Best practice advice offered for diagnosis, management of seronegative enteropathy

The American Gastroenterological Association (AGA) recently issued a clinical practice update on diagnosis and management of patients with suspected enteropathy but negative results on serologic tests for celiac disease.

The update, which was based on a review of the evidence and included best practice advice, was published Sept. 30 by Gastroenterology. Clinicians should measure total IgA level in patients in whom celiac disease is suspected but serologic results are negative, the update said. In addition, patients should be tested for anti-tissue transglutaminase, IgA against deamidated gliadin peptide, and endomysial antibody. Clinicians should consider patients whose total IgA levels are below the lower limit of detection and who have IgG against tissue transglutaminase or deamidated gliadin peptide, or endomysial antibody, to have celiac disease with selective IgA deficiency rather than seronegative celiac disease, the AGA said.

At the time of serologic testing, clinicians should carefully review patients' diets and collect and analyze duodenal biopsies in order to determine exposure to gluten and accuracy of test results, the update said. Thorough medication histories should pay particular attention to use of angiotensin II receptor blockers, while travel histories should attempt to identify potential causes of villous atrophy, according to the update.

Patients with suspected celiac disease who are seronegative but have villous atrophy and genetic risk factors must have endoscopic evaluation after one to three years on a gluten-free diet to determine whether villous atrophy has improved and to confirm the diagnosis of seronegative celiac disease, the update said. Seronegative patients with an identified cause of enteropathy should be treated accordingly and may not need a follow-up biopsy, according to the update. The AGA noted that budesonide treatment is recommended in patients with persistent signs and symptoms who do not respond to a gluten-free diet and who have no identified cause of enteropathy.

“Seronegative enteropathy is a histological finding that may be identified in accordance with a wide-range of etiologies,” the authors wrote. “In cases where seronegative enteropathy is suspected, it is of utmost importance that biopsies are reviewed by an expert pathologist to determine and confirm whether enteropathy is present.”

The update noted that while seronegative celiac disease is the most common cause of seronegative enteropathy, diagnosis can be complicated by misinterpretation of histological findings, insufficient serological testing, IgA deficiency, and initiation of a gluten-free diet before testing is complete. “Confirmation of seronegative [celiac disease] requires compatible [human leukocyte antigen] genetics, clinical improvement on a [gluten-free diet], and a follow-up endoscopy with biopsy to ensure mucosal improvement after sufficient time on a [gluten-free diet],” the authors concluded.