Open Access Research article

Celiac disease in the Mediterranean area

Francesca Tucci1, Luca Astarita1, Abdelhak Abkari2, Mona Abu-Zekry3, Thomas Attard4, Mongi Ben Hariz5, José Ramon Bilbao216, Ghazalia Boudraa7, Samir Boukthir8, Stefano Costa9, Veselinka Djurisic10, Jean-Pierre Hugot11, Iñaki Irastorza1221, Aydan Kansu13, Sanja Kolaček14, Giuseppe Magazzù9, Dušanka Mičetić-Turk15, Zrinjka Misak14, Eleftheria Roma16, Pasqualino Rossi17, Selma Terzic18, Virtut Velmishi19, Carmela Arcidiaco1, Renata Auricchio1 and Luigi Greco120*

Author Affiliations

1 European Laboratory for Food Induced Diseases, University of Naples Federico II, Naples 80131, Italy

2 Hôpital des Enfant IbnRochd de Casablanca, Casablanca 20050, Morocco

3 Children’s Hospital, Gastrointestinal Unit, Cairo University, Cairo 12511, Egypt

4 Mater Dei Hospital, Msida MSD 2090, Malta

5 Paediatric Unit, Mongi SLIM’s Hospital of Tunis, Marsa 2078, Tunisia

6 Endocrinology, Diabetes and Nutrition Research Group, Hospital de Cruces, Barakaldo-Bizkaia, Basque Country 48903, Spain

7 Clinique Amilcar Cabral, Oran 31026, Algeria

8 Hôpital d’enfants, Tunis, Tunisia

9 Regional Celiac Center, University Hospital G. Martino, Messina 98125, Italy

10 Clinical Centre of Montenegro, Institute for Children s Disease, Podgorica, Montenegro

11 UMR843, INSERM, Assistance Publique Hopitaux de Paris et Université, Paris Diderot, Paris, France

12 Pediatric Gastroenterology, Hospital de Cruces, Barakaldo 48903, Spain

13 Faculty of Medicine, Department of Pediatric Gastroenterology, Ankara University, Ankara 06100, Turkey

14 Children’s Hospital Zagreb, Zagreb 10000, Croatia

15 University Medical Centre Paediatric Department, Ljubljanska, Maribor 2000, Slovenia

16 Aghia Sophia Children’s Hospital, Athens University, Goudi, Athens 11527, Greece

17 International Affairs Direction, Ministry of Health, Rome, Italy

18 Department of Children Diseases, University Clinical Center, Tuzla, Bosnia Herzegovina

19 Gastrohepatology of University Hospital Centre “Mother Teresa”, 1000 Tirana, Albania

20 European Laboratory for Food-Induced Diseases, Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Via Sergio Pansini 5, 80131 Naples, Italy

21 BioCruces Research Institute, Cruces University Hospital, University of the Basque Country (UPV-EHU), Barakaldo, Basque Country, Spain

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BMC Gastroenterology 2014, 14:24  doi:10.1186/1471-230X-14-24

Published: 11 February 2014



The World Gastroenterology Organization recommends developing national guidelines for the diagnosis of Celiac Disease (CD): hence a profile of the diagnosis of CD in each country is required. We aim to describe a cross-sectional picture of the clinical features and diagnostic facilities in 16 countries of the Mediterranean basin. Since a new ESPGHAN diagnostic protocol was recently published, our secondary aim is to estimate how many cases in the same area could be identified without a small intestinal biopsy.


By a stratified cross-sectional retrospective study design, we examined clinical, histological and laboratory data from 749 consecutive unselected CD children diagnosed by national referral centers.


The vast majority of cases were diagnosed before the age of 10 (median: 5 years), affected by diarrhea, weight loss and food refusal, as expected. Only 59 cases (7.8%) did not suffer of major complaints. Tissue transglutaminase (tTG) assay was available, but one-third of centers reported financial constraints in the regular purchase of the assay kits. 252 cases (33.6%) showed tTG values over 10 times the local normal limit. Endomysial antibodies and HLA typing were routinely available in only half of the centers. CD was mainly diagnosed from small intestinal biopsy, available in all centers. Based on these data, only 154/749 cases (20.5%) would have qualified for a diagnosis of CD without a small intestinal biopsy, according to the new ESPGHAN protocol.


This cross-sectional study of CD in the Mediterranean referral centers offers a puzzling picture of the capacities to deal with the emerging epidemic of CD in the area, giving a substantive support to the World Gastroenterology Organization guidelines.

Mediterranean area; Celiac disease; World gastroenterology organization; ESPGHAN guidelines