Patchy villous atrophy in adult patients with suspected gluten-sensitive enteropathy: is a multiple duodenal biopsy strategy appropriate?

Importance of duodenal bulb biopsies in children for diagnosis of celiac disease in clinical practice

BACKGROUND

The patchy nature of villous lesion in celiac disease is increasingly being recognized. Current guidelines recommend four endoscopic duodenal mucosal biopsies from the second or more distal part of the duodenum to confirm the diagnosis of celiac disease. The purpose of the study was to investigate the usefulness of duodenal bulb mucosal biopsies in confirming the diagnosis of celiac disease in everyday clinical practice.

METHODS

All patients with a positive tissue-transglutaminase antibody requiring biopsy-confirmation of celiac disease over a two-year period were studied. Two endoscopic biopsies were taken from the duodenal bulb and four biopsies from the second (or distal) part of the duodenum.

RESULTS

Thirty-five patients were included, mean age 8.1 (+/- 4.7) years. Thirty-one (88.6%) patients had abnormal distal duodenal biopsies, one had Marsh type 1, one had Marsh type 2 and twenty-nine had Marsh type 3 lesion. All but two patients with abnormal distal duodenal biopsies also had abnormal bulb biopsies. Four (11.4%) patients had normal distal duodenal biopsies but abnormal bulb biopsies. Of these, one patient had Marsh type 2 and three had Marsh type 3 lesion. The distal duodenum was also grossly normal in these four patients. The histological diagnosis of celiac disease would not have been possible in these four cases with distal duodenal biopsies only.

CONCLUSION

The lesion in celiac disease in children can be patchy with duodenal bulb mucosa being the only area showing histological changes. The recommendations regarding the site of biopsies should be revised to include biopsies not only from distal duodenum but also from bulb to improve the diagnostic yield.

Water-immersion technique during standard upper endoscopy may be useful to drive the biopsy sampling of duodenal mucosa in children with celiac disease

OBJECTIVE

To evaluate the accuracy of the water-immersion technique during upper endoscopy in recognizing the duodenal villous pattern in a series of children who were undergoing endoscopy to obtain duodenal biopsy for histological analysis.

MATERIALS AND METHODS

The water-immersion technique was performed in 19 children. Endoscopic findings were compared with histology. Results were assessed on per biopsy analysis and per patient analysis, taking into account the worst endoscopic finding in each patient and correlating it with the worst histological diagnosis.

RESULTS

Per biopsy analysis: A total of 57 biopsy specimens were obtained and assessed. The endoscopic duodenal investigation correctly identified 53 areas (93%), which corresponded to histology, giving it an accuracy rate of 93%. Per patient analysis: The worst histology of the duodenal bulb was predicted by endoscopy in 18 of the 19 enrolled patients (95%), whereas the worst histopathological lesion of the second portion of the duodenum was recognized in 100% of cases. On the whole, therefore, the endoscopist suggested a diagnosis of celiac disease in 11 patients, with both positive and negative predictive values of 100%.

CONCLUSIONS

The water-immersion technique during upper endoscopy is highly accurate in recognizing the duodenal villous pattern in subjects who need a duodenal investigation. Our findings encourage a cost-saving and patient-retaining approach to the diagnosis of celiac disease by driving biopsy and reducing the number of duodenal samplings.

Symptoms and signs in individuals with serology positive for celiac disease but normal mucosa

Background

Antibody serology is an important tool in the investigation of celiac disease (CD), but does not always correlate with mucosal appearance in the small intestine. Patients with positive CD serology but normal mucosa (Marsh 0) are at increased risk of future CD. In this study we describe a model for identifying and characterizing individuals with normal mucosa but positive CD serology. Such individuals are sometimes referred to as having latent CD.

Methods

The records of ten Swedish pathology departments were used to identify individuals with biopsies indicating normal duodenal/jejunal mucosa. Using the national personal identification number, these data were linked with CD serology data (antigliadin, antiendomysial and tissue transglutaminase antibodies); and we thereby identified 3,736 individuals with normal mucosa but positive CD serology. Two independent reviewers then manually reviewed their biopsy reports to estimate comorbidity. We also randomly selected 112 individuals for validation through patient chart review.

Results

The majority of the 3,736 individuals were females (62%). Children (0–15 years) made up 21.4%. The median number of biopsy specimen was 3. Our review of biopsy reports found that other gastrointestinal comorbidity was rare (inflammatory bowel disease: 0.4%; helicobacter pylori infection: 0.2%). Some 22% individuals selected for patient chart review had a relative with CD. The most common symptoms among these individuals were diarrhea (46%) and abdominal pain (45%), while 26% had anemia. Although 27% of the individuals selected for validation had been informed about gluten-free diet, only 13% were adhering to a gluten-free diet at the end of follow-up.

Conclusion

Individuals with positive CD serology but normal mucosa often have CD-like symptoms and a family history of CD.

Enteroscopy in the diagnosis and management of celiac disease

Esophagogastroduodenoscopy (EGD) with 3 to 6 biopsies in the descending duodenum is the gold standard for the diagnosis of celiac disease. At the time of the first diagnosis of celiac disease, an extensive evaluation of the small bowel is not recommended. However, video capsule endoscopy, because of its good sensitivity and specificity in recognizing the Endoscopic features of celiac disease, can be considered a valid alternative to EGD in patients unable or unwilling to undergo EGD with biopsies. Capsule endoscopy is also a possible option in selected cases with strong suspicion of celiac disease but negative first-line tests. In evaluating patients with refractory or complicated celiac disease, in whom a complete evaluation of the small bowel is mandatory (at least in refractory celiac disease type II patients) because of the possible presence of complications beyond the reach of conventional endoscopes, both capsule endoscopy and balloon-assisted enteroscopy have been found to be helpful. In these patients, capsule endoscopy offers several advantages: it is well tolerated, it allows inspection of the entire small bowel, and it is able to recognize subtle mucosal changes. However, in this setting, capsule endoscopy should ideally be coupled with imaging techniques that provide important information about the thickness of the wall of the intestine and about extraluminal abnormalities. Although deep enteroscopy (such as balloon enteroscopy) is expensive, time-consuming, and potentially risky in these frail patients, they may have a key role, because they make it possible to take tissue samples from deep in the small intestine.

Role of magnified ileoscopy in the diagnosis of cases of coeliac disease with predominant abdominal symptoms

OBJECTIVE

Less severe histological changes have sometimes been reported in the terminal ileum (TI) of coeliac patients. The aim of this work was to assess whether magnified ileoscopy and the corresponding biopsy could be used when diagnosing coeliac disease (CD). This would be of clinical value in coeliac patients who show predominant abdominal symptoms and who undergo colonoscopy with ileoscopy as first clinical examination.

MATERIAL AND METHODS

All patients underwent conventional and magnified ileoscopy, along with histological examination of macroscopic mucosal abnormalities, if present. Patients whose ileoscopy with biopsy suggested CD underwent a blood test for quantitative determination of anti-transglutaminase antibodies and upper gastrointestinal endoscopy with corresponding duodenal biopsy.

RESULTS

Out of 143 patients enrolled, 21 had a TI mucosal lesion, and 10 of these showed villous atrophy at ileoscopy only after magnification. Six showed a count of intra-epithelial lymphocytes (IELs) >25/100 enterocytes and upper intestinal lesions, confirming the diagnosis of CD. Finally, of four patients diagnosed with Crohn's disease, TI mucosal aftoid lesions were seen in two only in magnified view.

CONCLUSIONS

Magnified ileoscopy reliably recognizes the presence of mucosal villous subtotal or total atrophy at TI. This finding, even if not specific to CD, can address the diagnosis of CD. Magnification in the course of ileoscopy could also be useful in the diagnosis of Crohn's disease.

Optimal approach to obtaining mucosal biopsies for assessment of inflammatory disorders of the gastrointestinal tract

Endoscopic evaluation and mucosal biopsy analysis have assumed important roles in the clinical management of patients with symptoms related to the gastrointestinal tract. Several common inflammatory diseases, including eosinophilic esophagitis, Barrett's esophagus, Helicobacter pylori infection, celiac disease, lymphocytic colitis, collagenous colitis, and inflammatory bowel disease, may display a patchy or discontinuous distribution and, thus, multiple mucosal samples may be required to obtain diagnostic tissue in some cases. Not surprisingly, clinicians and pathologists are increasingly challenged to determine the optimum number of procedures and tissue samples necessary to detect, or exclude, the presence of inflammatory disorders of the gastrointestinal tract. Unfortunately, clinical practice varies widely with respect to tissue sample procurement in the evaluation of these disorders, particularly when the endoscopic appearance of the gastrointestinal mucosa is normal or shows only minimal changes. Guidelines concerning the appropriate number of tissue samples are well established for some diseases, such as Barrett's esophagus and chronic gastritis, but are not clear in other instances. The purpose of this review is to discuss the available literature pertaining to appropriate endoscopic sampling in the assessment of medical diseases of the gastrointestinal tract, and to develop recommendations regarding the clinical evaluation of common gastrointestinal disorders.

Is this really celiac disease? Pitfalls in diagnosis

Celiac disease (CD) is an autoimmune enteropathy triggered in susceptible individuals by ingestion of gliadin-containing grains. Although the autoimmune process targets mainly the intestinal mucosa, CD can manifest itself with a variety signs and symptoms affecting any organ or tissue. For many years, CD has been underdiagnosed because of poor awareness. However, studies showing a high prevalence of CD in North America, followed by a consensus conference on CD organized by the National Institutes of Health, have fueled a campaign to raise awareness among subspecialists and primary physicians. Nevertheless, guidelines for the diagnosis of CD remain poorly appreciated and many health care professionals remain confused about its proper management. This review is intended to clarify "facts and fantasies" about CD diagnosis.

Emerging technologies in upper gastrointestinal endoscopy and celiac disease

Despite advances in our knowledge of celiac disease, the most current and authoritative recommendations conclude that diagnosis requires at least four biopsy specimens to be taken from the duodenal area. These recommendations are based on the perception that classic endoscopic markers are not adequate to target biopsy sampling to sites of villous damage in the duodenum. In the past few years, newly developed procedures and technologies have improved endoscopic recognition of the duodenum. These advances make possible the real-time recognition of the duodenal villous pattern during an upper endoscopy procedure, and thereby have the potential to optimize diagnostic accuracy. It is, therefore, reasonable to hypothesize that upper endoscopy might have a more incisive role in the diagnosis of celiac disease than merely providing a means of obtaining biopsy specimens for histological analysis. This Review highlights the new technologies in the field of upper endoscopy that could be helpful for the diagnosis of celiac disease, including the water-immersion technique, chromoendoscopy, high-resolution magnification endoscopy, optimal band imaging, optical coherence tomography and confocal endomicroscopy.

Systematic review: The evidence base for long-term management of coeliac disease

BACKGROUND

While gluten-free diet is an effective treatment for coeliac disease, the need for and goals of long-term management of patients are poorly defined.

AIM

To review systematically the complications and associations of coeliac disease, to identify potential risk factors, to define ways of assessing risk factors and to provide a strategy for management.

METHODS

Review of medical literature from 1975.

RESULTS

There is an increasing list of potential complications and/or conditions associated with coeliac disease, in particular, autoimmune disease, malignancy and bone disease. Risk factors that may predict or influence long-term outcomes include genetic susceptibility, environmental factors predominantly gluten ingestion, persistent small intestinal inflammation/injury and nutritional deficiencies. Genotyping of patients is yet to have an established clinical role in long-term management. Assessment of adherence to the gluten-free diet largely relies upon skilled dietary history, but the ultimate test is duodenal histopathology, which is the only currently established means of assessing healing. Symptoms, serology or other non-invasive means are poor predictors of healing and the likelihood of complications.

CONCLUSION

Evidence (albeit limited) that adherence to a gluten-free diet and mucosal healing prevent and/or ameliorate complications indicates that a planned long-term strategy for follow-up is essential.

Coeliac disease

INTRODUCTION

Coeliac disease is a common but often under diagnosed condition with important complications. It is due to immune-mediated gluten intolerance and may present in a number of ways. It has become more frequently diagnosed due to the recognition of the atypical presentations. In recent years, more sensitive and specific serological markers have been developed but the gold standard of diagnosis remains duodenal biopsy. Compliance with a strict, lifelong gluten-free diet is the cornerstone of management, improving symptoms and reducing complications of the disease.

SOURCES OF DATA

For this review, we focused on papers published on coeliac disease in recent years. Particular emphasis was given to clinical papers examining new methods for the diagnosis of coeliac disease or newer therapies for managing complications. The main source was PubMed and the major gastroenterology journals.

AREAS OF AGREEMENT

Coeliac disease is more common than once thought with a prevalence of around 1%. Diagnosis should always be confirmed with a duodenal biopsy. Management of coeliac disease with a gluten-free diet remains the cornerstone of treatment.

AREAS OF CONTROVERSY

Some complications of coeliac disease, especially neurological, are not widely accepted despite growing support from the literature. Management of enteropathy-associated lymphoma has been difficult, and the optimal therapy is not known.

GROWING POINTS

Current understanding is such that coeliac disease is the most widely understood autoimmune condition. 'Atypical' presentations are becoming the most common presenting features of coeliac disease.

AREAS TIMELY FOR DEVELOPING RESEARCH

Alternatives to the gluten-free diet are about to go into clinical studies. Similarly, better serological screening tests may obviate the need for duodenal biopsy. This review will try to summarize the current understanding of coeliac disease with regard to diagnosis, management, complications and future perspectives.