Background:
Despite mucosal healing being a vital endpoint for managing celiac disease (CeD), follow-up endoscopy to assess for mucosal healing on a gluten-free diet (GFD) is not always performed. Adult guidelines recommend repeat endoscopy two years following the adoption of a GFD, however, this is not the case in children except for select cases. Consequently, the natural history of mucosal healing is not well known, especially in the first year following the initiation of a GFD.

Methods:
Multicenter retrospective study in children (<18 years) who underwent an esophagogastroduodenoscopy (EGD) to confirm a CeD diagnosis from six pediatric centers in the United States and Canada from January 2016 to December 2021. Children diagnosed with biopsy-confirmed CeD who underwent at least one follow-up endoscopy where duodenal biopsies were obtained within 15 months of their diagnosis were included. If multiple endoscopies were performed, the first endoscopy with normal findings or the last endoscopy recorded within 15 months was used for analysis. Cases where duodenal biopsies were not taken on follow-up endoscopy, on systemic immune suppressive medications (e.g., biologics, systemic steroids), or documented poor adherence to a GFD were excluded. Demographic data, comorbidities, serology, and histopathologic findings were collected by chart review. Duodenal biopsies without abnormality or isolated intraepithelial lymphocytosis with normal villous architecture (i.e., Marsh I) were considered healed, while histopathology findings consistent with Marsh II, III or non-specific villous atrophy were interpreted as ongoing enteropathy.

Results:
101 children (mean 11.2 ± 4.5 years; 52.5% female) underwent at least one follow-up EGD within 15 months of their CeD diagnosis during the study period (Table 1). The most common indications for repeat endoscopy were the following: assessment of mucosal healing on a GFD (33.7%), follow-up of eosinophilic esophagitis (EoE) (28.7%), and persistent symptoms despite a GFD (21.8%). 74 children (73.2%) had mucosal healing, including 59 children (58.4%) with normal duodenal biopsies. 27 children (26.7%) had ongoing enteropathy. 50 children (67.6%) had resolution of their enteropathy within the first year of their CeD diagnosis, including some within three months (Table 2).

Conclusion:
In our cohort of newly diagnosed children with CeD, more than half had resolution of their enteropathy within 15 months of their diagnosis. Future prospective studies are needed to determine the timeline and potential factors that influence mucosal healing on a GFD.

Vahe Badalyan

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