Introduction

Coeliac disease (CeD) is a chronic autoimmune condition affecting the small intestine triggered by gluten. ​

Aims & Methods

To assess the national management of newly diagnosed CeD patients between 2013 and 2023 in Malta and whether this was carried out in accordance with “European Society for the Study of Coeliac Disease (ESsCD) guideline for CeD and other gluten-related disorders”¹.
The national statistics data of all the newly diagnosed patients with CeD between 2013 and 2023 in the Maltese Islands, were retrospectively analysed. Several factors were considered including patient demographics, serology, histology, imaging and dietitian referral.

Results

171 patients with newly diagnosed CeD (2013 n=46, 2023 n=125) were recruited. Adults, defined as ≥18 years, accounted for 72.5% (n=124) of the total cohort.
In 2013, 80.4%(n=37) were female while in 2023, 66.4% (n=83) were female (p=0.07), The mean age at diagnosis was 38.5 years (SD19.6) in 2013 and 36.6 years (SD23.4) in 2023. The largest proportion, 17.0%(n=29), were diagnosed in the 31 to 40 age group.
Anti-Tissue Transglutaminase Antibody (anti-TTG IgA-Ab) was taken in 99.4%(n=170), with 92.4%(n=158) having a positive anti-TTG. 4.1%(n=7) had negative anti-TTG IgA-Ab while 2.9%(n=5) had borderline anti-TTG IgA-Ab. Of these 12 patients, 11 patients had biopsies taken with histology confirming the diagnosis of CeD. The other patient was 8 years old with IgA deficiency and had a positive anti-TTG IgG-Ab, with a value of >250 U/mL.
73.1%(n=125) of the total cohort had biopsies taken, with 56.0%(n=70) taken from D2, 3.2%(n=4) taken from D1 and 37.6%(n=47) taken from both D1 and D2. In 3.2%(n=4), the biopsy site was not specified. In 2023, 48.2%(n=41) of patients had D1+D2 biopsies taken, versus only 15%(n=6) in 2013 (p<0.001). Of the remaining 26.9%(n=46) who did not have biopsies taken, 73.9%(n=34) were children.
48%(n=60) of the patients in 2023 were referred to the dietician versus 15.2%(n=7) in 2013 (p<0.001). From the total cohort, only 39.2%(n=67) were referred to the dietician. DEXA scan was carried out in 49.1%(n=84), 40% referred patients in 2023 versus 74% in 2013. 11 patients, 6.4%, required small bowel imaging.
73.7%(n=126) had repeat TTG taken after diagnosis. Only 9 patients, (7.2%), had repeat biopsies taken.

Conclusion

This is the first review of CeD in the Maltese Islands showing a percentage increase over ten years of 171% in diagnosis. The incidence rate was 9.2 new cases per 100,000 in 2013 and 24.3 new cases per 100,000 in 2023. CeD diagnosis was x2.4 times commoner in females. This significant change is also accompanied by the increase in D1 biopsies taken in addition to D2 (p<0.001).
An improvement was noted in the number of dietician referrals carried out from 2013 to 2023. DEXA scan testing was carried out in nearly half the total cohort emphasizing the need to consider this investigation especially in those patients who are at high risk of osteoporosis.
A limitation of this study was the fact that biopsies taken in the private sector were not available for review. Therefore from the total cohort only 7%(n=12) did not have an available biopsy result or review.
A multidisciplinary team approach to the management of CeD is crucial and will help to provide the best outcomes for the patient.

References

¹ Al-Toma, A., Volta, U., Auricchio, R., Castillejo, G., Sanders, D. S., Cellier, C., Mulder, C. J., & Lundin, K. E. A. (2019). European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European gastroenterology journal, 7(5), 583–613. https://doi.org/10.1177/2050640619844125.

Disclosure

No disclosures or Conflict of Interest