Diagnostic bulb biopsies in celiac disease

A prospective study of duodenal bulb biopsy in newly diagnosed and established adult celiac disease

OBJECTIVES

Recent reports suggest that the duodenal bulb may be the only site to demonstrate villous atrophy (VA) in celiac disease. However, there is a paucity of data from newly diagnosed adult celiac patients and no data from those patients with established celiac disease. The objective of this study was to compare the histological findings in the duodenal bulb and distal duodenum of patients with adult celiac disease (newly diagnosed or established) against controls.

METHODS

A total of 461 patients were prospectively recruited. Biopsies were graded using the Marsh criteria.

RESULTS

In all, 461 patients (300 females and 161 males) with median age 51 years were analyzed. In all, 126 had newly diagnosed celiac disease, 85 established celiac disease, and 250 controls. New diagnosis celiac disease (9%, P<0.0001) and established celiac disease (14%, P<0.0001) were more likely than controls to have VA in the bulb alone. Overall, when comparing the histological lesion of the bulb against the distal duodenum, 31/85 with established celiac disease (P<0.0001) and 21/126 newly diagnosed (P=0.0067) had a discrepancy in the severity of the lesion between the two sites compared with 18/250 controls. In all, 24/31 with established celiac disease and 16/21 newly diagnosed had the more severe lesion in the bulb.

CONCLUSIONS

VA may be present only in the duodenal bulb. This study suggests that the optimal assessment of patients in whom celiac disease is suspected (with positive serology) and those with established celiac disease requires a duodenal bulb biopsy in addition to distal duodenal biopsies.

Bulb biopsies for the diagnosis of celiac disease in pediatric patients

BACKGROUND

Celiac disease (CD) is a gluten-dependent enteropathy. The current standard for diagnosing CD involves obtaining 4 biopsy samples from the descending duodenum. It has been suggested that duodenal bulb biopsies may also be useful.

OBJECTIVE

To assess the utility of bulbar biopsies for the diagnosis of CD in pediatric patients.

DESIGN

Prospective study.

SETTING

Single center.

PATIENTS

Forty-seven consecutively enrolled pediatric patients with celiac serologies and a clinical suspicion of CD.

INTERVENTIONS

All patients underwent EGD, and 4 biopsy samples were obtained from the duodenal bulb and 4 from the descending duodenum of each child.

MAIN OUTCOME MEASUREMENTS

The pathologist blindly reported the Marsh histological grade for the diagnosis of CD of the bulb and descending duodenum.

RESULTS

The diagnosis of CD was histologically confirmed in 89.4% (42/47) of the cases of biopsy samples obtained from the descending duodenum and in all 47 obtained from the bulb. In 35 patients (74.5%), histology was the same in the bulb and duodenum; in 11 (23.4%) cases, the grade of atrophy was higher in the bulb than in the descending duodenum, and 5 (10.6%) had bulb histology positive for CD but negative duodenal findings. One child (2.1%) had a higher histological grade in the duodenum than in the bulb. The diagnostic gain with bulbar biopsies was 10.6%.

LIMITATIONS

Small sample and absence of a comparison group (asymptomatic children with normal CD antibodies).

CONCLUSIONS

We suggest examining 4 biopsy samples from the duodenal bulb and 4 from the descending duodenum to improve diagnostic accuracy of CD.