Celiac Disease – A Case Series from North India: Author’s Reply

Abstract

To the Editor: I thank you for going critically through our letter to editor entitled BCeliac disease -a case series from North India^published online [1].I agree to authors' observation that there is no mention of asymptomatic high risk group in our series. Ours was a retrospective study wherein we collected records from endoscopy software which has a limited space where the most prominent symptoms were entered. It is possible that there were a small number of patients who had got serology tested because they belonged to high risk group and had minor symptoms. There is an ongoing need to sensitize the pediatricians not only to pick up symptomatic cases early but also to screen the high risk group to diagnose asymptomatic ones.We had 51 children with tissue transglutaminase (TTG) > 10 times of upper limit of normal (ULN) in the total 234 children. We have not included the details of this group in our letter in view of the word limit [1]. The histology in this group was normal in 1, Marsh 2 in 2, Marsh 3 in 48. Thus 1 out of 51 (2 %) patient was not a Celiac despite TTG > 10 times ULN. This is an important observation considering the fact that the recent ESPGHAN guideline in 2012 allows this group of symptomatic TTG positive to skip the need of biopsy if an additional serology -Anti endomysial antibody(AEA) and HLA DQ2-DQ8 is positive [2]. We however do not have the AEA and HLA of this and most other patients. There is a need to do a prospective study to look for validation of this guideline in local population as concluded in the literature [3].The availability of pediatric endoscopy and histopathology is limited in most developing countries. However at the same time there is a cost as well as expertise involved in the additional serology -AEA recommended in the ESPGHAN guideline. The cost of HLA is also significant. In some of the centers in India the cost of an endoscopic procedure and histology reporting comes out to be less than the cost of an additional serology in the form of AEA and HLA testing. Thus, one needs to individualize the decision regarding biopsy or AEA and HLA testing in symptomatic high TTG antibodies depending upon the availability of resources.