After reading the clinical case published by Urbano et al. regarding a patient with diffuse digestive symptoms and findings suggestive of celiac disease¹, I would like to offer the following considerations. First, the diagnosis of celiac disease is made by a combination of clinical symptoms, in addition to paraclinical and histological findings.

Regarding the paraclinical findings, the presence of positive celiac disease antibodies is mentioned, with a cutoff of 1.1 and a result of 1.4. However, diagnosis of the disease requires that transglutaminase antibody values reach a value of more than 10 times the cut-off point, and even the detection of anti-endomysial antibodies². In the case of the patient, it would be appropriate to complement the studies to meet this criterion.

Additionally, the case mentions the histological findings showing a Marsh 1 and Marsh 2 score. However, there is no evidence of villous atrophy, which makes this diagnostic criterion a real challenge, since lymphocytic duodenosis (>25 intraepithelial lymphocytes per 100 epithelial cells) in the absence of villous atrophy is not specific for celiac disease^2-4, but may be a manifestation of multiple mimicking conditions of infectious (tropical sprue, bacterial overgrowth or Helicobacter pylori), drug or even immune origin (immunodeficiencies or autoimmune enteropathy)³. In these cases, it could be referred to as a non-atrophic type of celiac disease; however, further evidence would be needed to support this diagnosis.

I consider that this case could be considered as a potential celiac disease, given the presence of antibodies and a biopsy with no evidence of villous atrophy. This would need to be confirmed by histocompatibility testing for HLA-DQ2 and HLA-DQ8, which, if negative, would virtually exclude the possibility of celiac disease^2,5.

Unfortunately, in Colombia the prevalence studies of celiac disease have been based predominantly on the detection of antibodies⁶, which generates an underdiagnosis and a lack of knowledge of this pathology in our community. For this reason, it is important to consider the different clinical and paraclinical aspects for an adequate diagnosis of an entity that would force a radical change in life habits.

Referencess

Urbano-Albán DC, Díaz-Idrobo B, Hooker-Herrera RS, Hooker-Mosquera JC. Enfermedad celiaca, un enemigo silencioso: a propósito de un caso. Rev Colomb Gastroenterol. 2024;39(2):224-229. https://doi.org/10.22516/25007440.1090

Rubio-Tapia A, Hill ID, Semrad C, Kelly CP, Greer KB, Limketkai BN, et al. American College of Gastroenterology Guidelines Update: Diagnosis and Management of Celiac Disease. Am J Gastroenterol. 2023;118(1):59-76. https://doi.org/10.14309/ajg.0000000000002075

Villanacci V, Vanoli A, Leoncini G, Arpa G, Salviato T, Bonetti LR, et al. Celiac disease: histology-differential diagnosis-complications. A practical approach. Pathologica. 2020;112(3):186-196. https://doi.org/10.32074/1591-951X-157

Hassall E. Not everything is celiac disease. Gastrointest Endosc. 2010;72(3):569-71. https://doi.org/10.1016/j.gie.2010.02.030

Caio G, Volta U, Sapone A, Leffler DA, De Giorgio R, Catassi C, et al. Celiac disease: a comprehensive current review. BMC Med. 2019;17(1):142. https://doi.org/10.1186/s12916-019-1380-z

Velasco-Benítez CA, Ruíz-Extremera Á, Matallana-Rhoades AM, Giraldo-Lora SC, Ortiz-Rivera CJ. Prevalence of markers of celiac disease in Colombian children with diabetes mellitus type 1. Colomb Med (Cali). 2018;49(4):273-279. https://doi.org/10.25100/cm.v49i3.3650

Notes

Author notes

*Correspondence: Andrés José Gómez-Aldana. andresgomezmd@hotmail.com