TABLE 3 : Esophagogastroduodenoscopy ( EGD ) and Genetic Testing Results EGD Testing ( n = 59 ) n % Available endoscopy reports 43 73 % Endoscopy records not available 3 5 % Endoscopy performed after starting gluten free diet 2 3 % Patient declined endoscopy 11 19 % EGD Gross Findings n = 43 Grossly normal 12 28 % Abnormal findings 31 72 Duodenitis 21 49 % Esophagitis 6 14 % Gastritis 8 19 % EGD Pathology Findings n = 43 Inflammatory cells Increased IELs 26 60 % IELs not reported 17 40 %
Increase in inflammatory cells in lamina propria mentioned
in other large institutional , North American studies . 13 , 14 The age increase is believed to be related to increased awareness about variety in CD clinical presentations and the improved sensitivity and specificity of diagnostic tests . 15 CD was found to be more prevalent in females , agreeing with previous literature . 1 , 9 , 14 While the underlying basis for sexual dimorphism in CD remains undetermined , gender differences in various autoimmune diseases , including variances in immune reactivity , end organ vulnerability , parental inheritance , and epigenetics may contribute to the increased female prevalence . 16 Our study population of pediatric patients diagnosed with CD was predominantly white ( 97 % of patients ).
13 N / A
Inflammatory changes consistent with CD noted 2 N / A
No comment on inflammatory cells in report 2 N / A Villous atrophy Villous atrophy blunting – partial 9 21 % Villous atrophy blunting – complete 32 74 % No comment on villous atrophy 2 5 % HLA DQ2 / DQ8 Genetic Testing n = 5 Negative 1 20 % Positive 4 80 %
EGD = esophagogastroduodenoscopy ; IEL = intraepithelial lymphocytes
Previous research on CD has demonstrated racial / ethnicity disparities in healthcare . The rates of CD diagnoses have been found to be higher among non-Hispanic whites than non-Hispanic blacks ; 17 , 18 however these rate differences may be due to referral bias or healthcare access disparities . 17
Most patients with CD had positive tTG IgA and / or EMA serological levels at diagnosis . Based upon results from other studies , both tTG IgA and EMA have high sensitivity ( 90-100 % vs , 93-100 % respectively ) and high specificity ( 95-100 % vs , 98- 100 % respectively ) for CD . 7 DGP IgG has a lower sensitivity ( between 88-95 %) and therefore not used as a screening test . 7 , 19
In our study , both tTG IgA and DGP IgG were positive in 88 % of patients ; however , the percentage of patients positive for EMA decreased to only approximately 70 % of cases . We are unsure of the reasons that the EMA test failed to capture patients with biopsy-proven CD in our study . The EMA- IgA test is a qualitative immunofluorescent assay , thus more subjective than tTG-IgA assay . A review of literature suggests that the performance of the EMA test may be influenced by the degree of intestinal damage , thus making the test less sensitive in patients who have mild CD and children less than two years of age . 20
Follow-up with chronic autoimmune diseases is important to ensure treatment compliance and observe for disease changes over time ; however , a follow-up in our cohort was subpar with one-third of patients not having documented follow-up six to 12 months post-diagnosis . Several factors may have contributed to poor clinic follow-up , including financial insecurity , transportation issues , and poor understanding regarding disease complications . Future research will examine local barriers to continued CD follow-up . Our study demonstrated a reduction in symptoms and antibody levels after GFD introduction , consistent with previous literature . 21-23 Normalization of antibody levels was not present in all patients . GFD compliance is a principal factor in determining the rate of seroconversion . Factors possibly contributing to poor GFD adherence include GFDs availability and high cost , poor palatability and tolerance of GFD , and lack of education regarding complications of untreated CD . Newly diagnosed CD patients benefit from support and nutritional counseling from physicians and registered dieticians with CD expertise in addition to supplementary education opportunities .
The Appalachian region , and specifically WV , experience significant disparities in health outcomes and social determinants of health compared to the nation . 8 Patients with CD residing in Appalachia are doubly challenged by both health disparities accompanying living in the region and having a chronic health comorbidity . Children and adolescents with CD from southern WV presented as a unique patient population as they did not commonly have the classic CD
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