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With reference to the study reported by Korponay-Szabó et al,1 we do not know the natural history of screen detected patients with coeliac disease.2 Although the investigation process for population screening and case finding maybe the same, there is an important ethical difference between them, largely to do with who identifies the patient as ill.
We recently performed a primary care based cross sectional study using serological markers (endomysial and gliadin antibodies) to initially recognise coeliac disease.3 We recruited 1200 adult volunteers from January 1999 to June 2001 from five general practices in south Yorkshire, United Kingdom. Any participant with a positive serological result was offered a small bowel biopsy to confirm the diagnosis of coeliac disease. Twelve new cases of coeliac disease were diagnosed from 1200 samples. The prevalence of coeliac disease in this primary care population sample is 1% (95% confidence interval 0.4% to 1.3%).1 In this screening study, 9/12 diagnosed cases of coeliac disease ultimately had subtle symptoms that could be attributed to coeliac disease (for example, anaemia or subtle gastrointestinal symptoms). Five years later, 5/12 screen detected patients are no longer complying with the gluten free diet.
We, and others, have shown a delay in the diagnosis of coeliac disease—surely the important change in our clinical practice (both in primary and secondary care) is to have a low threshold for case finding. Now that point of care testing is here we must be cautious about how we advocate its use—if this test is available over the counter the risk is that individuals will test and treat themselves without ever seeking healthcare professionals’ advice or even a duodenal biopsy. With excellent technology comes the burden of increased responsibility.
Competing interests: None declared.