Review for 10.1186/1471-230X-13-156 (2013)

Reviewer's report
Title:Limited utilization of serologic testing in patients undergoing duodenal
biopsy for celiac disease
Version: 3Date:27 August 2013
Reviewer: Peter Green
Reviewer's report:
In its current form the paper adds little to neither the celiac disease literature nor
the endoscopy literature. While the authors have answered the reviewers
comments in their responses they have hardly addresses them at all in the
manuscript, instead stating that some of the requests were not part of their
research plan.
INTRODUCTION
Determination of HLA status is rarely used in the diagnosis of celiac disease. It is
used to exclude the disease if negative.
The authors have not addressed the fact that most people are having an
endoscopy for GERD related issues and an EGD presents an opportunity to
exclude celiac disease. Many patients with CD have had previous EGD without
biopsy of the duodenum, or with inadequate number of pieces. This is a missed
opportunity to diagnose celiac disease. This was recently addressed by Lebwohl
et al DDS, 2013.
Methods. It should be specifically stated that biopsies were not classified in a
grading system such as given a Marsh score, neither was the number of biopsy
pieces recorded. The latter is standard for all pathology reports from academic or
private pathology labs. One cannot interpret the validity of a pathology report of a
duodenal biopsy unless one is aware that the prerequisite 4 to 6 pieces are taken
as in the AGA guidelines. In addition numerous studies support biopsying the
bulb. The authors have dismissed comments by the reviewers concerning these
facts.
Because none of the original biopsies were reviewed we need to know more
about the pathologists performing the original reports. Such information as
number of pathologists, their years of experience and if there was an equal
distribution of reports among them.
We need more information on the 2% with positive serological testing and
non-celiac biopsy. What was the pathology for this group, and what antibodies
were positive? In addition was the patient with collagenous sprue on olmesarten?
Were other patients taking olmesarten?
As requested by reviewer one you need to determine the performance
characteristics of each antibody test used in your study. Providing references is
inadequate.
I disagree with the authors that they can claim that biopsies of the duodenum are
part of a “multi site survey” if two or three sites are biopsied. Patients with GERD
may have celiac disease as the cause of GERd for reflux improves after
diagnosis of celiac disease and commencement of the GF diet (there are ample
references available for that). Patients who at pathological examination have
lymphocytic duodenitis (their PVA-IEL) may infact have celiac disease (~20%), or
more commonly have H pylori gastritis and so whenever duodenal biopsies are
taken one needs to have sampling of the gastric mucosa. It is exceptionally rare
for endoscopists to merely biopsy the duodenum without sampling the stomach
for the reason given above.
The authors need to document the indication for the endoscopy in the patients
with negative diopsies. It is important to know how many of the patients were
having the procedure to evaluate diarrhea or anemia, both indications for
duodenal biopsy irrespective of the status of the celiac serology results.
Level of interest: An article of limited interest
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
no competing interests