Abdominal CT findings may suggest coeliac disease

Celiac Disease and Intussusception: A Common Association in Children

OBJECTIVES

In young childhood, intestinal intussusception (IS) is the most common cause of small bowel obstruction. A lead point such as Meckel diverticulum, polyps, tumors, enlarged lymph nodes, cystic fibrosis, and Schoenlein-Henoch purpura are recognized causes. Association between celiac disease (CD) and IS has been well recognized in adults but rarely in children. Data on causes and outcome of intussusception among Saudi children are lacking in the literature. Our objectives were to characterize the pattern of IS among Saudi children and investigate the frequency, clinical presentation, and outcome of intussusception among children with CD.

METHODS

We searched the hospital's picture archiving and communications system for abdominal imaging studies (ultrasound, magnetic resonance imaging, computed tomography scan, and barium contrast studies), performed between 2008 and 2019, using "intussusception" as a search key word. The hospital medical records of the identified cases of intussusception (aged 0-14 years) were then retrospectively reviewed to collect demographic, clinical, laboratory and imaging findings, management, and outcome.

RESULTS

During the study period, 57 cases were identified as confirmed IS (31 boys, median age 1.95 years, range 0.33-11 years). Abdominal ultrasound was the diagnostic imaging study in 93%. An underlying cause (secondary IS) could be identified in 19 (33.3%) cases: CD in 6, malignancy and Henoch-Schoenlein purpura, 5 each, and Meckel diverticulum in 3; the remaining 38 (66.6%) cases of IS were idiopathic (primary IS). The presence of hypoalbuminemia and abdominal distension were significantly associated with secondary IS as compared with primary IS ( P < 0.001, P = 0.006, respectively). All of the 6 cases of IS associated with CD resolved spontaneously, but 3 were recurrent.

CONCLUSIONS

Secondary causes contributed to a large proportion of IS in our study cohort (33%) as compared with 5% to 10% in the literature. Celiac disease is an underrecognized cause of IS among children. A child with IS and hypoalbuminemia, anemia, or chronic diarrhea needs to be investigated for CD to avoid unnecessary surgery.

Use of Ultrasound in the Diagnostic Work-Up of Adult Intussusception - A Multicenter Retrospective Analysis

PURPOSE

 To evaluate the use of ultrasound (US) in the diagnostic work-up of adult intussusception (AI).

METHODS

 This multicenter study includes 26 consecutive patients diagnosed with AI between January 2010 and November 2017. A retrospective chart analysis was conducted with a focus on abdominal US findings and diagnostic accuracy of different imaging modalities (ultrasound, computed tomography (CT), magnetic resonance imaging). If available, surgical and pathological findings served as the gold standard (76.9 %). US examiners certified according to DEGUM grade 2 or 3 were classified as experts. Otherwise, they were regarded to have basic skills.

RESULTS

 During diagnostic work-up, 92.3 % underwent abdominal US. US was the first-line imaging modality in 88.5 % of cases. The accuracy regarding the detection of AI (85 %), correct localization (95 %) and detection of complications (100 %) was excellent and comparable with CT (81 %, 90.5 %, and 91.7 %) when performed by experts. 72.7 % of tumorous lead points were detected by experienced examiners. In contrast, AI was detected in only 45.5 % of cases by examiners with basic skills. AI was diagnosed prior to surgery in all patients.

CONCLUSION

 US is reliable in the diagnostic work-up of AI when performed by experienced examiners with high-quality equipment. US, CT and MRI should be used in a complementary fashion since combination provides excellent sensitivity regarding the detection and correct localization of AI as well as the detection of complications. The impact of real-time imaging is illustrated by supplementary videos.

Intussusception in celiac disease: Is it a common feature in children?

BACKGROUND AND AIM

There are sporadic reports of occurrence of intussusception in celiac disease (CD) but no systematic study yet. We prospectively studied the prevalence and natural history of intussusception in newly diagnosed CD.

METHODS

From January 2010 to October 2013, 150 children, diagnosed to have CD on the basis of positive serology and duodenal biopsy, were recruited in this study. Abdominal ultrasonography was carried out before starting gluten-free diet (GFD) and repeated in those who had intussusception, on day 3 and then weekly till the resolution of intussusception.

RESULTS

The median age was 72 (range, 16-204) months, and 79 (53%) were boys. Diarrhea was the presenting symptom in 119 (79%) cases. A total of 45 intussusceptions were detected in 37 (25%) children. Out of 45 intussusceptions, 95% involved small bowel. All but one had asymptomatic intussusception. On GFD, intussusception resolved spontaneously within 7 days in 65%, within 14 days in 84%, and within 28 days in 92% of cases, and none required surgical or hydrostatic reduction. On univariate analysis, younger age, low weight z score, presentation with diarrhea, abdominal distension, rickets, lower serum albumin, more severe villous atrophy, and refeeding syndrome were more common in children with intussusception. On multivariate analysis, abdominal distension and hypoalbuminemia were found to be significantly associated with intussusception.

CONCLUSIONS

Intussusception is frequently (25%) seen in children with newly diagnosed CD, generally asymptomatic and resolves spontaneously on GFD. It is often associated with more severe disease. Children with CD and intussusception should not be subjected to surgical/radiological intervention.

Beyond moulage sign and TTG levels: the role of cross-sectional imaging in celiac sprue

Celiac disease is an autoimmune disorder that causes inflammation and destruction in the small intestine of genetically susceptible individuals following ingestion of gluten. Awareness of the disease has increased; however, it remains a challenge to diagnose. This review summarizes the intestinal and extraintestinal cross-sectional imaging findings of celiac disease. Small intestine fold abnormalities are the most specific imaging findings for celiac disease, whereas most other imaging findings reflect a more generalized pattern seen with malabsorptive processes. Familiarity with the imaging pattern may allow the radiologist to suggest the diagnosis in patients with atypical presentations in whom it is not clinically suspected. Earlier detection allows earlier treatment initiation and may prevent significant morbidity and mortality that can occur with delayed diagnosis. Refractory celiac disease carries the greatest risk of mortality due to associated complications, including cavitating mesenteric lymph node syndrome, ulcerative jejunoileitis, enteropathy-associated T cell lymphoma, and adenocarcinoma, all of which are described and illustrated. Radiologic and endoscopic investigations are complimentary modalities in the setting of complicated celiac disease.

Small bowel imaging in celiac disease

BACKGROUND

Modern small bowel imaging techniques allow detailed depiction of small-intestinal abnormalities. The role of these techniques in the investigation of celiac disease is increasing, especially in patients with suspected complicated celiac disease.

KEY MESSAGES

In general, there is no need for radiological small bowel imaging in uncomplicated celiac disease. It is however important that clinicians and radiologists are aware of certain specific radiological findings that may suggest celiac disease, especially since celiac disease is often not considered in adult patients, and small bowel radiology may be performed before specific tests for celiac disease. Radiological abnormalities can be observed with both conventional small bowel radiology studies, like small bowel follow-through or double-contrast small bowel enteroclysis, and newer modalities, like computed tomography or magnetic resonance enterography or enteroclysis. These signs include a decreased number of jejunal folds, an increased number of ileal folds, small bowel dilatation, wall thickening and intussusception. Extraintestinal abnormalities include mesenteric lymphadenopathy, vascular changes and splenic atrophy. Abnormalities congruent with refractory celiac disease type II include a severe decrease in jejunal folds, infiltration of the mesenteric fat and thickening of the small bowel wall. Additionally, a severely decreased splenic volume may indicate complicated celiac disease. Malignant complications of celiac disease, such as enteropathy-associated T-cell lymphoma and small-intestinal adenocarcinoma, can be reliably investigated with cross-sectional enteroclysis techniques.

CONCLUSIONS

Small bowel imaging and especially cross-sectional enteroclysis techniques are important extensions to the diagnostic workup of clinicians involved in the care of patients with celiac disease, especially those with suspected complicated disease.

Transient small bowel intussusception in adults: an overlooked feature of coeliac disease

Coeliac disease is the commonest immunological gastrointestinal disorder in the Western world. The symptoms of coeliac disease in adults are often non-specific, and a high index of suspicion may be required for timely diagnosis. We describe the case of a 46-year-old woman, with known dilated cardiomyopathy and pulmonary hypertension, who presented with non-specific abdominal symptoms, not initially attributed to gastrointestinal disease. Radiological investigations demonstrated transient small bowel intussusception without other abnormality, leading to the suggestion of coeliac disease as a cause, which was subsequently confirmed as the diagnosis.

Coeliac disease in an adult presenting as intussusception without a lead point

A case of adult intussusception is presented in which previously undiagnosed coeliac disease was the cause. The diagnosis was made following microscopic examination of a resected segment of small intestine containing multiple intussusception sites. Adult intussusception is rare and in most cases associated with a 'lead point' lesion, often a tumour. As illustrated here, intussusception without a lead point in the adult patient may be the presenting sign of coeliac disease. Recognition of such may allow correct diagnosis and thus prevent unnecessary surgery.

Should intussusception in children prompt screening for celiac disease?

OBJECTIVES

An association between adult celiac disease (CD) and intussusceptions (ISs) has been described. Although more common among children, intussusception has not been linked with childhood CD aside from isolated case reports. Our aim was to investigate the frequency of IS among children with CD.

METHODS

A patient database containing children with biopsy-proven CD was reviewed, in addition to radiology records contained in a hospital-maintained clinical data repository.

RESULTS

Of 254 children with biopsy-proven CD and complete records available for review, abdominal imaging was performed in 21%, mainly because of abdominal pain. Among children with CD, 1.2% experienced an IS <9 months before their diagnosis with CD. Among children seen at our institution in the same time period, 0.07% experienced an IS. The majority of those children with CD who were found to have IS had no evidence of nutritional deficit at the time of IS. IS was not identified in any children with CD who had been treated with a gluten-free diet.

CONCLUSIONS

IS was far more common among children in our cohort with untreated CD than in the general pediatric population simultaneously seen at our center. The diagnosis of CD should be considered in children with IS, even in the absence of signs of nutritional compromise.

A review of rifaximin and bacterial overgrowth in poorly responsive celiac disease

A proportion of patients with celiac disease have a poor response to a gluten-free diet, which may be due to small-intestinal bacterial overgrowth (SIBO). Treatment with rifaximin is often used in the clinical setting, but there is limited literature to support this practice. In addition, challenges in the diagnosis of SIBO confound response interpretation. Our recent placebo-controlled trial did not demonstrate any improvement in gastrointestinal symptoms after treatment with rifaximin and casts doubt on the utility of lactulose-hydrogen breath testing for SIBO in this population.

MR enteroclysis in refractory celiac disease: proposal and validation of a severity scoring system

PURPOSE

To determine magnetic resonance (MR) enteroclysis findings in patients with uncomplicated celiac disease (CD), refractory CD (RCD) type I, and RCD type II, to develop and validate a scoring system to identify patients with RCD II and to determine the diagnostic accuracy of MR enteroclysis to detect CD-related malignancies.

MATERIALS AND METHODS

This study was performed with approval of the institutional review board. One radiologist blinded to clinical details retrospectively evaluated quantitative and qualitative criteria of 28 studies obtained in symptomatic patients with CD (uncomplicated CD, n = 10; RCD I, n = 8; RCD II, n = 10). A scoring system was developed by using parameters identified in multivariate analysis to be associated with RCD II, which two radiologists evaluated in a second group of 40 symptomatic patients with CD. Accuracy to detect malignancy was assessed in the total study group. Cumulative survival was evaluated in the total study group by using the Kaplan-Meier method.

RESULTS

MR enteroclysis could not be used to discriminate between uncomplicated CD and RCD I. The presence of less than 10 folds per 5 cm jejunum, mesenteric fat infiltration, and bowel wall thickening were associated with RCD II. A positive MR score was defined as the presence of two or more of these features. In the validation group, the MR score was positive in 13 of 15 patients with RCD II (sensitivity, 0.87) and negative in 24 of 25 patients without RCD II (specificity, 0.96). The 5-year survival rate was 95% in patients with a negative MR score and 56% in patients with a positive MR score (P < .0001). MR enteroclysis helped to identify the presence of seven of eight malignancies and to diagnose absence of malignancy in 58 of 60 studies.

CONCLUSION

MR enteroclysis can be used to investigate the presence of RCD II or malignancy in symptomatic patients with CD.

Association of intussusception and celiac disease in adults

INTRODUCTION

Intussusception (IS) is rare in adults. However, the more frequent use of cross-sectional imaging has resulted in an increase in its detection. Because of the reported association with celiac disease, we determined the prevalence of IS among a cohort with celiac disease.

METHODS

An anonymized prospectively maintained celiac disease database and radiological database were reviewed.

RESULTS

Of a total of 880 patients, 14 (age 47 ± 17.5 years; 50% female) had IS that was detected by CT in 10, capsule endoscopy in three, and barium studies in two. The reason for evaluation was abdominal pain in 78% (11/14), whereas in the remainder (3/14) were incidental. IS was the initial manifestation of celiac disease in 57% (8/14). Two patients were found to have lead-point intussusceptions and both had small-bowel adenocarcinoma, and 10/14 had severe villous atrophy (subtotal or total). Among those with established celiac disease, IS was detected early, within 3 years of diagnosis. Follow-up was available for 11 patients, 9 of who adhered strictly to a gluten-free diet, and six had no recurrence. Among all the patients diagnosed with IS on radiologic studies at our institution, 45 were considered to have idiopathic IS. Only two of these patients had evaluation for celiac disease.

CONCLUSION

IS occurs in celiac disease. It may be the initial presentation and is associated with abdominal pain. Adenocarcinoma needs to be excluded. The majority of patients do not have recurrent symptoms after adherence to a gluten-free diet. Celiac disease should be considered more frequently when IS is encountered.

Current methods to diagnose the unresponsive and complicated forms of coeliac disease

Coeliac disease is a common disorder. Due to the protean manifestations of the disease and the often mild but indolent course, the diagnosis is often missed. The method to diagnose this in principle reversible disease after the introduction of a gluten-free diet has attracted the attention of several scientific disciplines to find the simplest and most patient-friendly test. This has resulted in a noticeable impact on the clinical practice next to a general increased awareness of its existence, its pathogenesis, its course and recent evidence of increased mortality. Amendments made in the diagnostic criteria of coeliac disease over the last half century have simplified the diagnosis. However, the aspect most relevant to the specialist in internal medicine is related to its grave consequences when the disease fails to respond to a gluten-free diet. These refractory cases may culminate in severe complications with sombre endings and malignancy. Fortunately, current technology can offer the specialist in internal medicine more facilities to diagnose the cause of the complicated cases in order to attempt to intervene in the course of disease and hopefully save these patients. We review the available tools that now exist and their indications that can be practiced in a modern clinical setting for the diagnosis of the complicated forms of this disease.

Assessment of appropriateness of indications for CT enterography in younger patients

BACKGROUND

The small potential risk of radiation-induced cancer is increased in younger patients undergoing serial imaging with computed tomography enterography (CTE). We sought to determine the appropriateness of CTEs based on clinical indication in patients < or =35 years old, and the potential impact of evolution of practice to alternative magnetic resonance enterography (MRE).

METHODS

Over a 7-year period, the medical records of all patients < or =35 years old undergoing CTE were reviewed to determine the clinical indications for each CTE exam. An interdisciplinary consensus panel evaluated the appropriateness of all CTE exams based on American College of Radiology appropriateness criteria and peer-reviewed literature, classifying indications into "appropriate" or "inappropriate." For repeat CTEs, an "alternative MRE suggested" pathway was created. Criteria for evolution of practice to "alternative MRE" were suspicion of obstruction and evaluation of disease activity/therapeutic response in the absence of new symptoms.

RESULTS

In all, 2022 patients < or =35 years old underwent 2295 CTEs. Ninety-nine percent (2008/2022) of first-time CTE exams were "appropriate" by the defined criteria. A total of 197 patients (9.7%) underwent multiple exams, with 73% of these patients having Crohn's disease. Repeat exams occurred in 9% (18/197) with obstructive symptoms and evaluation of disease activity/therapeutic response in the absence of new symptoms in 41% (80/197).

CONCLUSIONS

A multidisciplinary expert panel concluded that the vast majority of young patients underwent clinically appropriate first-time CTE exams. However, a shift in clinical practice to MRE appears warranted for approximately half of young patients undergoing repeat CTE examinations.

Enteropathy associated T-cell lymphoma and its precursor lesions

Enteropathy Associated T-cell Lymphoma (EATL) is an intestinal tumour of intra-epithelial lymphocytes. Based on morphology, immunohistochemistry and genetic profile EATL can be divided into two groups. EATL type I is a large cell lymphoma which is highly associated with Coeliac Disease (CD) and mostly presents with malabsorption, weight loss and CD-related symptoms. EATL type II consists of small to medium-sized cells and presents often with obstruction or perforation of the small bowel. This type of EATL has no known association with CD. When EATL has been diagnosed a thorough diagnostic work-up is needed. This work-up preferably includes video capsule enteroscopy (VCE), double-balloon enteroscopy (DBE), computed tomography (CT) combined with 18F-fluorodeoxyglucose positron emission tomography scan (18F-FDG-PET scan) if possible and magnetic resonance enteroclysis (MRE). Nowadays, most EATL patients are treated with chemotherapy mostly preceded by resection of the tumour and followed by stem cell transplantation. Despite these therapies outcome of EATL remains very poor with a 5-year survival of 8-20%. In order to improve survival prospective multicentre trials, studying new therapies are needed. The combination of chemotherapy, monoclonal antibodies and/or apoptosis inducing small molecules might be a potential treatment for EATL in the (nearby) future.

CT enteroclysis features of uncomplicated celiac disease: retrospective analysis of 44 patients

PURPOSE

To describe the computed tomographic (CT) enteroclysis features of uncomplicated celiac disease (CD) and to determine the most indicative appearance of this condition by using a retrospective case-control study.

MATERIALS AND METHODS

This study had institutional review board approval. The CT enteroclysis examinations of 44 consecutive patients with proved uncomplicated CD (21 men, 23 women; mean age, 44.45 years) were reviewed by two blinded readers and compared with those obtained in 44 control subjects (21 men, 23 women; mean age, 44.48 years), who were matched for sex and age. Comparisons were calculated by using univariate analysis.

RESULTS

Reversed jejunoileal fold pattern had the highest specificity (100%; 44 of 44; 95% confidence interval [CI]: 91.96%, 100%) and was the most discriminating independent variable for the diagnosis of uncomplicated CD (odds ratio, 39.9; P < .0001) but had a sensitivity of 63.64% (28 of 44; 95% CI: 47.77%, 77.59%). Ileal fold thickening, vascular engorgement, and splenic atrophy were other variables that strongly correlated with the presence of uncomplicated CD.

CONCLUSION

CT enteroclysis may help establish a diagnosis of uncomplicated CD and may clarify the cause of nonspecific gastrointestinal symptoms in patients with unknown CD. However, future prospective trials are needed to determine the actual value of CT enteroclysis in patients with CD and validate the clinical usefulness of CT enteroclysis in the detection of unknown uncomplicated CD.

Imaging features of primary extranodal lymphomas

Lymphomas are generally considered tumours of lymph nodes, but up to 40% arise extranodally. This group shows distinctive pathological, radiological, and clinical features. Different subtypes of extranodal lymphoma may show sufficiently specific radiological features to be of significant value in both establishing a diagnosis of lymphoma and ascertaining the exact subtype. Rapidly evolving lymphoma classifications and emergence of new entities have, however, hampered the accurate description of these features in the literature. In this review, we discuss the radiological appearances, using a variety of imaging methods, of the full spectrum of primary extranodal lymphomas, categorized according to the current World Health Organisation classification.

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.

Flow cytometric determination of aberrant intra-epithelial lymphocytes predicts T-cell lymphoma development more accurately than T-cell clonality analysis in Refractory Celiac Disease

BACKGROUND

Refractory celiac disease (RCD) patients with aberrant, often clonal, intraepithelial T-cells are at high risk for development of enteropathy associated T-cell lymphoma (EATL). Early detection of those patients that actually develop EATL is of utmost importance for curative intervention.

AIM

First, to establish an optimal cut-off value for the percentage of aberrant lymphocytes, previously determined based on clinical observations, via reference ranges for aberrant T-cells in the duodenal mucosa of celiac disease patient and control groups. Secondly, to compare aberrancy with intestinal T-cell clonality as a prognostic parameter for EATL development in RCD.

METHODS

Immunophenotyping using flow cytometry was performed on small intestinal biopsy-derived lymphocytes, obtained from distinct celiac disease (CD) patient and control groups (N=167 in total). T-cell clonality in duodenal biopsy specimens was assessed by PCR in RCD, ulcerative jejunitis and EATL patients (N=31 in total).

RESULTS

In 95% of non-refractory CD patients, the highest percentage aberrant T-cells was 20%. Using this cut-off value, EATL development was exclusively seen in RCD with more than 20% aberrant T-cells (median 52% aberrant T-cells, range 27-94%). When compared with T-cell clonality analysis, >20% aberrancy showed a much higher negative predictive value and sensitivity (both 100%) for EATL development in RCD patients than T-cell clonality analysis (respectively 75% and 78%).

CONCLUSIONS

Quantification of aberrant T-cells by flow cytometry is preferable to T-cell clonality analysis for identification of RCD patients at risk for EATL development. A cut-off value of 20% is of use in risk stratification, therapeutic options and subsequent follow-up of RCD patients.

Clinical significance of incidental colorectal wall thickening on computed tomography scan in African-American and Hispanic patients

We sought to assess the significance of an incidental finding of colorectal wall thickening (CRWT) on computed tomography (CT) scan in African-American and Hispanic patients. We retrospectively reviewed charts of African-American and Hispanic patients from January 1994 to December 2005. Those patients were included in whom the colonoscopy was performed due to incidental CRWT on CT scan. Patients with a history or a family history of colorectal malignancy, inflammatory bowel disease, or colorectal surgery, with an incomplete colonoscopic examination, or <18 years of age were excluded. Endoscopic and pathological findings were abstracted. Thirty-two patients met the criteria. Endoscopic examination was abnormal in 21 (65.6%). The positive predictive value of CRWT for abnormal endoscopic examination was 65.6%. Abnormal endoscopic examination revealed diverticulosis in 9 (43%), erythematous mucosa in 8 (38%), polyps in 6 (29%), mass in 2 (9%), thickened folds in 1 (5%), and diverticulitis in 1 (5%). Histopathological findings revealed colitis in 7 (33%), adenoma in 4 (19%), hyperplastic polyps in 4 (19%), adenocarcinoma in 2 (9%), lymphoid aggregates in 2 (9%), melanosis coli in 1 (5%), and normal in 1 (5%) in the abnormal examination group. Abnormal endoscopic examination was found in 65.6% of patients. The prevalence of colitis, adenomas, and malignancy was high, therefore abnormal CRWT warrants further endoscopic evaluation.

Intramural Fat in the Duodenum and Proximal Small Intestine in Patients with Celiac Disease

OBJECTIVE

The purpose of this article is to describe and illustrate intramural fat in the duodenum and jejunum, to our knowledge a previously undescribed finding in celiac disease.

CONCLUSION

Celiac disease is known to produce inflammation of the duodenum and jejunum. We propose that postinflammatory intramural fat deposition occurs in a distribution likely unique for celiac disease. CT scans of the chest and abdomen obtained for many indications include these portions of the bowel. Celiac disease is now recognized as a common disease, and the recognition of intramural fat in the duodenum and jejunum on CT may allow earlier diagnosis.

Abdominal computed tomography in refractory coeliac disease and enteropathy associated T-cell lymphoma

AIM: To evaluate computed tomography (CT) findings, useful to suggest the presence of refractory celiac disease (RCD) and enteropathy associated T cell lymphoma (EATL).

METHODS: Coeliac disease (CD) patients were divided into two groups. GroupI: uncomplicated CD (n = 14) and RCD typeI(n = 10). Group II: RCD type II (n = 15) and EATL (n = 7).

RESULTS: Both groups showed classic signs of CD on CT. Intussusception was seen in 1 patient in groupIvs 5 in group II (P = 0.06). Lymphadenopathy was seen in 5 patients in group II vs no patients in groupI(P = 0.01). Increased number of small mesenteric vessels was noted in 20 patients in groupIvs 11 in group II (P = 0.02). Eleven patients (50%) in group II had a splenic volume < 122 cm³vs 4 in groupI(14%), 10 patients in groupI had a splenic volume > 196 cm³ (66.7%) vs 5 in group II (33.3%) P = 0.028.

CONCLUSION: CT scan is a useful tool in discriminating between CD and (Pre) EATL. RCD II and EATL showed more bowel wall thickening, lymphadenopathy and intussusception, less increase in number of small mesenteric vessels and a smaller splenic volume compared with CD and RCDI.

Adult celiac disease: what is the role of MRI?

PURPOSE

To evaluate the ability of MRI to identify intra- and extraintestinal findings of celiac disease in an adult population.

MATERIALS AND METHODS

Forty-one subjects (18 men and 23 women; mean age = 41.3 years; 31 with biopsy-proven celiac disease, and 10 healthy volunteers) underwent MRI of the small bowel. MR studies were performed on a 1.5-T magnet using T2-weighted half-Fourier single-shot turbo spin-echo (HASTE) and true fast imaging in steady-state precession (True-FISP) sequences. The MR features and sensitivity, and the specificity and accuracy of some of these features are described.

RESULTS

In the 31 celiac patients, MRI showed bowel dilatation in 61.3% (N = 19), increased number of ileal folds in 48.4% (N = 15), reversed fold pattern abnormality in 38.7% (N = 12), increased wall thickness in 16.1% (N = 5), duodenal stenosis in 6.5% (N = 2), intussusception in 12.9% (N = 4), mesenteric lymphadenopathy in 41.9% (N = 13), mesenteric vascular changes in 22.6% (N = 7), ascites in 6.5% (N = 2), and no abnormalities in 12.9% (N = 4). The volunteers had unremarkable exams. The overall specificity and accuracy were 100%, and sensitivity was 79% and 75% for increased number of ileal folders and reversed fold pattern abnormality, respectively.

CONCLUSION

MRI is able to demonstrate intra- and extraintestinal features that may lead to the diagnosis of celiac disease in adults.

Cladribine therapy in refractory celiac disease with aberrant T cells

BACKGROUND & AIMS

Refractory celiac disease (RCD) may be subdivided into RCD types I and II with phenotypically normal and aberrant intraepithelial T-cell populations, respectively. In RCD II, transition into enteropathy-associated T-cell lymphoma (EATL) is seen frequently. We have evaluated the effect of cladribine (2-CDA), a purine analogue inducing T-cell depletion, on clinical, histopathologic, and immunologic parameters, as well as the toxicity and side effects in a group of RCD II patients.

METHODS

Between 2000 and 2005, 17 patients were included (8 men, 9 women). All patients had a clonal rearrangement of the T-cell receptor gamma gene and immunophenotyping showed an aberrant T-cell population lacking surface expression of CD3, CD8, and T-cell receptor alphabeta, in the presence of expression of surface CD103 and intracytoplasmic CD3. Treatment consisted of 2-CDA (0.1 mg/kg/day) intravenously for 5 days, given in 1-3 courses every 6 months depending on the response.

RESULTS

All patients tolerated 2-CDA without serious side effects. Six patients (35.8%) showed a clinical improvement (weight gain, improvement of diarrhea, and hypoalbuminemia). In 10 patients (58.8%) a significant histologic improvement and in 6 patients (35.2%) a significant decrease in aberrant T cells was seen. Seven patients (41.1%) developed EATL and died subsequently. One patient died of progressive refractory state with emaciation.

CONCLUSIONS

Treatment with 2-CDA in RCD II is feasible, well tolerated, and can induce clinical and histologic improvement as well as a significant decrease of aberrant T cells in a subgroup of patients, albeit it does not prevent EATL development. However, the earlier reported potential risk of precipitating an overt lymphoma should be taken into consideration.

High accuracy and cost-effectiveness of a biopsy-avoiding endoscopic approach in diagnosing coeliac disease

BACKGROUND

The 'immersion' technique during upper endoscopy allows the visualization of duodenal villi and the detection of total villous atrophy.

AIM

To evaluate the accuracy of the immersion technique in detecting total villous atrophy in suspected coeliac patients. The accuracy in diagnosing coeliac disease and the potential cost-sparing of a biopsy-avoiding approach, based on selection of individuals with coeliac disease-related antibodies and on endoscopic detection of absence of villi, were also analysed.

METHODS

The immersion technique was performed in 79 patients with positive antibodies and in 105 controls. Duodenal villi were evaluated as present or absent. As reference, results were compared with histology. Diagnostic approaches, including endoscopy with or without biopsy, were designed to investigate patients with coeliac disease-related antibodies and total villous atrophy. A cost-minimization analysis was performed.

RESULTS

All patients with positive antibodies had coeliac disease. The sensitivity, specificity, positive and negative predictive values of endoscopy to detect total villous atrophy was always 100%. The sensitivity, specificity, positive and negative predictive values of biopsy-avoiding or biopsy-including strategies in diagnosing coeliac disease when villi were absent was always 100%. The biopsy-avoiding strategy was cost-sparing.

CONCLUSIONS

Upper endoscopy is highly accurate in detecting total villous atrophy coeliac patients. A biopsy-avoiding approach is both accurate and cost-sparing to diagnose coeliac disease in subjects with marked duodenal villous atrophy.