Introduction
Celiac disease (CD) is an autoimmune disorder triggered by gluten ingestion, leading to intestinal villous atrophy. While a gluten-free diet (GFD) is the mainstay of treatment, some patients exhibit persistent villous atrophy (pVA) on follow-up biopsies. This raises concerns about the long-term health consequences of pVA in CD patients adhering to GFD.
Aims & Methods
Objectives: To evaluate the association between pVA and long-term outcomes in CD patients.
To assess the performance of a scoring system identifying patients at high risk of pVA.
Methods: We conducted a retrospective analysis including all the patients diagnosed with CD between 2014 and 2020, who underwent follow-up duodenal biopsies. Patients were categorized as having pVA or not based on the Marsh classification (≥3a).
We considered as complications of CD malignant and premalignant conditions arising in the abdomen, including refractory CD, ulcerative jejuno-ileitis, abdominal lymphomas and small bowel carcinomas. In particular, persistence of malabsorption symptoms and VA despite a strict GFD for at least 12 months in the absence of lymphoma, malignancies and non-coeliac enteropathies allowed the diagnosis of refractory CD (RCD).
Additionally, we applied the 5-point scoring system to predict pVA risk, incorporating the following factors:
•Age at diagnosis ≥45 years
•Classical pattern of celiac disease (CCD)
•Lack of clinical response to GFD
•Poor GFD adherence
Each of the first three factors was assigned a point score and the fourth item was assigned two points score, with higher scores indicating a greater risk of pVA.
Results
We collected 151 patients with CD. Approximately 24.5% of patients had pVA. Patients with pVA exhibited a significantly higher risk of complications (HR 7.61, 95% CI 3.18 to 17.64, p<0.001). Overall, during follow-up, 9 patients (5.96%) developed a complication (three refractory CD, one B-cell lymphoma, three persistence of malabsorption symptoms and two ulcerative jejuno-ileitis). Over these 9, 7 patients had a pVA.
While most patients adhered to GFD, 35.1% still had persistent VA at follow-up.
Up to 29.72% of patients with persistent villous atrophy do not have ongoing symptoms.
The 5-point scoring system stratified patients by risk of pVA into
• Low risk (0-1 points): 4.1% pVA prevalence (3 patients out of 73).
• Intermediate risk (2 points): 20% pVA prevalence (9 patients out of 45).
• High risk (3-5 points): 75.75% pVA prevalence (25 patients out of 33).
Conclusion
This study demonstrates that persistent villous atrophy in CD patients following GFD is associated with increased risk of complications. It also shows the effectiveness of the 5-point scoring system, in stratifying CD patients by risk of pVA. The system accurately identified high-risk patients with a significantly higher prevalence of pVA. It can also help identify these individuals who, despite a lack of current symptoms, may still be at higher risk for future complications so it can be used in clinical practice to personalized follow-up modalities.
References
Rossi A, Lohi J, Mustalahti K, et al. Persistent villous atrophy predicts development of complications and mortality in adult patients with coeliac disease: a multicentre longitudinal cohort study and development of a score to identify high-risk patients [Internet]. BMJ Gut. 2023;72(11):2095-2105. Available from: https://gut.bmj.com/content/72/11/2095
