Applying ESPGHAN and WGO Guidelines of Celiac Disease on Iraqi Patients


  • Alaa S. Alattabi Department of Microbiology, College of Medicine, University of Karbala, Karbala, Iraq.
  • Israa H. Aljerrah Department of Microbiology, College of Medicine, University of Karbala, Karbala, Iraq.



Celiac disease, ESPGHAN criteria, WGO guideline, tTG (IgA) antibodies, challenge test, biopsy findings


Objective: The goal of the study is to check the degree to which the physicians and pediatricians can apply ESPGHAN and WGO criteria of celiac disease (CD) on their patients in Karbala city.

Methods: This is a cross-sectional study conducted in Karbala city hospitals (Al-Hussein-medical city hospital, the pediatric teaching hospital) for the period from August 2017 to February 2018. A random selection of one hundred eight CD patients was carried out and the clinical data including the biopsy results were collected directly from patients or their family members via a questionnaire sheets. Statistically, the quantitative variables were analyzed using non-parametric t-test and the qualitative variables were analyzed using Chi-square test.

Results: The study shows that of the total 108 patients, only n=43 (39.8%) of candidates who did biopsy even with tTG IgA>10 fold ULN (200 RU/ml and more) due to the shortage in EMA/HLA tests recommended by ASPGHAN to omit duodenal biopsy., while n=51 (47.2%) accomplished only one of the triple tests (only tTG IgA>10 fold ULN) suggested by ASPGHAN and then applied challenge test and n=14 (12.9) achieved non of the triple tests (tTG IgA antibody titer>5 fold ULN, but <10 fold ULN). On the other hand, the WGO guideline is more suitable if properly applied as it considers tTG (IgA) a convenient substituent of EMA test where high tTG (IgA) serum level being diagnostic and to be confirmed by the available DGP (IgA and IgG) antibodies.

Conclusion: The WGO guideline for symptomatic and asymptomatic patients is more applicable for the areas with limited facilities, while ESPGHAN guideline for pediatrics can be applied to a less degree. Generally in Iraq there is a delay in disease diagnosis due to many reasons to be evaluated.


1- Akirov A. and Pinhas-Hamiel O. 2015. Co-occurrence of type 1 diabetes mellitus and celiac disease. World journal of diabetes. 6(5): 707-14. doi: [10.4239/wjd.v6.i5.707].

2-Bai J., Zeballos E., Fried M., Corraza G., et al. 2013. World Gastroenterology Organisation Practice Guidelines: Celiac Disease; World Gastroenterology Organisation: Milwaukee, WI, USA; 48: 1–18. doi: [10.1097/MCG.0b013e31827a6f83]. No abstract available.PMID: 23314668
3-Dalgic B., Sari S., Basturk B., et al. 2011. Prevalence of celiac disease in healthy Turkish school children. Am J Gastroenterol. 106 (8):1512-7. doi: [10.1038/ajg.2011.183. Epub 2011 Jun 21].
4-Dixit R., Lebwohl B., Ludvigsson J.F., Lewis S.K., Rizkalla-Reilly N., Green PH., 2014. Celiac disease is diagnosed less frequently in young adult males. Dig Dis Sci. 59:1509-12. doi: [10.1007/s10620-014-3025-6. Epub 2014 Jan 21].
5-Ermarth A., Bryce M., Woodward S., Stoddard G., Book L., Jensen MK., 2017. Identification of Pediatric Patients With Celiac Disease Based on Serology and a Classification and Regression Tree Analysis. Clin Gastroenterol Hepatol. 15(3):396-402.e2. doi: [10.1016/j.cgh.2016.10.035. Epub 2016 Nov 12].
6-Fasano A. and Catassi C., 2012. Celiac disease. The New England Journal of Medicine. 367(25):2419–2426. doi: [10.1056/NEJMcp1113994].
7-Hameed W.S., Abdul-Mehdi R.J., Tarish H.R. and Alsherees H.A.A., 2016. Prevalence of DQ2, DQ8 and DR4 Alleles in Iraqi Celiac Patients.International Archives of BioMedical and Clinical Research, 2 (3), pp.118-121.
8-Hawamdeh H., Al-Zoubi B., Al Sharqi Y., Qasrawi A., Abdelaziz Y., & Barbar M. (2016). Association of Tissue Transglutaminase Antibody Titer with Duodenal Histological Changes in Children with Celiac Disease. Gastroenterology Research and Practice, 2016, 6718590. doi: [10.1155/2016/6718590]
9-Husby S, Koletzko S, Korponay-Szabo IR et al., 2012. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease . J Pediatr Gastroenterol Nutr. 54: 136–60.
10-Jeon MK, Klaus C, Kaemmerer E, Gassler N., 2013. Intestinal barrier: Molecular pathways and modifiers.World J Gastrointest Pathophysiol. 4: 94–99. [PMID: 24244877 doi: 10.4291/wjgp.
11-Kelly CP, Bai JC, Liu E, et al. 2015. Advances in diagnosis and management of celiac disease. Gastroenterology. 148:1175–86.
12-Lahdeaho M L., Mak i M., Laurila K et al., 2011. Small-bowel mucosal changes and antibody responses after low-and moderate-dose gluten challenge in celiac disease. BMC Gastroenterol. 11: 129.
13-Leffler, D. Schuppan, D. Pallav, K. Najarian, R. Goldsmith, J.D. Hansen, J. Kabbani, T. Dennis, M. Kelly, C.P., 2012. Kinetics of the histological, serological and symptomatic responses to gluten challenge in adults with coeliac disease. Gut. 62(7): 996–1004. doi: [10.1136/gutjnl-2012-302196].
14-Lewis N. R. and Scott B. B. 2010. Meta-analysis: deamidated gliadin peptide antibody and tissue transglutaminase antibody compared as screening tests for coeliac disease . Aliment Pharmacol Ther. 31: 73 – 81.
15-Ludvigsson JF, Leffler DA, Bai JC, et al. 2013. The Oslo definitions for coeliac disease and related terms. Gut .62(1):43–52. doi: [10.1136/gutjnl-2011-301346. Epub 2012 Feb 16].
16-Marsh M.N. 1992. Mucosal pathology in gluten sensitivity. In Coeliac Disease, ed. M Marsh, pp. 136–91.Oxford, UK: Blackwell Sci.
17-Mubarak A., Wolters V.M., Gerritsen S.A., Gmelig-Meyling F.H., Ten Kate F.J., Houwen R.H., et al., 2011.A biopsy is not always necessary to diagnose celiac disease. J Pediatr Gastroenterol Nutr. 52(5): 554-7
18-Mubarak A., Wolters V.M., Gmelig-Meyling F.H., Ten Kate F.J., Houwen R.H., et al., 2012. Tissue transglutaminase levels above 100 U/mL and celiac disease: a prospective study. World J Gastroenterol. 28; 18(32):4399-403.
19-Oberhuber G. 2000. Histopathology of celiac disease. Biomed Pharmacother. 54(7):368-372. doi: [10.1016/S0753-3322(01)80003-2]
20-Reilly N.R., Aguilar K., Hassid B.G., Cheng J., Defelice A.R., Kazlow P., et al. 2011. Celiac disease in normal-weight and overweight children: clinical features and growth outcomes following a gluten-free diet. J Pediatr Gastroenterol Nutr. 53(5): 528-31. doi: [10.1097/MPG.0b013e3182276d5e].
21- Rubio-Tapia A., Hill I.D., Kelly C.P., et al. 2013. ACG guidelines: Diagnosis and management of celiac disease. Am J Gastroenterol. 108: 656–676. doi: [10.1038/ajg.2013.79. Epub 2013 Apr 23].
22- Sapone A., Bai J.C., Ciacci C., Dolinsek J., Green P.H.R., Hadjivassiliou M., Kaukinen K., Rostami K., Sanders D.S., Schumann M., et al. 2012. Spectrum of gluten-related disorders: Consensus on new nomenclature and classification.BMC Med. 10: 13. doi: [10.1186/1741-7015-10-13].
23-Tucci F., Astarita L., Abkari A., Abu-Zekry M., Attard T., Ben Hariz M., Greco L., 2014. Celiac disease in the Mediterranean area. BMC Gastroenterology. 14: 24. doi: [10.1186/1471-230X-14-24].
24-Werkstetter K.J., Korponay-Szabó I.R., Popp A., Villanacci V., Salemme M., Heilig G., Lillevang S.T., Mearin M.L., Ribes-Koninckx C., Thomas A., et al. 2017. Accuracy in Diagnosis of Celiac Disease without Biopsies in Clinical Practice. Gastroenterology; 153(4):924-935. doi: [10.1053/j.gastro.2017.06.002. Epub 2017 Jun 15].
25-You Yi Hong. 2015. “Deaminated Gliadin Peptide Antibody in the Diagnosis of Celiac Disease.” International Journal of Celiac Disease. 3(2): 56-57. doi: [10.12691/ijcd-3-2-8].
26- Zintzaras E. and Germenis A.E. 2006. Performance of antibodies against tissue transglutaminase for the diagnosis of celiac disease: meta-analysis. Clin Vaccine Immunol. 3:187-92.




How to Cite

Alattabi, A. S., & Aljerrah, I. H. (2018). Applying ESPGHAN and WGO Guidelines of Celiac Disease on Iraqi Patients. Journal of Contemporary Medical Sciences, 4(4), 232–236.