnosis.. We compared new patient diagnosis rates in two catchment areas, one served by aa large district general hospital with a medical gastroenterology facility and the other by smallerr hospitals without. Results s AA total of 239 patients had coeliac profile testing by 69 of 177 general practitioners in the area.. Data were available for 181 patients not previously known to have coeliac disease of whomm 20 (11%) had EmA. All EmA +ve patients were referred to hospital where 19 underwentt smal bowel biopsy, which confirmed coeliac disease in all 19. Only 7 (35%) of thee 20 had diarrhoea and there was no significant difference in EmA prevalence among patientss tested with and without diarrhoea. Although the mean number of new patients (per 100,0000 population per annum) diagnosed by biopsy was 11 at the large hospital compared withh 5 elsewhere, the numbers identified by EmA in general practice for the two catchment areass were similar (2, 3). Conclusion n Generall  practitioners have an important role in the identification of patients with coeliac 26 6 ChapterChapter 2 disease,, particularly where there is no local medical gastroenterology facility, which is made possiblee by EmA testing. 27 7 UseUse of Endomysial antibody testing by family doctors Introduction n Coeliacc disease is common in western Europe, with population screening studies suggesting prevalencess of the order of 1:150-1:30 [1-3]. However, failed or delayed diagnosis is commonn [4]. Although smal bowel biopsy remains mandatory for diagnosis, serological testingg for IgA class endomysial antibodies (EmA) has sufficiently sensitivity and specificity too allow selection of patients for biopsy [5]: EmA may be useful for clinicians other than gastroenterologists,, including general practitioners in primary care. We studied the appropriatenesss and value of EmA requests by general practitioners in a defined geographical areaa of Northern Ireland using a retrospective questionnaire study. Methods s Sincee 1991 the Northern Ireland Regional Immunology Service has offered EmA testing, measuredd by indirect immunofluorescence with titres of 1:5 or greater taken as positive [6], too all hospital clinicians and general practitioners in Northern Ireland. We studied a defined areaa in the west of Northern Ireland with a population of 271,400. This area has primary caree services provided by 177 general practitioners working in 57 practices. As elsewhere inn the United Kingdom, all patients are seen initially by their general practitioners who determinee whether referral to hospital specialists is needed. One district general hospital (DGH)) with a long established medical gastroenterology service provides acute medical servicess for approximately 58% of the population (157,800). The remaining population (113,600,, 42%) is served by smaller general hospitals where most of the gastroenterology workloadd is managed by surgeons, with some support from consultants in general internal medicine. . Fromm our records we identified patients for whom EmA had been requested by general practitionerss in this area during the years 1994 to 1996 inclusive. In April 1997, we sent individuall  patient questionnaires to the general practitioners involved. Each questionnaire statedd patient name, date of birth and date of testing, and requested the following data: 1. Indicationss for testing- presence or absences of diarrhoea; anaemia; family history of coeliac disease;; skin rash (possible dermatitis herpetiformis) or assessment of known coeliac disease-withh free text invited for other indications if appropriate; 2. Action taken following result-28 8 ChapterChapter 2 whetherr or not hospital referral; smal bowel biopsy; and commencement on gluten-free diet-- with free text invited for other actions if taken; 3. Final diagnosis (if known). In July 19977 reminders and duplicate questionnaires were sent to GP s who had not responded, and alll  data received by 1 September 1997 were analysed. Histopathologyy services for all hospitals within the area are provided by a single laboratory. Fromm records we identified patients undergoing biopsy for the first time in 1994-1996 who hadd subtotal or total villous atrophy and thus calculated the number of new diagnoses of coeliacc disease made in hospitals over the same period. Statisticall  analysis used Fisher's exact test with p< 0.05 taken as significant. Results s Overr the study period 69 of the 177 general practitioners requested EmA on 239 patients, of whomm 26 (11%) were positive for EmA. Questionnaires for 209 patients were returned by 533 (77%) general practitioners. Data on 20 patients were unavailable because they had left theirr practices. Thus, full data were available for 189 (79%) patients, of whom 25 (13%) hadd EmA. Eight patients (5 EmA +ve) had EmA testing but previous histological confirmation off  coeliac disease and were excluded, leaving data of 181 patients, including 20 (11%) EmAA +ve, for analysis. Seventy-nine patients (44%) tested for EmA had diarrhoea, including 166 with a family history of coeliac disease; indications in the remaining 102 comprised one orr more of anaemia (42 patients), family history (23), underweight or weight loss (17), abdominall  pain/bloating (15), fatigue (6), skin rash (4) and mouth ulcers (3). Only 7 EmA +vee (35%) patients had diarrhoea, and there was no significant difference in EmA prevalence betweenn patients with and without diarrhoea (7 of 79 (9%) v. 13 of 102 (13%); p= 0.48). Characteristicss of the 13 EmA +ve patients without diarrhoea are listed in the Table. The EmAA prevalence among patients aged 30 or over was 20% (17 of 85) compared with 3% (3 off  93) of patients under 30 (p< 0.001); the three patients under 30 were aged 13, 17 and 19, withh none of 16 patients under 10 tested having EmA. Of the 20 EmA +ve patients, all were referredd to hospital where 19 had subsequent biopsy confirmation of subtotal or total villous atrophyy before starting gluten free diets; one patient was seen at a general medical clinic wheree diet was prescribed without biopsy. 29 9 UseUse of' Endomysial antibody testing by family doctors Table.. Details of 13 patients with EmA and no history of diarrhoea Patientt no. 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 0 11 1 12 2 13 3 Age e 48 8 17 7 48 8 30 0 38 8 45 5 49 9 57 7 55 5 43 3 13 3 19 9 53 3 Sex x Female e Female e Male e Male e Female e Female e Male e Female e Male e Male e Female e Female e Female e Indication n Bloating,, constipation Anaemia a Anaemia,, joint pains Anaemia,, family history of coeliac Familyy history of coeliac, no symptoms Jointt pains, fatigue Anaemia a Anaemia a Fatigue,, family history of coeliac Anaemia a Abdominall  pain, family history of coeliac Dermatitiss herpetiformis Weightt loss Yearlyy figures for new patients having villous atrophy on smal bowel biopsy at the DGH withh medical gastroenterology were 10 (1994), 16 (1995), and 25 (1996) for a catchment areaa of 157,800, representing a mean 11 new cases per 100,000 population per annum. Assumingg all 20 patients identified by general practitioners as EmA +ve had villous atrophy, 111 lived within the same catchment area, representing 2 new cases identified in primary caree per 100,000 per annum. Comparative figures for all other hospitals without medical gastroenterologyy were 6 (1993), 3 (1994) and 7 (1996) for a population of 113,600- mean 55 new cases identified in hospital per 100,000 per annum: 3 new cases per 100,000 per annumm were identified in primary care in the same catchment area (9 patients from a populationn of 113,600 over 3 years). Off  161 EmA negative patients, 68 (42%) were referred to hospital clinics, with final diagnoses off  irritable bowel syndrome in 24 (35%), inflammatory bowel disease (7; 10%), diverticulosis (4;6%),, neoplasia (4;6%), other diagnoses in 11 (16%) and no diagnosis in 18 (26%). Final 30 0 ChapterChapter 2 diagnosess among 93 patients not referred were irritable bowel syndrome (22; 24%), nonspecificc self-limiting illness (17; 18%), negative family screening for coeliac disease (13;; 14%), menorrhagia (10,11%), dietary deficiency (8, 9%), and toddler diarrhoea in 1 (1%)) with no diagnosis in 22 (25%). Discussion n Coeliacc disease is much commoner in western Europe than previously appreciated. Population studiess show prevalences for biopsy proved coeliac disease of 1:256 among Swedish blood donorss [1], 1:300 in Italian secondary schoolchildren [2], and 1:150 in an adult population inn Northern Ireland [3]. In two recent series from Northern Ireland less than half of patients hadd the "classic" textbook history of diarrhoea [4,7] and this trend has been confirmed elsewheree [8]. In particular, iron deficiency anaemia without gastrointestinal symptoms is commonn [9]. The diagnosis rate, as a proportion of outpatients seen, at an English DGH was threefoldd that of two neighbouring hospitals combined due to an increased biopsy rate among patientss with haematological and other non-gastroenterological problems [10]. Accurate diagnosiss is essential even if symptoms are trivial in view of the increased long-term risks off  osteopenia and gastrointestinal malignancy, which are reduced by early treatment [11,12]. Althoughh the only reliable method of confirming diagnosis is by smal bowel biopsy, serologicall  tests facilitate selection of patients particularly where symptoms are non-specific. EmAA has specificity in many studies of 100% with sensitivity of 74-98% [5,6,7,13]. Our studyy confirms that there is already considerable awarenes of the varied presentations of coeliacc disease among general practitioners, with a high proportion of patients having serologicall  testing for indications other than diarrhoea and overal 11 % tested having EmA: ass in other series, a minority had diarrhoea. The final diagnoses in EmA negative patients nott referred to hospital imply that EmA is being used as an "insurance" before confidently diagnosingg irritable bowel syndrome or attributing anaemia to poor diet or menorrhagia. Thiss seems appropriate given the often trivial or non-specific nature of coeliac symptoms. Muchh of the diagnostic yield arose from testing patients over 30, with no children under 10 identified.. Elsewhere in Ireland childhood coeliac disease is declining [ 14] though elsewhere, notablyy the Netherlands, it is increasing [15]. Inn the area studied, the incidence of biopsy proved coeliac disease at a DGH with medical UseUse of Endomysial antibody testing by family doctors 31 1 gastroenterologyy was over twice that of hospitals without, yet diagnosis rates in terms of generall  practitioner identified EmA+ve patients were similar in the two catchment areas, suggestingg that a lack of awarenes among hospital clinicians other than gastroenterologist accountss for the disparity rather than any epidemiological difference. Of 39 patients diagnosed ass coeliac at another DGH in Northern Ireland, 14 had been referred to hospital a total of 30 timess with features of coeliac disease unrecognised [4]: gastroenterologist had an 85% diagnosticc succes rate compared with 7% for surgeons. Our study suggests that general practitionerss can help correct this deficit and have an important role in case-finding, although itt must be emphasised that EmA does not have 100% sensitivity. IgA deficiency in particular iss an important cause of false-negative EmA [7]. Accordingly, general practitioners should referr patients to a medical gastroenterology unit for consideration of biopsy if the presentation iss suggestive even if EmA is negative. Acknowledgement t Wee thank the general practitioners who participated in the study. 32 2 ChapterChapter 2 References s 1.. Grodzinsky E, Franzen L, Hed J, Strom M. High prevalence of celiac disease in healthy adultss revealed by antigliadin antibodies. Ann Allergy 1992; 69: 66-70. 2.. Catassi C, Ratsch IM, Fabiani E et al. Coeliac disease in the year 2000: exploring the iceberg.. Lancet 1994; 343: 200-3. 3.. Johnston SD, Watson RGP, McMillan SA et al. Preliminary results from follow-up of a large-scalee population survey of antibodies to gliadin, reticulin and endomysium. Acta Paediatrr Suppl 1996; 412: 61-41. 4.. Dickey W, McConnell JB. How many hospital visits does it take before celiac sprue is diagnosed?? J Clin Gastroenterol 1996; 23: 21-3. 5.. Ascher H, Hahn-Zoric M, Hanson L et al. Value of serologic markers for clinical diagnosis andd population studies of coeliac disease. Scand J Gastroenterol 1996; 31: 61-7. 6.. McMillan SA, Haughton DJ, Biggart JD et al. Predictive value for coeliac disease of antibodiess to gliadin, endomysium and jejunum in patients attending for jejunal biopsy. Brr Med J 1991; 303: 1163-5. 7.. Dickey W, McMillan SA, McCrum EE, Evans AE. Association between serum levels of totall  IgA and IgA class endomysial and antigliadin antibodies: implications for coeliac diseasee screening. Eur J Gastroenterol Hepatol 1997; 9: 559-62 (Chapter 4, this thesis). 8.. Sategna-Guidetti C, Grosso S. Changing pattern in adult coeliac disease: a 24-year survey. Eurr J Gastroenterol Hepatol 1994; 6: 15-9. 9.. Corazza GR, Valentini RA, Andreani ML et al. Subclinical coeliac disease is a frequent causee of iron-deficiency anaemia. Scand J Gastroenterol 1995; 30: 153-6. 10.. Swinson CM, Levi AJ. Is coeliac disease underdiagnosed? Br Med J 1980; 281: 1258-60. . 11.. Valdimarsson T, Lofman O, Toss G, Strom M. Reversal of osteopenia with diet in adult coeliacc disease. Gut 1996; 38: 322-7. 12.. Holmes GKT, Prior P, Lane MR et al. Malignancy in coeliac disease- effect of a gluten-freee diet. Gut 1989; 30: 333-8. 13.. Valdimarsson T, Franzen L, Grodzinsky E et al. Is smal bowel biopsy necessary in adultss with suspected celiac disease and IgA anti-endomysial antibodies? Dig Dis Sci 1996;41:83-7. . 33 3 UseUse of Endomysial antibody testing by family doctors H.Gumaaa SN, McNicholl B, Egan-Mitchell B et al. Coeliac disease in Galway, Ireland 1971-1990.. Ir Med J 1997; 90: 60-1. 15.. George EK, Mearin ML, Franken HC et al. Twenty years of childhood coeliac disease in thee Netherlands- a rapidly increasing incidence? Gut 1997; 40: 61-6. 34 4 

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UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)
UvA-DARE (Digital Academic Repository)
Serology and endoscopy in coeliac disease: applications and limitations
Dickey, W.
Link to publication
Citation for published version (APA):
Dickey, W. (2000). Serology and endoscopy in coeliac disease: applications and limitations.
General rights
It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),
other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).
Disclaimer/Complaints regulations
If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating
your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask
the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam,
The Netherlands. You will be contacted as soon as possible.
Download date: 04 Feb 2021
22 2 
ChapterChapter 2 
23 3 
Chapterr 2 
Usee of Endomysial antibody testing by family doctors 
IDENTIFICATIONN OF COELIAC DISEASE IN PRIMARY CARE 
WW DICKEY, SA MCMILLAN, DF HUGHES 
Departmentss of Gastroenterology and Histopathology, Altnagelvin Hospital, Londonderry; 
Regionall  Immunology Service, Royal Group of Hospitals, Belfast; Northern Ireland, UK 
Scandinaviann Journal of Gastroenterology 1998; 33: 491-3 
24 4 
ChapterChapter 2 
25 5 
UseUse of Endomysial antibody testing by family doctors 
Abstract t 
Background Background 
Coeliacc disease is common yet often undiagnosed because symptoms may be trivial, non-
specific,, or non-gastrointestinal, or because of lack of clinician awareness. Serum IgA class 
endomysiall  antibodies (EmA) have high specificity for coeliac disease and may facilitate 
case-findingg by clinicians other than gastroenterologists. We assessed the appropriateness 
andd diagnostic yield of requests for EmA by primary care general practitioners in a defined 
geographicall  area of Northern Ireland. 
Methods s 
Wee identified patients who had EmA requests by their general practitioners during 1994-
1996.. Individual patient questionnaires were posted to the general practitioners concerned, 
seekingg information on indications for testing, management following the result and final 
diagnosis.. We compared new patient diagnosis rates in two catchment areas, one served by 
aa large district general hospital with a medical gastroenterology facility and the other by 
smallerr hospitals without. 
Results s 
AA total of 239 patients had coeliac profile testing by 69 of 177 general practitioners in the 
area.. Data were available for 181 patients not previously known to have coeliac disease of 
whomm 20 (11%) had EmA. All EmA +ve patients were referred to hospital where 19 
underwentt smal bowel biopsy, which confirmed coeliac disease in all 19. Only 7 (35%) of 
thee 20 had diarrhoea and there was no significant difference in EmA prevalence among 
patientss tested with and without diarrhoea. Although the mean number of new patients (per 
100,0000 population per annum) diagnosed by biopsy was 11 at the large hospital compared 
withh 5 elsewhere, the numbers identified by EmA in general practice for the two catchment 
areass were similar (2, 3). 
Conclusion n 
Generall  practitioners have an important role in the identification of patients with coeliac 
26 6 
ChapterChapter 2 
disease,, particularly where there is no local medical gastroenterology facility, which is made 
possiblee by EmA testing. 
27 7 
UseUse of Endomysial antibody testing by family doctors 
Introduction n 
Coeliacc disease is common in western Europe, with population screening studies suggesting 
prevalencess of the order of 1:150-1:30 [1-3]. However, failed or delayed diagnosis is 
commonn [4]. Although smal bowel biopsy remains mandatory for diagnosis, serological 
testingg for IgA class endomysial antibodies (EmA) has sufficiently sensitivity and specificity 
too allow selection of patients for biopsy [5]: EmA may be useful for clinicians other than 
gastroenterologists,, including general practitioners in primary care. We studied the 
appropriatenesss and value of EmA requests by general practitioners in a defined geographical 
areaa of Northern Ireland using a retrospective questionnaire study. 
Methods s 
Sincee 1991 the Northern Ireland Regional Immunology Service has offered EmA testing, 
measuredd by indirect immunofluorescence with titres of 1:5 or greater taken as positive [6], 
too all hospital clinicians and general practitioners in Northern Ireland. We studied a defined 
areaa in the west of Northern Ireland with a population of 271,400. This area has primary 
caree services provided by 177 general practitioners working in 57 practices. As elsewhere 
inn the United Kingdom, all patients are seen initially by their general practitioners who 
determinee whether referral to hospital specialists is needed. One district general hospital 
(DGH)) with a long established medical gastroenterology service provides acute medical 
servicess for approximately 58% of the population (157,800). The remaining population 
(113,600,, 42%) is served by smaller general hospitals where most of the gastroenterology 
workloadd is managed by surgeons, with some support from consultants in general internal 
medicine. . 
Fromm our records we identified patients for whom EmA had been requested by general 
practitionerss in this area during the years 1994 to 1996 inclusive. In April 1997, we sent 
individuall  patient questionnaires to the general practitioners involved. Each questionnaire 
statedd patient name, date of birth and date of testing, and requested the following data: 1. 
Indicationss for testing- presence or absences of diarrhoea; anaemia; family history of coeliac 
disease;; skin rash (possible dermatitis herpetiformis) or assessment of known coeliac disease-
withh free text invited for other indications if appropriate; 2. Action taken following result-
28 8 
ChapterChapter 2 
whetherr or not hospital referral; smal bowel biopsy; and commencement on gluten-free 
diet-- with free text invited for other actions if taken; 3. Final diagnosis (if known). In July 
19977 reminders and duplicate questionnaires were sent to GP s who had not responded, and 
alll  data received by 1 September 1997 were analysed. 
Histopathologyy services for all hospitals within the area are provided by a single laboratory. 
Fromm records we identified patients undergoing biopsy for the first time in 1994-1996 who 
hadd subtotal or total villous atrophy and thus calculated the number of new diagnoses of 
coeliacc disease made in hospitals over the same period. 
Statisticall  analysis used Fisher's exact test with p< 0.05 taken as significant. 
Results s 
Overr the study period 69 of the 177 general practitioners requested EmA on 239 patients, of 
whomm 26 (11%) were positive for EmA. Questionnaires for 209 patients were returned by 
533 (77%) general practitioners. Data on 20 patients were unavailable because they had left 
theirr practices. Thus, full data were available for 189 (79%) patients, of whom 25 (13%) 
hadd EmA. Eight patients (5 EmA +ve) had EmA testing but previous histological confirmation 
off  coeliac disease and were excluded, leaving data of 181 patients, including 20 (11%) 
EmAA +ve, for analysis. Seventy-nine patients (44%) tested for EmA had diarrhoea, including 
166 with a family history of coeliac disease; indications in the remaining 102 comprised one 
orr more of anaemia (42 patients), family history (23), underweight or weight loss (17), 
abdominall  pain/bloating (15), fatigue (6), skin rash (4) and mouth ulcers (3). Only 7 EmA 
+vee (35%) patients had diarrhoea, and there was no significant difference in EmA prevalence 
betweenn patients with and without diarrhoea (7 of 79 (9%) v. 13 of 102 (13%); p= 0.48). 
Characteristicss of the 13 EmA +ve patients without diarrhoea are listed in the Table. The 
EmAA prevalence among patients aged 30 or over was 20% (17 of 85) compared with 3% (3 
off  93) of patients under 30 (p< 0.001); the three patients under 30 were aged 13, 17 and 19, 
withh none of 16 patients under 10 tested having EmA. Of the 20 EmA +ve patients, all were 
referredd to hospital where 19 had subsequent biopsy confirmation of subtotal or total villous 
atrophyy before starting gluten free diets; one patient was seen at a general medical clinic 
wheree diet was prescribed without biopsy. 
29 9 
UseUse of' Endomysial antibody testing by family doctors 
Table.. Details of 13 patients with EmA and no history of diarrhoea 
Patientt no. 
1 1 
2 2 
3 3 
4 4 
5 5 
6 6 
7 7 
8 8 
9 9 
10 0 
11 1 
12 2 
13 3 
Age e 
48 8 
17 7 
48 8 
30 0 
38 8 
45 5 
49 9 
57 7 
55 5 
43 3 
13 3 
19 9 
53 3 
Sex x 
Female e 
Female e 
Male e 
Male e 
Female e 
Female e 
Male e 
Female e 
Male e 
Male e 
Female e 
Female e 
Female e 
Indication n 
Bloating,, constipation 
Anaemia a 
Anaemia,, joint pains 
Anaemia,, family history of coeliac 
Familyy history of coeliac, no symptoms 
Jointt pains, fatigue 
Anaemia a 
Anaemia a 
Fatigue,, family history of coeliac 
Anaemia a 
Abdominall  pain, family history of coeliac 
Dermatitiss herpetiformis 
Weightt loss 
Yearlyy figures for new patients having villous atrophy on smal bowel biopsy at the DGH 
withh medical gastroenterology were 10 (1994), 16 (1995), and 25 (1996) for a catchment 
areaa of 157,800, representing a mean 11 new cases per 100,000 population per annum. 
Assumingg all 20 patients identified by general practitioners as EmA +ve had villous atrophy, 
111 lived within the same catchment area, representing 2 new cases identified in primary 
caree per 100,000 per annum. Comparative figures for all other hospitals without medical 
gastroenterologyy were 6 (1993), 3 (1994) and 7 (1996) for a population of 113,600- mean 
55 new cases identified in hospital per 100,000 per annum: 3 new cases per 100,000 per 
annumm were identified in primary care in the same catchment area (9 patients from a 
populationn of 113,600 over 3 years). 
Off  161 EmA negative patients, 68 (42%) were referred to hospital clinics, with final diagnoses 
off  irritable bowel syndrome in 24 (35%), inflammatory bowel disease (7; 10%), diverticulosis 
(4;6%),, neoplasia (4;6%), other diagnoses in 11 (16%) and no diagnosis in 18 (26%). Final 
30 0 
ChapterChapter 2 
diagnosess among 93 patients not referred were irritable bowel syndrome (22; 24%), 
nonspecificc self-limiting illness (17; 18%), negative family screening for coeliac disease 
(13;; 14%), menorrhagia (10,11%), dietary deficiency (8, 9%), and toddler diarrhoea in 1 
(1%)) with no diagnosis in 22 (25%). 
Discussion n 
Coeliacc disease is much commoner in western Europe than previously appreciated. Population 
studiess show prevalences for biopsy proved coeliac disease of 1:256 among Swedish blood 
donorss [1], 1:300 in Italian secondary schoolchildren [2], and 1:150 in an adult population 
inn Northern Ireland [3]. In two recent series from Northern Ireland less than half of patients 
hadd the "classic" textbook history of diarrhoea [4,7] and this trend has been confirmed 
elsewheree [8]. In particular, iron deficiency anaemia without gastrointestinal symptoms is 
commonn [9]. The diagnosis rate, as a proportion of outpatients seen, at an English DGH was 
threefoldd that of two neighbouring hospitals combined due to an increased biopsy rate among 
patientss with haematological and other non-gastroenterological problems [10]. Accurate 
diagnosiss is essential even if symptoms are trivial in view of the increased long-term risks 
off  osteopenia and gastrointestinal malignancy, which are reduced by early treatment [11,12]. 
Althoughh the only reliable method of confirming diagnosis is by smal bowel biopsy, 
serologicall  tests facilitate selection of patients particularly where symptoms are non-specific. 
EmAA has specificity in many studies of 100% with sensitivity of 74-98% [5,6,7,13]. Our 
studyy confirms that there is already considerable awarenes of the varied presentations of 
coeliacc disease among general practitioners, with a high proportion of patients having 
serologicall  testing for indications other than diarrhoea and overal 11 % tested having EmA: 
ass in other series, a minority had diarrhoea. The final diagnoses in EmA negative patients 
nott referred to hospital imply that EmA is being used as an "insurance" before confidently 
diagnosingg irritable bowel syndrome or attributing anaemia to poor diet or menorrhagia. 
Thiss seems appropriate given the often trivial or non-specific nature of coeliac symptoms. 
Muchh of the diagnostic yield arose from testing patients over 30, with no children under 10 
identified.. Elsewhere in Ireland childhood coeliac disease is declining [ 14] though elsewhere, 
notablyy the Netherlands, it is increasing [15]. 
Inn the area studied, the incidence of biopsy proved coeliac disease at a DGH with medical 
UseUse of Endomysial antibody testing by family doctors 
31 1 
gastroenterologyy was over twice that of hospitals without, yet diagnosis rates in terms of 
generall  practitioner identified EmA+ve patients were similar in the two catchment areas, 
suggestingg that a lack of awarenes among hospital clinicians other than gastroenterologist 
accountss for the disparity rather than any epidemiological difference. Of 39 patients diagnosed 
ass coeliac at another DGH in Northern Ireland, 14 had been referred to hospital a total of 30 
timess with features of coeliac disease unrecognised [4]: gastroenterologist had an 85% 
diagnosticc succes rate compared with 7% for surgeons. Our study suggests that general 
practitionerss can help correct this deficit and have an important role in case-finding, although 
itt must be emphasised that EmA does not have 100% sensitivity. IgA deficiency in particular 
iss an important cause of false-negative EmA [7]. Accordingly, general practitioners should 
referr patients to a medical gastroenterology unit for consideration of biopsy if the presentation 
iss suggestive even if EmA is negative. 
Acknowledgement t 
Wee thank the general practitioners who participated in the study. 
32 2 
ChapterChapter 2 
References s 
1.. Grodzinsky E, Franzen L, Hed J, Strom M. High prevalence of celiac disease in healthy 
adultss revealed by antigliadin antibodies. Ann Allergy 1992; 69: 66-70. 
2.. Catassi C, Ratsch IM, Fabiani E et al. Coeliac disease in the year 2000: exploring the 
iceberg.. Lancet 1994; 343: 200-3. 
3.. Johnston SD, Watson RGP, McMillan SA et al. Preliminary results from follow-up of a 
large-scalee population survey of antibodies to gliadin, reticulin and endomysium. Acta 
Paediatrr Suppl 1996; 412: 61-41. 
4.. Dickey W, McConnell JB. How many hospital visits does it take before celiac sprue is 
diagnosed?? J Clin Gastroenterol 1996; 23: 21-3. 
5.. Ascher H, Hahn-Zoric M, Hanson L et al. Value of serologic markers for clinical diagnosis 
andd population studies of coeliac disease. Scand J Gastroenterol 1996; 31: 61-7. 
6.. McMillan SA, Haughton DJ, Biggart JD et al. Predictive value for coeliac disease of 
antibodiess to gliadin, endomysium and jejunum in patients attending for jejunal biopsy. 
Brr Med J 1991; 303: 1163-5. 
7.. Dickey W, McMillan SA, McCrum EE, Evans AE. Association between serum levels of 
totall  IgA and IgA class endomysial and antigliadin antibodies: implications for coeliac 
diseasee screening. Eur J Gastroenterol Hepatol 1997; 9: 559-62 (Chapter 4, this thesis). 
8.. Sategna-Guidetti C, Grosso S. Changing pattern in adult coeliac disease: a 24-year survey. 
Eurr J Gastroenterol Hepatol 1994; 6: 15-9. 
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Serology and endoscopy in coeliac disease: applications and limitations

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