Screening for celiac disease A. George F. Davidson, BSc, MD; Eric G. Hassall, MD Résumé DANS CE NUMÉRO, le Dr Ernest G. Seidman et des collègues présentent un compte rendu sur uneétude de dépistage de l’anticorps de l’antigliadine sérique pour détecter la maladie coeliaque chez les enfants. Dans cetéditorial, les auteurs soutiennent que la mise en service de tels tests constitue un progrès important,étant donné surtout que l’on est très loin de diagnostiquer suffisamment la maladie coeliaque en Amérique du Nord. Des programmes de dépistage général de routine de la maladie coeliaque seraient néanmoins prématurés tant qu’on n’accumulera pas plus de données probantes sur leur efficacité. Il ne faut pas oublier non plus que les tests sérologiques sont utiles comme moyen de dépistage seulement. Il faut quand même confirmer les résultats positifs par une biopsie de l’intestin grêle.

EditorialÉditorial Dr. Davidson is Professor and Head, Division of Biochemical Diseases, Department of Pediatrics, University of British Columbia, Vancouver, BC, and Chair of the Professional Advisory Board of the Canadian Celiac Association. Dr. Hassall is Associate Professor and Head, Division of Gastroenterology, Department of Pediatrics, University of British Columbia, Vancouver, BC. Can Med Assoc J 1997;157:547-8

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eliac disease (CD) is a serious, lifelong, gastrointestinal disorder that can cause a wide spectrum of clinical symptoms in children and adults. The classic symptoms of diarrhea, abdominal distension, weight loss and malnutrition were described by Samual Gee in 1888, but our current understanding of CD dates from the 1950s, when the therapeutic effect of a gluten-free diet was discovered, the presence of typical small-bowel mucosal lesions in untreated patients was recognized, and the ability to obtain smallbowel biopsy specimens via the oral route was developed.1 Since that time, knowledge about CD and its clinical manifestations has increased, but the interest of the North American medical and scientific community in this disease has remained very limited. This is at least in part because of the comparative infrequency of the diagnosis on this continent. The rarity of CD in North America may be more apparent than real, however.2 A low index of suspicion and reliance on classic symptoms may be resulting in significant underdiagnosis of CD. This supposition is supported by the results of the Canadian Celiac Association’s survey, conducted in 1989–91, of its members with CD.3–5 Fewer than 75% of the 1294 respondents with biopsy-confirmed CD had presented with classic symptoms. The average duration of symptoms in adults before diagnosis was more than 7 years for fatigue, diarrhea, bloating and abdominal pain. For headache or“neuropsychiatric” symptoms, the mean duration before diagnosis of CD was almost 14 years; the average delay in diagnosis for patients with associated skin rash (dermatitis herpetif

ormis) was on average 11 years.5 In over a third of pediatric cases, symptoms were present for 1 year or longer. Nearly 60% of the respondents, whether children or adults, had had to consult 3 or more physicians before the diagnosis was made, and 15% had had to consult 5 or more physicians. Most children were first misdiagnosed as having an illness other than CD, such as gastroenteritis or food allergy. In adults, the most frequent misdiagnoses were viral or other infection, anemia, stress, nervous condition, irritable bowel and food allergy. The survey results also showed that CD was considered and investigated in only 1.5% of first-degree relatives of patients with biopsyproven CD, despite findings reported in the literature that approximately 10% of first-degree relatives also have small-bowel changes typical of CD.1 Another factor that may contribute to the apparently low prevalence of CD in North America is the deplorable practice of many physicians of advising a trial of a wheat-free or gluten-free diet without first performing a small-bowel biopsy.6 If gluten is reintroduced, as often happens several months or years after symptoms are controlled, the disease may remain latent for many years, setting the scene for

ß See related article on page 527

CAN MED ASSOC J SEPT. 1, 1997; 157 (5)© 1997 Canadian Medical Association (text and résumé)

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