Introduction

Coeliac disease (CD) is a chronic small intestinal immune-mediated enteropathy which occurs in genetically predisposed individuals by exposure to ingested gluten, globally about 1% of the world’s population. CD mainly affects the gastrointestinal tract but may also affect other organs. CD may therefore present with a wide range of symptoms and signs. Diagnosing CD involves assessment of symptoms, clinical findings, serology, and endoscopy with duodenal biopsies. In children and adolescents, endoscopy with biopsies can be omitted if serology is conclusive, but this is controversial in adults. Endoscopy can have an additional yield by diagnosing other non-CD related findings, including premalignant and malignant lesions of the upper gastrointestinal tract.

Aims & Methods

The aim of this study was to assess the additional non-CD related findings at the diagnostic endoscopy for CD in an adult population screened for CD. The study was based on the fourth Trøndelag Health Study (HUNT4), a population-based study of adults above 20 years of age in Norway (1). Serum samples of 54,505 participants were analysed using a dual anti-transglutaminase 2 immunoglobulin A and G assay, and the 1107 seropositive individuals were invited to upper gastrointestinal endoscopy with duodenal biopsies. CD was confirmed if histological findings corresponding to Marsh grade 3 were found. At the diagnostic investigation performed by specialists in gastroenterology, additional endoscopic findings were recorded systematically. Multivariable logistic regression analysis was used to estimate the risk of additional findings at the diagnostic endoscopy for CD. The risk was adjusted for sex, age, and use of medications (non-steroid anti-inflammatory drugs/acetylsalicylic acid and proton pump inhibitors/histamine-2 receptor antagonists).

Results

In the present study, 476 individuals with confirmed CD were included. Median age was 55 years and 54.6% were women. The proportion of additional non-CD related endoscopic findings increased with increasing age, especially above 50 years of age. Seven Barrett’s oesophagus and one duodenal adenoma with low grade dysplasia were found, all among participants above 50 years of age. No malignant lesions were found. The risk of additional endoscopic findings increased with advancing age and was higher among men and those using proton pump inhibitors or histamine-2 receptor antagonists.

Conclusion

This study suggests that diagnosing CD without endoscopy will not result in missing clinically significant additional findings in the younger adult population below 50 years of age. However, with advancing age above 50 years, the risk of non-CD related premalignant lesions increases. These lesions can be detected at the diagnostic endoscopy for CD and treated or included in surveillance programs to prevent sinister outcomes.

References

1. Lukina P, Andersen IL, Eggen PT, Mjones PG, Ronne E, Bolstad N, et al. Coeliac disease in the Trondelag Health Study (HUNT), Norway, a population-based cohort of coeliac disease patients. BMJ Open. 2024;14(1):e077131.