目的:乳糜泻具有其他疾病的特征。只有根据十二指肠组织学分析才能最终诊断,这对于筛查目的是不实际的。血清学分析可用于确定活检分析的候选者。我们旨在开发一种简单的诊断方法,所有临床医生都可以遵循该方法,以增加初次就诊时准确诊断为乳糜泻的患者百分比。
方法:我们对752例患者(88例乳糜泻,2007年1月至2008年12月期间,均未出现IgA缺陷),他在英国地区综合医院就诊,并接受了活检分析和血清学检查,以测量针对组织转谷氨酰胺酶(tTG)的内肌抗体和IgA抗体。在饮食中避免麸质的患者被排除在外。患者被分配到4组中的1组:高风险(基于贫血的存在,慢性腹泻,无意的减肥,或疱疹样皮炎),低风险(基于消化不良等因素,肝功能异常,共济失调,或慢性咳嗽),营养缺乏(基于铁的水平,维生素B12和D,或叶酸),或筛查(因为他们有1型糖尿病或乳糜泻家族史)。使用改良的Marsh标准(1-3级)对乳糜泻患者进行鉴定,以解释十二指肠组织学。我们比较了临床类别,血清学概况,以及有和没有乳糜泻的患者的活检结果。
结果:在高风险组565例患者中,有64例(11%)被诊断为乳糜泻,低危组156例患者中有14例(9%;与高风险组相比,P=0.47),营养缺乏组的28名患者中有7名,筛查组3例患者中的3例。在71例两种抗体(tTG和肌内膜抗体)检测均为阳性的患者中,乳糜泻的阳性预测值为97%;tTG阴性检测结果的阴性预测值为98%.在708例活检样本正常的患者中,只有62人患有乳糜泻(9%).在44例活检样本异常的患者中,26人患有乳糜泻(59%)。
结论:基于回顾性分析,有和没有乳糜泻的患者不能根据临床特征进行区分。出现乳糜泻症状的患者应进行tTG测试,确定十二指肠活检分析的候选人。
OBJECTIVE: Celiac disease shares features of other disorders. It can be diagnosed conclusively only based on duodenal histology analysis, which is not practical for screening purposes. Serologic analysis might be used to identify candidates for biopsy analysis. We aimed to develop a simple diagnostic approach that all clinicians could follow to increase the percentage of patients accurately diagnosed with celiac disease at initial presentation.
METHODS: We performed a retrospective analysis of data from 752 patients (88 with celiac disease, none were IgA deficient) who attended a UK district general hospital from January 2007 through December 2008 and underwent biopsy analysis and serologic tests to measure endomyseal antibodies and IgA antibodies against tissue transglutaminase (tTG). Patients avoiding gluten in their diet were excluded. Patients were assigned to 1 of 4 groups: high-risk (based on presence of anemia, chronic diarrhea, unintentional weight loss, or dermatitis herpetiformis), low-risk (based on such factors as dyspepsia, abnormal liver function, ataxia, or chronic cough), nutrient deficiency (based on levels of iron, vitamins B12 and D, or folate), or screening (because they had type 1 diabetes or a family history of celiac disease). Patients with celiac disease were identified using the modified Marsh criteria (grades 1-3) for interpreting duodenal histology. We compared clinical category, serology profiles, and biopsy results between patients with and without celiac disease.
RESULTS: Celiac disease was diagnosed in 64 of 565 patients in the high-risk group (11%), 14 of 156 patients in the low-risk group (9%; P = .47 compared with high-risk group), 7 of 28 patients in the nutrient-deficiency group, and 3 of 3 patients in the screening group. Among 71 patients who tested positive for both antibodies (tTG and endomyseal antibodies), the positive predictive value for celiac disease was 97%; a negative test result for tTG had a negative predictive value of 98%. Among 708 patients with normal-looking biopsy samples, only 62 had celiac disease (9%). Among 44 patients with abnormal biopsy samples, 26 had celiac disease (59%).
CONCLUSIONS: Based on a retrospective analysis, patients with and without celiac disease cannot be distinguished based on clinical features. Patients who present with symptoms of celiac disease should be tested for tTG, to identify candidates for duodenal biopsy analysis.