Disappearance of endomysial antibodies in treated celiac disease does not indicate histological recovery

OBJECTIVE: Although serum IgA-class endomysial antibody (EmA) has high sens itivity for villous atrophy (VA) in patients with untreated celiac disease, few studies have attempted to correlate EmA seroconversion with histologic al recovery after starting a gluten-free diet. We prospectively studied cha nges in EmA status and in duodenal histology of seropositive patients after dietary treatment. METHODS: Patients with VA and EmA had repeat EmA testing at 3, 6, and 12 mo nths after starting gluten-free diet, plus assessment of dietary compliance by dietitians and follow-up duodenal biopsy at 12 months. VA before and af ter treatment was classified as partial (P), subtotal (ST), and total (T). RESULTS: Of 77 patients with newly diagnosed VA and without IgA deficiency, 62 (81%) had EmA: 46 of 57 (81%) with T or STVA and 16 of 20 (80%) with PV A. Of 53 initially EmA-positive patients who completed study criteria, EmA was undetectable in 31 patients (58%) after 3 months' diet, in 40 (75%) aft er 6 months, and in 46 (87%) after 12 months. However, only 21 patients (40 %), all seronegative by 12 months, had complete villous recovery. Only thre e (33%) of 10 patients with persisting ST or TVA and two (9%) of 22 with PV A remained EmA positive. Four of the five patients with persisting EmA had poor dietary compliance. CONCLUSIONS: EmA is a poor predictor of persisting VA after patients have s tarted gluten-free diet, although it may be of value in monitoring dietary compliance. Although then are no clear guidelines regarding the need for fo llow-up biopsy, EmA seroconversion cannot substitute. The apparent associat ion between dietary compliance and seroconversion suggests that gluten inta ke may determine whether untreated celiac patients are EmA positive or nega tive for a given degree of small bowel damage. (Am J Gastroenterol 2000;95: 712-714. (C) 2000 by Am. Coll. of Gastroenterology).