Pre-endoscopy serological testing for coeliac disease: evaluation of a clinical decision tool

Objective: To determine an effective diagnostic method of detecting all cases of coeliac disease in patients referred for gastroscopy without performing routine duodenal biopsy.

Design: An initial retrospective cohort of patients attending for gastroscopy was analysed to derive a clinical decision toot that could increase the detection of coeliac disease without performing routine duodenal biopsy. The toot incorporated serology (measuring antibodies to tissue transglutaminase) and stratifying patients according to their referral symptoms (patients were classified as having a "high risk" or "low risk" of coeliac disease). The decision tool was then tested on a second cohort of patients attending for gastroscopy. In the second cohort all patients had a routine duodenal biopsy and serology performed.

Setting: Teaching hospital in Sheffield.

Participants: 2000 consecutive adult patients referred for gastroscopy recruited prospectively.

Main outcome measure: Evaluation of a clinical decision toot using patients' referral symptoms, tissue transglutaminase antibody results, and duodenal biopsy results.

Results: No cases of coeliac disease were missed by the pre-endoscopy testing algorithm. The prevalence of coeliac disease in patients attending for endoscopy was 3.9% (77/2000, 95% confidence interval 3.1% to 4.8%). The prevalence in the high risk and low risk groups was 9.6% (71/739, 7.7% to 12.0%) and 0.5% (6/1261, 0.2% to 1.0%). The prevalence of coeliac disease in patients who were negative for tissue transglutaminase antibody was 0.4% (7/2000). The sensitivity, specificity, positive predictive value, and negative predictive value for a positive antibody result to diagnose coeliac disease was 90.9%, 90.9%, 28.6%, and 99.6%, respectively. Evaluation of the clinical decision toot gave a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 60.8%, 9.3%, and 100%, respectively.

Conclusions: Pre-endoscopy serological testing in combination with biopsy of high risk cases detected all cases of coeliac disease. The use of this decision toot may enable the endoscopist to target patients who need a duodenal biopsy.