Validation of no‐biopsy pathway for the diagnosis of celiac disease in Asian adults: a multicenter retrospective study

Background and Aim While European Society of Pediatric Gastroenterology Hepatology and Nutrition advocates a no‐biopsy pathway for the diagnosis of celiac disease (CeD) in children if IgA anti‐tissue transglutaminase antibody (anti‐tTG ab) titer is ≥10‐fold upper limit of normal (ULN) and have a positive IgA anti‐endomysial antibody (EMA); the data for anti‐tTG Ab titer‐based diagnosis of CeD in adults is still emerging. We planned to validate if IgA anti‐tTG Ab titer ≥10‐fold predicts villous abnormalities of modified Marsh grade ≥2 in Asian adult patients with CeD. Methods We recruited 937 adult patients with positive anti‐tTG Ab from two databases, including AIIMS Celiac Clinic and Indian National Biorepository. The diagnosis of definite CeD was made on the basis of a positive anti‐tTG Ab and the presence of villous abnormalities of modified Marsh grade ≥2. Results Of 937 adult patients with positive anti‐tTG Ab, 889 (91.2%) showed villous abnormalities of modified Marsh grade ≥2. Only 47.6% of 889 adults with CeD had anti‐ tTG Ab titers of ≥10‐fold. The positive predictive value (PPV) and specificity of anti tTG Ab titer ≥10‐fold for predicting modified Marsh grade ≥2 were 99.8% and 98%, respectively. At anti‐tTG Ab titer ≥11‐fold, specificity and PPV were 100% for predicting villous abnormalities of modified Marsh grade ≥2. Conclusions Approximately 50% of adults with CeD may benefit from the no biopsy pathway, reducing the health burden and risks of gastroscopy/anesthesia.