Avoiding Small Intestinal Biopsies for Diagnosis of Celiac Disease in Children: A Reliable Strategy for All Patients?.

Background: Current reports applying ESPGHAN exception criteria (EEC) to diagnose celiac disease (CD) without duodenal biopsies indicate that a high percentage of patients with CD may be identified when applied correctly in specialized settings. However, application of the EEC in "daily life conditions" at the different levels of medical services is not clear. Methods: EEC was applied to 130 pediatric patients evaluated for CD at five public hospitals in Santiago, Chile, during 2010-2015. Clinical presentation, serum anti-tissue transglutaminase 2 (TTG) and anti-endomysium antibodies (EMA), genotyping and small intestinal histology were obtained from clinical charts. Results: 78/130 patients reviewed had some of the data required for analysis, but EMA was determined in 54% and genotyping in 2.3% of patients, limiting the study. After offering free genotyping, only 12/78 (15%) had all data required for EEC application. In this small group, 10/12 (83.3%) patients could avoid duodenal biopsies and two (16.7%) with potential CD were misdiagnosed. Main reasons for not doing EMA and genotyping were that they are expensive, unavailable in the local health-care center and considered "not necessary" for diagnosis. Conclusion: Limited resources in clinical settings reduce availability of EMA and genotyping, making application of EEC criteria difficult and only possible only in 15% of our patients. Within this subgroup, biopsies could be avoided in 83.3%, and 16.7% of patients with potential CD were misdiagnosed. Insufficient studies and incorrect interpretation of EEC contributed to incomplete assessment in 52/130 (40%) patients. The Chilean public health system is likely representative of several others present in developing and developed countries. (C) 2017 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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