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Patel N, Leffler DA, Al-Toma A, Mulder CJ, Elli L, Gan G, Patil P, Atsawarungruangkit A, Kuijpers KC, Del Gobbo A, Goldsmith J, Hintze Z, Pacheco MC, Vieth M, Melcher B, Salomao M, Pai R, Hart J, Olivas A, Naini B, Meyerson C, Choi WT, Kakar S, Westerhoff M, Cheng J, Gopal P, Hammer S, Moreno Prats M, Bronner MP, Robert ME. Clinical Data Do Not Reliably Predict Duodenal Histology at Follow-up in Celiac Disease: A 13 Center Correlative Study. Am J Surg Pathol 2024; 48:212-220. [PMID: 37994653 DOI: 10.1097/pas.0000000000002150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Validated nonbiopsy methods to assure duodenal mucosal healing in celiac disease are lacking, yet ongoing mucosal injury is associated with anemia, osteoporosis, and lymphoma. Most providers utilize clinical data as surrogates of mucosal status to avoid additional esophagogastroduodenoscopy. The reliability of such surrogates to predict mucosal recovery has been incompletely evaluated. The aim of this study was to rigorously assess patterns of histologic mucosal recovery at follow-up in celiac disease and to correlate findings with clinical data. Gastrointestinal pathologists from 13 centers evaluated initial and follow-up duodenal biopsies from 181 celiac disease patients. Marsh scores and intraepithelial lymphocytes (IELs)/100 enterocytes were assessed blindly. Histology at follow-up was correlated with symptoms, immunoglobulin A anti-tissue transglutaminase titers and gluten-free diet adherence. Fifty-six/181 (31%) patients had persistent villous blunting and 46/181 (25%) patients had just persistently elevated IELs at follow-up, with only 79/181 (44%) patients having complete histologic remission. IEL normalization (82/181; 45%) lagged villous recovery (125/181;69%). In a minority of patients, villous blunting was limited to proximal duodenal biopsies. No correlation was found between Marsh scores and symptoms, normalization of immunoglobulin A anti-tissue transglutaminase serology, or diet adherence. Children showed greater recovery of Marsh score ( P <0.001) and IELs ( P <0.01) than adults. Persistent mucosal injury is common in celiac disease, with discordant villous/IEL normalization. Pathologist awareness of expected findings in celiac disease follow-up biopsies, including their frequent lack of correlation with clinical data, is important for patient management, and has implications for eligibility criteria for therapeutics currently in development.
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Affiliation(s)
| | | | | | - Chris J Mulder
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Luca Elli
- Center for Prevention and Diagnosis of celiac disease, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Italy
| | | | | | | | | | - Alessandro Del Gobbo
- Division of Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Italy
| | | | | | | | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Balint Melcher
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | | | | | - John Hart
- University of Chicago Medical Center, Chicago, IL
| | | | | | | | - Won-Tak Choi
- Department of Pathology, University of California, San Francisco, CA
| | - Sanjay Kakar
- Department of Pathology, University of California, San Francisco, CA
| | | | - Jerome Cheng
- Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Purva Gopal
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Suntrea Hammer
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Mary P Bronner
- University of Utah Health Sciences Center and ARUP Labs, Salt Lake City, UT
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Chronische Diarrhoe. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00654-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Coverlizza S, Masu L, Manini C. Multiple Adenocarcinomas of the Small Bowel in a Patient with Brunner’s Glands Agenesia: A Previously Unreported Association. Clin Pract 2022; 12:672-676. [PMID: 36136863 PMCID: PMC9498684 DOI: 10.3390/clinpract12050069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/20/2022] [Accepted: 08/23/2022] [Indexed: 11/16/2022] Open
Abstract
Adenocarcinoma of the small bowel is rather uncommon and several etio-pathogenic factors have been proposed. We report a case of multiple synchronous adenocarcinomas arising in the non-ampullary duodenum and first tract of the jejunum in a background of Brunner’s glands agenesia, chronic duodenitis, and extensive dysplasia in a 64 year-old woman. To the best of our knowledge such association has not been reported so far.
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Affiliation(s)
- Sergio Coverlizza
- Department of Pathology, San Giovanni Bosco Hospital, 10154 Turin, Italy
| | - Lavinia Masu
- Department of Pathology, S. Andrea Hospital, ASLVC, 13100 Vercelli, Italy
| | - Claudia Manini
- Department of Pathology, San Giovanni Bosco Hospital, 10154 Turin, Italy
- Department of Sciences of Public Health and Pediatrics, University of Turin, 10124 Turin, Italy
- Correspondence:
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Jansson-Knodell CL, Kessler WR. The role of female endoscopists: are women gastroenterologists better at obtaining biopsies for celiac disease than men? Scand J Gastroenterol 2021; 56:505-507. [PMID: 33599184 DOI: 10.1080/00365521.2021.1887926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Celiac disease (CD) is commonly found in women. Given the sex differences in diagnosed patients, we hypothesized sex differences in physicians obtaining biopsies for CD may exist. MATERIALS AND METHODS We retrospectively reviewed duodenal biopsies for suspected CD excluding pre-existing CD patients. Appropriate biopsy practice was defined as ≥5 specimens per ACG guidelines. RESULTS We included 125 patients (females, 92). There were 85 properly (68%) biopsied. Presence of a female endoscopist was associated with better adherence to biopsy guidelines (OR, 2.99, 95% CI, 1.19-7.54; p = .02) which remained significant after multivariable adjustment (adjusted OR, 2.7; p = .047). CONCLUSIONS Physician sex-based differences in biopsy patterns may exist.
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Affiliation(s)
- Claire L Jansson-Knodell
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, IN, USA
| | - William R Kessler
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University, Indianapolis, IN, USA
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Lei H, Johnson LA, Eaton KA, Liu S, Ni J, Wang X, Higgins PDR, Xu G. Characterizing intestinal strictures of Crohn's disease in vivo by endoscopic photoacoustic imaging. BIOMEDICAL OPTICS EXPRESS 2019; 10:2542-2555. [PMID: 31143502 PMCID: PMC6524586 DOI: 10.1364/boe.10.002542] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 05/21/2023]
Abstract
Crohn's disease (CD) is one type of inflammatory bowel disease where both inflammation and fibrosis cause the thickening of the bowel wall and development of the strictures. Accurate assessment of the strictures is critical for the management of CD because the fibrotic strictures must be removed surgically. In this study, a prototype capsule-shaped acoustic resolution photoacoustic (PA) endoscope, which can perform mulitwavelength side-view scanning, was developed to characterize the intestinal strictures of CD. The imaging performance of the probe was tested in phantom experiments and a rabbit trinitrobenzene sulfonic acid (TNBS) model with acute (inflammatory only) or chronic (mixed fibrotic and inflammatory) colitis in vivo. The motion artifacts due to intestinal peristalsis and the respiratory motion of the animals were compensated to improve image qualities. Quantitative molecular component images derived from multi-wavelength PA measurements of normal, acute and chronic intestinal strictures demonstrated statistically significant differences among the three groups that were confirmed by histopathology. A longitudinal study demonstrated the capability of the system in monitoring the development of fibrosis. The results suggest that the proposed novel, capsule-shaped acoustic resolution PA endoscope can be used to characterize fibrostenotic disease in vivo.
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Affiliation(s)
- Hao Lei
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Laura A. Johnson
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Kathryn A. Eaton
- Department of Microbiology and Immunology, University of Michigan Medical Center, Ann Arbor, Michigan, MI 48109, USA
| | - Shengchun Liu
- College of Physical Science and Technology, Heilongjiang University, Harbin, 150080, China
| | - Jun Ni
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Xueding Wang
- Department of Biomedical Engineering, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Department of Radiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Peter D. R. Higgins
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Guan Xu
- Department of Radiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Zhu Y, Johnson LA, Huang Z, Rubin JM, Yuan J, Lei H, Ni J, Wang X, Higgins PDR, Xu G. Identifying intestinal fibrosis and inflammation by spectroscopic photoacoustic imaging: an animal study in vivo. BIOMEDICAL OPTICS EXPRESS 2018; 9:1590-1600. [PMID: 29675304 PMCID: PMC5905908 DOI: 10.1364/boe.9.001590] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/23/2018] [Accepted: 02/26/2018] [Indexed: 05/05/2023]
Abstract
Crohn's disease (CD) is a chronic autoimmune disease characterized by obstructing intestinal strictures. Conventional imaging modalities can identify the strictures but cannot characterize whether a stricture is predominantly inflammatory or fibrotic. The purpose of this study is to examine the capability of photoacoustic (PA) imaging to characterize intestinal fibrosis and inflammation in vivo. Intestinal strictures in a rat model of CD were imaged with a PA-ultrasound parallel imaging system. Internal and external illuminations were attempted, both with transcutaneous PA signal reception. The PA signal magnitudes acquired at wavelengths targeting individual molecular components and the derived functional information showed significant differences between the inflammatory and fibrotic strictures, consistent with histological inflammation and fibrosis.
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Affiliation(s)
- Yunhao Zhu
- Department of Electronic Science and Engineering, Nanjing University, Nanjing, Jiangsu 21000, China
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Laura A. Johnson
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Ziyi Huang
- Department of Electrical and Computer Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jonathan M. Rubin
- Department of Radiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Jie Yuan
- Department of Electronic Science and Engineering, Nanjing University, Nanjing, Jiangsu 21000, China
| | - Hao Lei
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jun Ni
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Xueding Wang
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Peter D. R. Higgins
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Guan Xu
- Department of Radiology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Abstract
Chronic diarrhea is a frequently encountered symptom in clinical practice. The etiologies for chronic diarrhea are diverse and broad with varying clinical implications. A useful method of categorizing chronic diarrhea to guide a diagnostic work-up is a pathophysiology-based framework. Chronic diarrhea may be categorized as malabsorptive, secretory, osmotic, and inflammatory or motility related. Frequently, overlap between categories may exist for any given diarrhea etiology and diagnostic testing must occur with an understanding of the differential diagnosis. Investigations to achieve a diagnosis for chronic diarrhea range from screening blood and stool tests to more directed testing such as diagnostic imaging, and endoscopic and histological evaluation. The pathophysiology-based framework proposed in this chapter will allow the clinician to select screening tests followed by targeted tests to minimize cost and complications to the patient, while providing a highly effective method to achieve an accurate diagnosis.
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Affiliation(s)
- M Raman
- University of Calgary, Calgary, AB, Canada.
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Latorre M, Lagana SM, Freedberg DE, Lewis SK, Lebwohl B, Bhagat G, Green PHR. Endoscopic biopsy technique in the diagnosis of celiac disease: one bite or two? Gastrointest Endosc 2015; 81:1228-33. [PMID: 25638509 DOI: 10.1016/j.gie.2014.10.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 10/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The diagnosis of celiac disease is dependent on the quality of biopsy specimens obtained at EGD. Endoscopists may obtain a single- or double-biopsy specimen with each pass of the forceps. OBJECTIVE To compare the quality of biopsy specimens obtained with the single-biopsy and double-biopsy techniques. DESIGN Prospective cohort study. SETTING U.S. tertiary-care university hospital. PATIENTS Patients undergoing upper endoscopy with confirmed, suspected, or unknown celiac disease status. INTERVENTIONS Four biopsy specimens from the second portion of the duodenum: 2 by using the single-biopsy technique (1 bite per pass of the forceps) and an additional 2 by using the double-biopsy technique (2 bites per pass of the forceps). Specimens were blindly reviewed to determine orientation, consecutive crypt-to-villous units, and Marsh score. MAIN OUTCOME MEASUREMENTS Proportion of well-oriented biopsy specimens. RESULTS Patients (N = 86) were enrolled, 47% with known celiac disease, 36% with suspected celiac disease, and 17% with an unknown celiac disease status. Well-oriented biopsy specimens were noted in 66% of patients with the single-biopsy technique and 42% of patients with the double-biopsy technique (P < .01). Analysis of matched pairs showed improved orientation with the single-biopsy technique (odds ratio 3.1; 95% confidence interval, 1.5-7.1; P < .01). This persisted in subgroup analysis of patients with known celiac disease (P = .02), villous atrophy (P = .02), and a final diagnosis of celiac disease (P < .01). LIMITATIONS A single-center trial. CONCLUSION The single-biopsy technique improves the yield of well-oriented duodenal biopsy specimens. Endoscopists should consider taking only 1 biopsy specimen per pass of the forceps in patients undergoing biopsies of the duodenal mucosa.
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Affiliation(s)
- Melissa Latorre
- Celiac Disease Center, Department of Medicine, Columbia University, New York, New York, USA
| | - Stephen M Lagana
- Celiac Disease Center, Department of Medicine, Columbia University, New York, New York, USA
| | - Daniel E Freedberg
- Celiac Disease Center, Department of Medicine, Columbia University, New York, New York, USA
| | - Suzanne K Lewis
- Celiac Disease Center, Department of Medicine, Columbia University, New York, New York, USA
| | - Benjamin Lebwohl
- Celiac Disease Center, Department of Medicine, Columbia University, New York, New York, USA
| | - Govind Bhagat
- Celiac Disease Center, Department of Medicine, Columbia University, New York, New York, USA
| | - Peter H R Green
- Celiac Disease Center, Department of Medicine, Columbia University, New York, New York, USA
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Abstract
BACKGROUND Because of its technical characteristics (i.e. 8-fold magnification, capability to inspect the entire small bowel) and minimal invasiveness, videocapsule endoscopy (VCE) has been proposed as a useful tool for managing patients with celiac disease (CD). KEY MESSAGES Although VCE has been found to be highly sensitive and specific in identifying CD endoscopic markers, it is still inadequate to replace esophagogastroduodenoscopy (EGD) with biopsies in the diagnosis of CD. Nevertheless, it represents a reliable alternative in patients unable or unwilling to undergo EGD. Up to now, available studies have failed to identify any correlation between the length of small bowel involvement and the severity of symptoms. The available evidence on the use of VCE in diagnosing CD in equivocal cases (patients with positive serology and negative or nonspecific histology or those with negative serology and histologically proven villous atrophy) is limited, and its role is still under discussion. In CD patients not improving on gluten-free diet, a complete workup is necessary. In patients with nonresponsive (NRCD) or refractory CD (RCD), VCE has been shown to be able not only to detect significant findings, driving further management, but also to rule out major complications. Nevertheless, in this setting, the inability of VCE to take tissue samples and the risk of capsule retention can represent major limitations. CONCLUSIONS At the present time, for diagnostic purposes, VCE can be proposed only in patients unable or unwilling to undergo EGD, whereas it could be useful in some equivocal cases. Conversely, there is no room for VCE either to estimate the length of the small bowel affected by villous atrophy or to follow up patients improving on gluten-free diet. In patients with NRCD or RCD, VCE can play a role, but it should be combined with other diagnostic techniques.
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Lee JH, Kim JG, Jung HK, Kim JH, Jeong WK, Jeon TJ, Kim JM, Kim YI, Ryu KW, Kong SH, Kim HI, Jung HY, Kim YS, Zang DY, Cho JY, Park JO, Lim DH, Jung ES, Ahn HS, Kim HJ. [Synopsis on clinical practice guideline of gastric cancer in Korea: an evidence-based approach]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 63:66-81. [PMID: 24561693 DOI: 10.4166/kjg.2014.63.2.66] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although, gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to that of Western countries. However, there is no Korean multidisciplinary guideline for gastric cancer and thus, a guideline adequate for domestic circumstances is required. Experts from related societies developed 22 recommendation statements for the diagnosis (n=9) and treatment (n=13) based on relevant key questions. Evidence levels based on systematic review of literatures were classified as five levels from A to E, and recommendation grades were classified as either strong or weak. The topics of this guideline cover diagnostic modalities (endoscopy, endoscopic ultrasound, radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, radiotherapy) and pathologic evaluation. External review of the guideline was conducted at the finalization phase.
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Affiliation(s)
- Jun Haeng Lee
- Department of Gastroenterology, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul 156-861, Korea
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Lee JH, Kim JG, Jung HK, Kim JH, Jeong WK, Jeon TJ, Kim JM, Kim YI, Ryu KW, Kong SH, Kim HI, Jung HY, Kim YS, Zang DY, Cho JY, Park JO, Lim DH, Jung ES, Ahn HS, Kim HJ. Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach. J Gastric Cancer 2014; 14:87-104. [PMID: 25061536 PMCID: PMC4105383 DOI: 10.5230/jgc.2014.14.2.87] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 06/26/2014] [Indexed: 12/13/2022] Open
Abstract
Although gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to those in western countries. However, there are currently no Korean multidisciplinary guidelines for gastric cancer. Experts from related societies developed guidelines de novo to meet Korean circumstances and requirements, including 23 recommendation statements for diagnosis (n=9) and treatment (n=14) based on relevant key questions. The quality of the evidence was rated according to the GRADE evidence evaluation framework: the evidence levels were based on a systematic review of the literature, and the recommendation grades were classified as either strong or weak. The applicability of the guidelines was considered to meet patients' view and preferences in the context of Korea. The topics of the guidelines cover diagnostic modalities (endoscopy, endoscopic ultrasound, and radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, and radiotherapy), and pathologic evaluation. An external review of the guidelines was conducted during the finalization phase.
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Affiliation(s)
- Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae G. Kim
- Department of Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University, College of Medicine, Seoul, Korea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Joo Jeon
- Department of Nuclear Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Mee Kim
- Department of Pathology, Inha University School of Medicine, Incheon, Korea
| | - Young Il Kim
- Department of Surgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Dae Young Zang
- Department of Internal Medicine, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Jae Yong Cho
- Department of Medical Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Oh Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Sun Jung
- Department of Pathology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
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Abstract
BACKGROUND Although the prevalence of celiac disease in the USA approaches 1%, most cases are undiagnosed, in part, because of low adherence to the recommendation of submitting at least four specimens during duodenal biopsy. We aimed to determine whether physician and practice characteristics are associated with adherence to this recommendation. MATERIALS AND METHODS We used a large national pathology database to identify all adult patients who underwent duodenal biopsy during 2006-2009. Hierarchical modeling was used to determine whether procedure volume, the number of gastroenterologists per endoscopy suite, and the number of gastroenterologists per capita of the zip code of the practice were associated with adherence. RESULTS We identified 92 580 patients (67% female, mean age 53.5 years) who met our inclusion/exclusion criteria. Specimens were submitted by 669 gastroenterologists from 200 endoscopy suites, located in 191 zip codes, with a mean of 3.4 gastroenterologists per suite. On multivariate analysis, a higher procedure volume was associated with a decreased adherence [odds ratio (OR) for each additional 100 procedures, 0.92; 95% confidence interval (CI), 0.88-0.97; P=0.002]. An increased adherence was reported for gastroenterologists working at suites with higher numbers of gastroenterologists (OR for each additional gastroenterologist, 1.08; 95% CI, 1.04-1.13; P<0.001) but not for a higher gastroenterologist density in the zip code of the practice (OR for each additional gastroenterologist per capita, 1.01; 95% CI, 0.99-1.03; P=0.21). CONCLUSION High-volume physicians exhibit lower rates of adherence to biopsy guidelines, possibly because of the additional time required to submit at least four specimens. In contrast, a greater number of endoscopists working in an endoscopy suite are associated with an increased adherence, possibly because of peer education.
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Harris LA, Park JY, Voltaggio L, Lam-Himlin D. Celiac disease: clinical, endoscopic, and histopathologic review. Gastrointest Endosc 2012; 76:625-40. [PMID: 22898420 DOI: 10.1016/j.gie.2012.04.473] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 04/30/2012] [Indexed: 02/08/2023]
Affiliation(s)
- Lucinda A Harris
- Department of Gastroenterology, Mayo Clinic in Arizona, Scottsdale, Arizona 85259, USA
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Kav T, Sivri B. Is enteroscopy necessary for diagnosis of celiac disease? World J Gastroenterol 2012; 18:4095-101. [PMID: 22919241 PMCID: PMC3422789 DOI: 10.3748/wjg.v18.i31.4095] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 03/26/2012] [Accepted: 04/09/2012] [Indexed: 02/06/2023] Open
Abstract
Celiac disease (CD) is an autoimmune inflammatory disease of the small intestine as a result of reaction to wheat protein, gluten. Exclusion of dietary gluten is the mainstay of the treatment that necessitates a precise diagnosis of the disease. Serological screening may aid in identifying patients with suspected CD, which should be confirmed by intestinal biopsy. It has been shown that duodenal biopsies are good for detection of the disease in most patients. However, there is a group of patients with positive serology and inconclusive pathology. As a result of the widespread use of serology, many patients with equivocal findings grow quickly. Unfortunately current endoscopic methods can only diagnose villous atrophy, which can be present in the later grades of disease (i.e., Marsh III). To diagnose CD correctly, going deeper in the intestine may be necessary. Enteroscopy can reveal changes in CD in the intestinal mucosa in 10%-17% of cases that have negative histology at initial workup. Invasiveness of the method limits its use. Capsule endoscopy may be a good substitute for enteroscopy. However, both techniques should be reserved for patients with suspected diagnosis of complications. This paper reviews the current literature in terms of the value of enteroscopy for diagnosis of CD.
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A prospective study of duodenal bulb biopsy in newly diagnosed and established adult celiac disease. Am J Gastroenterol 2011; 106:1837-742. [PMID: 21606978 DOI: 10.1038/ajg.2011.171] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Abstract
At upper gastrointestinal endoscopy to investigate unexplained diarrhea and iron deficiency anemia, duodenal biopsies are often taken to exclude a diagnosis of coeliac disease. While histology remains the gold standard for this diagnosis, recent developments in serological testing may overtake this as a first line test and biopsy restricted to confirming the diagnosis. Established coeliac disease on biopsy is straightforward, but early lesions may pose a challenge. Newer endoscopic procedures such as push-pull enteroscopy (balloon enteroscopy) with biopsy allow access to the small bowel beyond the second part of the duodenum. Controversy remains as to what constitutes the normal histology of the duodenum, and small bowel. Lymphocytic duodenosis (increased intraepithelial lymphocytes with normal villous architecture) in patients with negative coeliac serology can be associated with Helicobacter pylori, drugs, autoimmune and other diseases including food allergy. Full thickness small intestinal biopsies can aid in investigation of enteric neuropathies in severe dysmotility disorders. Biopsies are also taken to investigate malabsorption due to suspected infectious and metabolic disorders. Despite highly active anti-retroviral therapy (HAART), immunosuppressed patients may be affected by duodenal pathogens. The histology of duodenal mucosa in acid related disorders reflects the damage seen at endoscopy. Although the prevalence of duodenal ulcer disease is decreasing, drugs causing ulceration remain an important disease entity. Recent observations in functional bowel disorders suggest that the duodenum may be a key site for pathology. In functional dyspepsia, patients with early satiety may have excess eosinophil infiltration, and the mast cell is probably a key player in the irritable syndrome in the small intestine.
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Abstract
Coeliac disease is increasing in prevalence, which is currently estimated at one in 100 of the population and may occur de novo in adults. The diagnosis requires a joint clinicopathological approach; the recommended first-line test is serology with immunoglobulin A (IgA) tissue transglutaminase and IgA endomysial antibodies. These serological tests show high levels of sensitivity and specificity, but biopsy is the gold standard to confirm the diagnosis. It is important that both tests are performed before the introduction of a gluten-free diet. Although the classical histopathology changes of coeliac disease with partial or total villous atrophy are well recognized, the pathology classification of coeliac disease is changing, with recognition that coeliac disease may show minimal pathology (normal architecture and an intraepithelial lymphocyte count/100 enterocytes ≥ 25). This entity is also described as lymphocytic duodenosis, and recommendation of follow-up serology testing is paramount in this condition. Follow-up of patients with coeliac disease is warranted, as normal serology does not predict mucosal recovery. Failure to heal predicts risk of progression to refractory coeliac disease and malignancies. Refractory coeliac disease occurs in 1-2% of patients and this diagnosis requires a combined clinical and histopathology approach with immunocytochemistry.
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Affiliation(s)
- Marjorie M Walker
- Department of Histopathology, Imperial College London, St. Mary's Hospital, London, UK.
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Gonzalez S, Gupta A, Cheng J, Tennyson C, Lewis SK, Bhagat G, Green PHR. Prospective study of the role of duodenal bulb biopsies in the diagnosis of celiac disease. Gastrointest Endosc 2010; 72:758-65. [PMID: 20883853 DOI: 10.1016/j.gie.2010.06.026] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 06/10/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Studies have demonstrated that villous atrophy in celiac disease is patchy and have suggested that duodenal bulb biopsies aid in diagnosis. OBJECTIVE To determine the role of the addition of duodenal bulb biopsies to distal duodenum (D2) biopsies in the diagnosis of celiac disease. DESIGN Prospective, case-control study. SETTING Tertiary referral hospital. PATIENTS Patients undergoing upper endoscopy with biopsy for diagnosis or follow-up of celiac disease and control patients. INTERVENTIONS Blinded review of duodenal biopsy samples. MAIN OUTCOME MEASUREMENTS Increasing the yield as well as accuracy of the histologic diagnosis of celiac disease with the addition of bulb biopsies. RESULTS Of 128 patients enrolled in the study, 67 had celiac disease. Of 1079 biopsy specimens, only 319 (30%) were adequate for complete histologic analysis, resulting in 40 celiac patients and 40 control patients for analysis. Of the 40 celiac patients, 35 (87.5%) had atrophy in either the bulb or D2, 30 (75%) exhibited atrophy at both sites with an identical grade of atrophy seen in 18 patients (45%). Fourteen patients (35%) had identical types of Marsh lesions in both biopsy sites. Twelve patients (30%) had atrophy detected in the bulb, D2, or both, but lacked intraepithelial lymphocytes and thus could not be assigned a Marsh grade. Five patients (13%) had a diagnosis of celiac disease based on findings in the bulb biopsy only. LIMITATIONS Small sample size and study performed in an academic medical center. CONCLUSIONS Our study confirms the patchy nature of villous atrophy as well as intraepithelial lymphocytosis in biopsy specimens from individuals with celiac disease. Adding duodenal bulb biopsies to our sampling regimen increased the diagnostic yield of celiac disease.
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Affiliation(s)
- Susana Gonzalez
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Mangiavillano B, Masci E, Parma B, Barera G, Viaggi P, Albarello L, Tronconi GM, Mariani A, Testoni S, Santoro T, Testoni PA. Bulb biopsies for the diagnosis of celiac disease in pediatric patients. Gastrointest Endosc 2010; 72:564-8. [PMID: 20630510 DOI: 10.1016/j.gie.2010.05.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Accepted: 05/14/2010] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Benedetto Mangiavillano
- Gastrointestinal Endoscopy, Azienda Ospedaliera San Paolo University Hospital, University of Milan, Italy.
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Novel screening assay performance in pediatric celiac disease and adult dermatitis herpetiformis. J Pediatr Gastroenterol Nutr 2010; 51:19-23. [PMID: 20453680 DOI: 10.1097/mpg.0b013e3181c992be] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES : Several serologic assays are commercially available to aid in the diagnosis of gluten-sensitive enteropathy (GSE). Our objective in this study was to assess the performance of a novel combined antigen-screening assay for GSE. PATIENTS AND METHODS : Deidentified sera from 111 pediatric patients suspected of having celiac disease (CD), 130 adults diagnosed with dermatitis herpetiformis (DH), and 77 pediatric and 49 adult normal controls were included in the study. Sera from 10 patients submitted to our laboratory for GSE testing with IgA deficiency and IgG antibodies against 1 or more of the traditional serologic markers associated with GSE were also included. All sera were screened for antibodies (IgA and IgG) against tissue transglutaminase (tTG) and deamidated gliadin peptides (DGP) by enzyme immunoassay (EIA) in a single test well. In addition, all sera were assessed for each individual marker and isotype using separate EIAs. RESULTS : The IgA/IgG anti-tTG/DGP EIA screen was 92.6% sensitive and 94.3% specific in pediatric CD and detected 1 patient (Marsh 3c) who was IgA anti-tTG negative; this patient was not IgA deficient (<7.0 mg/dL). All 10 IgA-deficient sera gave positive results by the tTG/DGP EIA screen. Sensitivity and specificity of the tTG/DGP EIA screen in retrospective and prospective DH were 65% and 100% versus 62% and 100%, respectively. CONCLUSIONS : The new IgA/IgG anti-tTG/DGP EIA screen was slightly more sensitive than IgA anti-tTG alone in pediatric CD. This novel screening assay may allow the current recommendation of measuring total serum IgA in suspected GSE patients to be eliminated.
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Shen B, Khan K, Ikenberry SO, Anderson MA, Banerjee S, Baron T, Ben-Menachem T, Cash BD, Fanelli RD, Fisher L, Fukami N, Gan SI, Harrison ME, Jagannath S, Lee Krinsky M, Levy M, Maple JT, Lichtenstein D, Stewart L, Strohmeyer L, Dominitz JA. The role of endoscopy in the management of patients with diarrhea. Gastrointest Endosc 2010; 71:887-92. [PMID: 20346452 DOI: 10.1016/j.gie.2009.11.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 11/13/2009] [Indexed: 02/08/2023]
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Optical coherence tomography in pediatric patients: a feasible technique for diagnosing celiac disease in children with villous atrophy. Dig Liver Dis 2009; 41:639-43. [PMID: 19386560 DOI: 10.1016/j.dld.2009.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 01/24/2009] [Accepted: 02/03/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Celiac disease is a common condition with many atypical manifestations, where histology serves as the "gold standard" for diagnosis. A useful new technique, optical coherence tomography, can depict villous morphology in detail, using light waves. This study examined the correlation between the sensitivity and specificity of optical coherence tomography in pediatric patients undergoing esophago-gastro-duodenoscopy for the diagnosis of celiac disease. MATERIALS AND METHODS A total of 134 children were prospectively enrolled, 67 with a serological suspicion of celiac disease (group 1) and 67 with negative histology for celiac disease (group 2). During a diagnostic esophago-gastro-duodenoscopy we acquired multiple images and films in the four quadrants of the second part of the duodenum, and biopsies were taken in the area where optical coherence tomography had been done. Three patterns of villous morphology were considered: pattern 1=no atrophy (types 0, 1 or 2 of the Marsh classification); pattern 2=mild atrophy (type 3a or 3b); pattern 3=marked atrophy (type 3c). RESULTS The diagnosis of celiac disease was histologically confirmed in all 67 children with positive antiendomysium and/or antitransglutaminase antibodies. Optical coherence tomography correlated with pattern 1 histology in 11/11 cases, pattern 2 in 30/32 (93.8%) and pattern 3 in 22/24 (91.6%). Sensitivity and specificity were 82% and 100%. In the control group there was 100% concordance between optical coherence tomography and histology. The overall concordance between optical coherence tomography and histology in determining patchy lesions was 75%. CONCLUSION Optical coherence tomography could be a helpful diagnostic tool in children with mild or marked villous atrophy for diagnosing celiac disease during upper gastrointestinal (GI) endoscopy, avoiding biopsies. However, duodenal biopsies are mandatory if the optical coherence tomography shows normal villous morphology in patients with positive antibodies.
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Rondonotti E, Villa F, Saladino V, de Franchis R. Enteroscopy in the diagnosis and management of celiac disease. Gastrointest Endosc Clin N Am 2009; 19:445-60. [PMID: 19647651 DOI: 10.1016/j.giec.2009.04.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Emanuele Rondonotti
- Department of Medical Sciences, Gastroenterology 3 Unit, University of Milan, IRCCS Policlinico, Mangiagalli, Regina Elena Foundation, 20122 Milan, Italy.
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Prasad KK, Thapa BR, Nain CK, Singh K. Assessment of the diagnostic value of duodenal bulb histology in patients with celiac disease, using multiple biopsy sites. J Clin Gastroenterol 2009; 43:307-11. [PMID: 18827714 DOI: 10.1097/mcg.0b013e31815b9d11] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multiple endoscopic biopsies from the descending duodenum are usually recognized as the standardized method for the evaluation of mucosal changes in celiac disease (CD). Generally, the duodenal bulb is not considered a useful site for biopsies, owing to some difficulties in histologic evaluation. GOAL We wanted to verify if duodenal bulb histology establish a correct diagnosis of CD. STUDY Fifty-two consecutive children with suspicion of CD and positive antitissue transglutaminase antibodies were enrolled in a prospective fashion. During upper gastrointestinal endoscopy, 2 to 4 biopsies each were taken from descending duodenum distal to the papilla of Vater (D2) and duodenal bulb (B). The histologic lesions were classified according to the modified Oberhuber classification by single pathologist who was blinded to the site of biopsy. RESULTS A total of 52 children had a final diagnosis of CD. The main presenting symptoms were diarrhea 43/52 (82.7%), anemia 40/52 (76.9%), and failure to thrive 32/52 (61.5%). All had type 3 lesion-(a) mild, (b) moderate, or (c) severe-in at least 1 site. There was 45/52 (86.5%) CD patients with lesions of identical type (type 2 or 3) in both biopsy sites. The number of intraepithelial lymphocytes was not significantly different in the descending part of the duodenum as compared with duodenal bulb. CONCLUSIONS The biopsies from the duodenal bulb and second part of the duodenum in CD can be equally representative of the underlying disease. The diagnosis of CD can reliably be made even if biopsies are taken from the duodenal bulb rather than distal duodenum or jejunum.
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Affiliation(s)
- Kaushal Kishor Prasad
- Division of GE Histopathology and Pediatric Gastroenterology, Department of Superspeciality of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, Union Territory, India.
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Pais WP, Duerksen DR, Pettigrew NM, Bernstein CN. How many duodenal biopsy specimens are required to make a diagnosis of celiac disease? Gastrointest Endosc 2008; 67:1082-7. [PMID: 18308317 DOI: 10.1016/j.gie.2007.10.015] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2007] [Accepted: 10/03/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND It is unknown how many endoscopic biopsy specimens are needed to diagnose celiac disease (CD). OBJECTIVE To determine the numbers of duodenal biopsy specimens needed to diagnose CD. DESIGN Retrospective medical record audit, histology slide analysis, and chart review. SETTING A tertiary-care university hospital. PATIENTS Adults who underwent EGD to diagnose CD. INTERVENTIONS Our pathology database was searched for the keywords "consistent with celiac disease," "not consistent with celiac disease," "villous atrophy," and "intraepithelial lymphocytes" from January 2001 to May 2006. The number of biopsy specimens was determined and graded for a modified Marsh classification, and charts were reviewed for diagnosis verification. CD was confirmed if Marsh grade 3A was found, even on one biopsy specimen. MAIN OUTCOME MEASUREMENTS The number of biopsy specimens needed to make the diagnosis of CD. RESULTS Of 247 cases, 102 patients were diagnosed with biopsy specimen-confirmed CD. In 9 patients, CD could not be confirmed on the basis of histology alone (highest Marsh lesion was grade 1 or 2), but a clinical diagnosis was made on the basis of presentation and serology. CD could be confirmed if only 2 biopsy specimens were obtained in 84 patients (90%), if only 3 biopsy specimens were obtained in an additional 5 patients (95%), and if at least 4 biopsy specimens were taken in the remainder. CD was ruled out in 145 patients. In 142 patients, biopsy specimens were uniformly negative; 3 patients had Marsh grade 1 lesions but negative serology. LIMITATIONS A retrospective design. CONCLUSIONS Only 2 biopsy specimens will lead to a confirmed diagnosis of CD in 90%, and a suspected diagnosis in all. For 100% confidence in diagnosis of CD, 4 duodenal biopsy specimens should be taken.
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Affiliation(s)
- Wilson P Pais
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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26
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Green PHR. Celiac disease: how many biopsies for diagnosis? Gastrointest Endosc 2008; 67:1088-90. [PMID: 18513550 DOI: 10.1016/j.gie.2007.12.035] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 12/24/2007] [Indexed: 02/08/2023]
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Strongly positive tissue transglutaminase antibodies are associated with Marsh 3 histopathology in adult and pediatric celiac disease. J Clin Gastroenterol 2008; 42:256-60. [PMID: 18223500 DOI: 10.1097/mcg.0b013e31802e70b1] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
GOALS Our objective was to determine whether high serologic IgA tissue transglutaminase antibodies (TTGA) are exclusively associated with celiac disease (CD). BACKGROUND IgA TTGA are found in the serum of most individuals with CD. This serologic marker is used to screen individuals with suspected CD for duodenal biopsy, the gold standard of CD diagnosis. Data suggest strongly positive IgA TTGA >or= 100 units are highly specific for CD histopathology in pediatric patients and may be sufficient for diagnosis. STUDY Records of adult and pediatric subjects in the celiac study at the University of Utah and University of California Irvine were reviewed for strongly positive TTGA. Pathology reports from duodenal biopsies of subjects with IgA TTGA >or= 100 units were graded as 0 to 3 by modified Marsh criteria. RESULTS From a pool of 1882 subjects with IgA TTGA assayed, 208 had IgA TTGA >or= 100 units. Seventy-six of these, including 28 children and 48 adults, also had duodenal biopsies. Villous atrophy (Marsh 3 histopathology) was found on biopsy in 73 (96%) of these subjects. The remaining 3 subjects had intermediate Marsh histology. One (Marsh 1) had a complete serologic response to a gluten-free diet and 2 had Marsh 2 lesions and positive endomysium, making early CD most likely. CONCLUSIONS IgA TTGA >or= 100 units occur almost exclusively in the setting of Marsh 3 duodenal histopathology in adults and children. Rare cases without villous atrophy were marked by intermediate Marsh changes suggestive of early CD. IgA TTGA >or= 100 arbitrary units indicate duodenal changes consistent with CD.
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Donaldson MR, Firth SD, Wimpee H, Leiferman KM, Zone JJ, Horsley W, O'Gorman MA, Jackson WD, Neuhausen SL, Hull CM, Book LS. Correlation of duodenal histology with tissue transglutaminase and endomysial antibody levels in pediatric celiac disease. Clin Gastroenterol Hepatol 2007; 5:567-73. [PMID: 17428743 DOI: 10.1016/j.cgh.2007.01.003] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS IgA antibodies against tissue transglutaminase (TTGA) and endomysium (EMA) are sensitive and specific markers for celiac disease (CD). Data correlating TTGA and EMA levels with degree of villous atrophy are limited. We compared duodenal histopathology in pediatric CD patients with TTGA and EMA serologies, symptoms, height, and weight. METHODS We identified 117 pediatric patients retrospectively who had serologic testing for IgA TTGA and IgA EMA and duodenal biopsies graded by modified Marsh criteria as 0-3c. Data were analyzed with Spearman rank correlation and multinomial logistic regression. RESULTS IgA TTGA (r = .704, P < .001) and IgA EMA (r = 0.740, P < .001) correlated with intestinal villous atrophy in pediatric CD patients by Spearman rank correlation. Similar correlations were found in a subset of 23 patients younger than 3 years of age. Multinomial logistic regression revealed increased probability of Marsh 3a or greater changes with increasing TTGA or EMA levels. Strongly positive antibody levels (TTGA >100 units or EMA titer >1:1280) were highly specific (>98%) for Marsh 3a or greater lesions. Among symptoms, abdominal distention and diarrhea were associated with abnormal histology. CONCLUSIONS IgA TTGA and EMA levels correlate with duodenal villous atrophy in pediatric CD patients. IgA TTGA >100 or EMA >1:1280 were nearly always associated with CD histopathology. With further validation of this observation, strongly positive titers might be considered sufficient for diagnosis of pediatric patients at risk for CD. Symptoms, height, and weight are not reliable predictors of CD.
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Abstract
Coeliac disease is the manifestation of an immune hypersensitivity reaction towards gluten and related proteins, in genetically predisposed people. Although the precise pathogenesis of this condition remains to be fully elucidated, it is probably multifactorial in origin. The diagnosis of coeliac disease has traditionally depended on intestinal biopsies alone; nowadays, the diagnosis has been expanded to include an array of serological markers. This review is intended to offer pathologists an update of the relevant history and immunopathology pertaining to coeliac disease and also to offer recommendations on the ongoing responsibilities of the pathologist in the diagnosis and reporting of coeliac disease.
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Affiliation(s)
- B C Dickson
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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Abstract
A wide variety of small intestinal mucosal diseases lead to malabsorption. Although stool studies, especially stool for excess fat, and functional tests for deficiency states are important clues to malabsorption, small intestinal biopsies are probably the most crucial part of the diagnostic process. Many mucosal disorders have distinctive histologic features that allow for precise diagnosis. However, these histologic changes might be subtle. The role of the gastroenterologist is to provide the pathologist with adequate clinical information and tissue material to ensure a complete examination pathologically. Celiac disease is the most common mucosal cause of chronic malabsorption in the western world. Celiac disease can present classically as large volume fatty diarrhea, but it more commonly presents with subtle clinical symptoms or iron deficiency anemia. Although the histologic hallmark of celiac disease is increased intraepithelial lymphocytosis along with villous atrophy, increased intraepithelial lymphocytosis alone in an appropriate clinical context might suggest the diagnosis of celiac disease. The aim of this review is to highlight the importance of close cooperation and communication between the gastroenterologist and the pathologist to optimize the diagnosis of mucosal diseases that result in malabsorption.
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Affiliation(s)
- Brian A Babbin
- Department of Pathology & Laboratory Medicine, Emory University, Atlanta, Georgia 30322, USA
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Abstract
Celiac disease is an autoimmune disease that occurs in genetically predisposed individuals as the result of an immune response to gluten. This immune response occurs in both the lamina propria and the epithelium of the small intestine. There is a close link to HLA DQ2 and DQ8, although these HLA genes account for only 40% of the genetic influence. Environmental factors, such as the amount and timing of gluten administration in infancy, as well as breastfeeding, influence the disease. Serologic screening studies that use sensitive and specific antibody tests have revealed the disease to be common, occurring in approximately 1% of the population. Clinical presentations are diverse and atypical; the majority of patients lack diarrhea. Therapy is a gluten-free diet that requires avoidance of wheat, rye, and barley, although there is potential for other therapies based on our understanding of the pathophysiology of the disease.
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Affiliation(s)
- Peter H R Green
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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Brocchi E, Tomassetti P, Volta U, Piscitelli L, Bonora M, Campana D, Corinaldesi R. Adult coeliac disease diagnosed by endoscopic biopsies in the duodenal bulb. Eur J Gastroenterol Hepatol 2005; 17:1413-5. [PMID: 16292098 DOI: 10.1097/00042737-200512000-00023] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Multiple endoscopic biopsies in the descending duodenum are usually recognized as the standardized method for the evaluation of mucosal changes in coeliac disease. Generally, the duodenal bulb is not considered a useful site for biopsies, due to some difficulties in histological evaluation. A case in which the diagnosis of coeliac disease was possible only with the aid of biopsies in the duodenal bulb is reported; noteworthy, this unusual site for biopsies was strongly suggested by the presence of a mosaic-like endoscopic appearance. Only few cases (mainly in childhood) have been reported in which diagnosis was made with the aid of biopsies in the duodenal bulb. This occurrence suggests that performing biopsies only in the descending duodenum may not be sufficient in some patients, and raises the question of whether obtaining specimens both from the first and the second part of the duodenum might be a more correct and complete approach to this problem.
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Affiliation(s)
- Emilio Brocchi
- Department of Internal Medicine and Gastroenterology, Cardio-Angiology and Hepatology, University of Bologna, Italy.
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Abstract
PURPOSE OF REVIEW The primary objective of this review is to highlight the evidence for the role of endoscopy in celiac disease. RECENT FINDINGS Evidence is presented that the endoscopic markers of celiac disease are specific although not sensitive for the disease. Villous atrophy, the hallmark of celiac disease, is patchy in the duodenum, and various techniques may identify areas of villous atrophy. These methods include magnification endoscopy and chromoendoscopy. The most recent innovation, video capsule endoscopy, may be of value in the diagnosis of celiac disease and in the assessment of patients with complicated celiac disease. SUMMARY Endoscopy and duodenal biopsies are the mainstay for diagnosing celiac disease. Although characteristic endoscopic features may be useful, their absence does not exclude celiac disease. Random biopsy, even of normal-appearing mucosa is necessary for the diagnosis of celiac disease.
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Affiliation(s)
- Susie K Lee
- Celiac Disease Center, Columbia University College of Physicians, New York, New York, USA
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Chang F, Mahadeva U, Deere H. Pathological and clinical significance of increased intraepithelial lymphocytes (IELs) in small bowel mucosa. APMIS 2005; 113:385-99. [PMID: 15996156 DOI: 10.1111/j.1600-0463.2005.apm_204.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intestinal intraepithelial lymphocytes (IELs) belong to a unique T-cell population interspersed between epithelial cells of both the small and large intestine. It is becoming increasingly recognised that an increased number of IELs with a normal villous architecture is within the wide spectrum of histological abnormalities observed in coeliac disease. An increased number of IELs is the earliest pathological change following gluten challenge and a high IEL count may be the only sign of gluten sensitivity. Therefore, the finding of a raised IEL count with normal villous architecture is of sufficient clinical importance to be reported in routine small bowel biopsies. However, it is evident that not all small intestinal biopsy specimens showing increased IELs are explained by gluten sensitivity. Increased IELs in small bowel mucosa have also been associated with autoimmune disorders, tropical sprue, food protein intolerance, Helicobacter pylori-associated gastritis, peptic duodenitis, parasitic and viral infections, as well as the development of intestinal lymphoma. Histological examination of a biopsy specimen of the small bowel remains the diagnostic gold standard for coeliac disease. There will be an ever increasing demand for histological confirmation of gluten sensitivity in patients in whom the classic microscopic appearance of flattened villi may not have fully developed. The more widespread recognition by histopathologists of the pattern of injury manifested by increased numbers of IELs in intestinal biopsy specimens will certainly help in early diagnosis of coeliac disease, lessen diagnostic confusion and influence the modern practice of gastrointestinal tract medicine. This review discusses some of the recent developments in clinical pathology pertaining to increased IELs in small bowel mucosal biopsies.
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Affiliation(s)
- Fuju Chang
- Department of Histopathology, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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Abstract
The diagnosis of coeliac disease depends on the finding of characteristic, though not specific changes, of intraepithelial lymphocytosis, crypt hyperplasia and various degrees of villous height reduction identified in duodenal biopsies of individuals ingesting a gluten containing diet, together with symptomatic and histologic improvement on gluten withdrawal. Serologic testing has become the main mode of determining who will undergo biopsy. The IgA endomysial antibody and IgA tissue transglutaminase antibody have approximately 90% sensitivity and specificity, though there are reports of lower sensitivity and specificity in the clinical practice setting. This is due to lower titers of these antibodies in the presence of lesser degrees of mucosal damage. The widespread availability of serologic tests for coeliac disease allows the diagnosis to be considered by any physician. Gastroenterologists will be required to interpret the results of serologic tests and perform duodenal biopsies when indicated. Pathologists likewise need to be better acquainted with the more subtle changes of cell mediated immunity within the mucosa that are suggestive of underlying gluten sensitivity.
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Affiliation(s)
- Peter H R Green
- Department of Medicine, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, New York 10032, USA.
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Ravelli A, Bolognini S, Gambarotti M, Villanacci V. Variability of histologic lesions in relation to biopsy site in gluten-sensitive enteropathy. Am J Gastroenterol 2005; 100:177-85. [PMID: 15654798 DOI: 10.1111/j.1572-0241.2005.40669.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES It is generally believed that in gluten-sensitive enteropathy or celiac disease (CD), mucosal lesions may have a patchy distribution. We wanted to verify this concept and establish whether one or more biopsy samples are needed in order to make a correct diagnosis of CD. METHODS One hundred and twelve consecutive children with positive antiendomysium (EMA) or antitissue transglutaminase (tTGA) antibodies, referred to us for suspected CD, were enrolled in a prospective fashion. During upper GI endoscopy four to five biopsies were taken from Treitz and/or distal duodenum (D3), intermediate duodenum (D2), proximal duodenum (D1), and duodenal bulb (B). Histologic lesions were classified according to Marsh criteria modified by Oberhuber. RESULTS A total of 110 patients, all HLA-DQ2 or DQ8 positive, had a final diagnosis of CD (59 classic, 28 atypical, and 23 silent): 102/110 (92.7%) had type 3 lesion-(a) mild, (b) moderate, or (c) severe-in at least one site and 94/110 (85.4%) had villous atrophy (VA) of some degree in all sites. VA of identical degree was present in all biopsy sites in 55/110 (50%) patients. Total VA (type 3c) was present in at least one site in 85/110 (75%), in all sites in 50/110 (45.4%), and significantly increased in aborad direction ((chi(2) > 26.22 with (= 0.01 and d.f. (degrees of freedom) = 12). Eight out of 110 (7.2%) CD patients had exclusively type 1 or 2 lesions, no patient had lesion variability >1 degree and none had normal biopsies. There was no correlation between type or distribution of histologic lesions and clinical presentation of CD. CONCLUSIONS Mucosal atrophy is present in 85% of patients with CD and total VA is significantly more frequent in distal duodenum or proximal jejunum. Fifty percent of patients have identical VA throughout the duodenum and no duodenal areas are histologically normal. In genetically susceptible children with positive serology, a diagnosis of CD can reliably be made even if biopsies are not taken from the distal duodenum or jejunum.
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Affiliation(s)
- Alberto Ravelli
- Gastrointestinal Pathophysiology, University Department of Pediatrics, Children's Hospital, Spedali Civili, 25123 Brescia, Italy
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Abstract
Coeliac disease is a chronic inflammatory condition associated with small intestinal injury that results in the malabsorption of different nutrients. The damaging factor is gluten present in wheat, barley and rye. The diagnosis relies on the clinical picture of the patient, serological markers for coeliac disease, characteristic findings of small intestinal biopsy and, eventually, clinical improvement on a gluten-free diet. Our strategies for the diagnosis of coeliac disease have changed dramatically within the last 10 years. The advent of serological markers with high sensitivity and specificity is changing our understanding of the disease and its prevalence. Treatment includes a life-long gluten-free diet to prevent the recurrence of symptoms and other potential consequences. Most coeliac disease remains under-diagnosed; the utilization of more accurate serological tests and a greater awareness of its many presentations will aid its identification.
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Affiliation(s)
- Gregory Olds
- University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106-5066, USA
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Fantin AC, Neuweiler J, Binek JS, Suter WR, Meyenberger C. Diagnostic quality of biopsy specimens: comparison between a conventional biopsy forceps and multibite forceps. Gastrointest Endosc 2001; 54:600-4. [PMID: 11677476 DOI: 10.1067/mge.2001.118945] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The endoscopic biopsy is a prerequisite for histopathologic diagnosis. Various types of forceps are used to obtain tissue specimens. The aim of this study was to assess and compare the diagnostic quality of biopsy specimens obtained with a conventional forceps and a Multibite forceps. METHODS In a prospective, partially blinded, and randomized trial that included 250 patients referred for diagnostic upper and/or lower endoscopy, 510 biopsy specimens obtained with the Multibite forceps were compared with 520 specimens obtained with a conventional forceps. An experienced, blinded pathologist evaluated the specimens for diameter, depth of specimen, artifacts, anatomic orientation, vitality, general histologic quality, and diagnostic quality. Statistical analysis was performed by using the Fisher exact test. A p value of < 0.05 was regarded as significant. RESULTS There were no statistically significant differences between the specimens obtained with the 2 forceps. The p values for the evaluated parameters were as follows: diameter 0.45, depth of specimen 0.56, artifacts 1.0, pathoanatomic orientation 0.40, vitality 0.45, and histologic diagnostic quality 0.53. CONCLUSION The quality of biopsy specimens obtained with the Multibite forceps is comparable with that of specimens taken with a conventional forceps. Use of the Multibite forceps saves time in that 4 specimens can be obtained in 1 pass in situations in which a large number of specimens are needed or when the potential for transmission of infection is of concern.
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Affiliation(s)
- A C Fantin
- Department of Internal Medicine, Division of Gastroenterology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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40
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Van Beers EH, Rings EH, Taminiau JA, Heymans HS, Einerhand AW, Dekker J, Büller HA. Regulation of lactase and sucrase-isomaltase gene expression in the duodenum during childhood. J Pediatr Gastroenterol Nutr 1998; 27:37-46. [PMID: 9669724 DOI: 10.1097/00005176-199807000-00007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND In children, lactase and sucrase-isomaltase are essential intestinal glycohydrolases, and insufficiency of either enzyme causes diarrhea and malnutrition. Little is known about the regulation of lactase and sucrase-isomaltase expression in the duodenum during childhood. In this study, the mechanisms of regulation of duodenal expression of both enzymes were examined in a study population with ages ranging from 1 to 18 years. METHODS Duodenal biopsy specimens from 60 white children were used to analyze tissue morphology and to quantify lactase and sucrase-isomaltase mRNA and protein. RESULTS Among healthy subjects, high interindividual variability was noted in both mRNA and protein levels for lactase and sucrase-isomaltase. Lactase mRNA level per subject did not correlate with sucrase-isomaltase mRNA level and thus appeared independent. Both lactase and sucrase-isomaltase protein levels correlated significantly with their respective mRNA levels. For each enzyme, a significant inverse correlation was observed between the degree of villus atrophy and mRNA levels. Aging from 1 to 18 years did not result in significant changes in mRNA or protein levels of either enzyme. Immunostaining patterns within the duodenal epithelium for lactase differed from sucrase-isomaltase in adjacent sections, illustrating independent regulation at the cellular level. CONCLUSIONS In the duodenum of white children, lactase and sucrase-isomaltase seem primarily regulated at the transcriptional level. The expression of each enzyme in the intestinal epithelium is regulated by an independent mechanism. Lactase and sucrase-isomaltase exhibit stable mRNA and protein levels in healthy children as they grow to adulthood. Mucosal damage affected levels of both enzymes negatively.
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Affiliation(s)
- E H Van Beers
- Laboratory for Pediatric Gastroenterology and Nutrition, Academic Medical Center, University of Amsterdam, The Netherlands
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Branski D, Faber J, Freier S, Gottschalk-Sabag S, Shiner M. Histologic evaluation of endoscopic versus suction biopsies of small intestinal mucosae in children with and without celiac disease. J Pediatr Gastroenterol Nutr 1998; 27:6-11. [PMID: 9669719 DOI: 10.1097/00005176-199807000-00002] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Concern over the adequacy of histologic diagnosis of endoscopic duodenal biopsies in children prompted this comparative study on the histologic quality of endoscopic versus capsule biopsies. We found this problem addressed in only six previous reports. METHODS Blind examinations of the histologic sections of 48 duodenal biopsies obtained by gastrointestinal endoscopy in children aged 2-18 years were compared to 52 biopsies obtained by the small bowel suction method (from children aged 1-16 years). RESULTS Although 87.5% of endoscopic biopsies and 94.2% of capsule biopsies were adequate for histologic diagnosis, fragmentation or squashing was seen in 83.3% of endoscopic biopsies and only in 25% of capsule biopsies. CONCLUSIONS Biopsies obtained by suction are of better quality than those obtained by endoscopy. If endoscopy is preferred for technical reasons, the following conditions should be observed: the patients should be aged over 2 years, and a minimum of four biopsies should be obtained with forceps of a diameter greater than 2 mm. Adequate histologic criteria for diagnosis should include at least one full-thickness mucosal specimen more than 3 mm in length, vertically oriented, and not fragmented. In children under age 2, duodenal or jejunal capsule biopsies are preferred, since the specimens are usually larger and less fragmented. Endoscopy is technically more difficult in the very young patient.
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Affiliation(s)
- D Branski
- Department of Pediatrics, Shaare Zedek Medical Center, Hebrew University-Hadassah Medical School, Jerusalem, Israel
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42
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Van Beers EH, Einerhand AW, Taminiau JA, Heymans HS, Dekker J, Büller HA. Pediatric duodenal biopsies: mucosal morphology and glycohydrolase expression do not change along the duodenum. J Pediatr Gastroenterol Nutr 1998; 26:186-93. [PMID: 9481636 DOI: 10.1097/00005176-199802000-00013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Duodenal mucosal biopsies are routinely taken for diagnosis in children with complaints of the upper gastrointestinal tract. Surprisingly, little is known about the usefulness of proximal duodenal versus distal duodenal biopsies for routine diagnostic purposes. This study evaluated the comparability of proximal and distal duodenal biopsies with respect to mucosal morphology as well as glycohydrolase expression as an indicator of intestinal epithelial function. METHODS Specimens obtained in duodenal endoscopic biopsies from 64 children, ranging in age from 3 months to 18 years with normal or affected mucosa, were studied. Biopsies were performed in anatomically defined regions in the bulbus duodeni (the very proximal part of the duodenum) and distally of the papilla of Vater (distal of the pancreatic duct). Biopsy specimens were paraformaldehyde-fixed for histologic examination and immunohistochemical evaluation or were homogenized to isolate RNA. Crypt/villus morphology was assessed as is routinely determined by pathologists. In addition, several aspects of lactase and sucrase-isomaltase expression as paradigms of intestinal brush border enzymes were assessed: localization at the cellular level, semiquantitative immunohistochemistry, and quantitative measurement of the messenger RNA levels of the respective brush border glycohydrolases. RESULTS As anticipated, there was a wide interpatient variation in mucosal morphology and expression of lactase and sucrase-isomaltase. Nonetheless, the consistent finding was that in each patient, measurements of morphology and lactase and sucrase-isomaltase gene expression were very similar between samples obtained in the proximal and distal biopsies. CONCLUSIONS Biopsies performed in either location in the duodenum are equally suitable for diagnostic workup of patients suspected of mucosal abnormalities affecting morphology or small intestinal brush border glycohydrolase activities.
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Affiliation(s)
- E H Van Beers
- Department of Pediatrics, Academic Medical Center, University of Amsterdam, Emma's Childrens Hospital AMC, The Netherlands
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Rawashdeh MO, Abu-Farsakh N, al-Jaberi TM. Paediatric upper gastro-intestinal endoscopy in developing countries. ANNALS OF TROPICAL PAEDIATRICS 1996; 16:341-6. [PMID: 8985532 DOI: 10.1080/02724936.1996.11747847] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A retrospective study of 200 endoscopies performed on 168 children (90 girls and 78 boys) aged 3 months to 18 years (median 6 years) is reported. All procedures were completed successfully in an adult endoscopy unit in a comprehensive health centre. Most children of less than 6 months and above 12 years of age needed no intravenous sedation. One child developed respiratory depression and was successfully resuscitated. Indications for endoscopy were: small intestinal biopsy, 78 (46%); recurrent abdominal pain, 40 (24%); acute epigastric pain, 13 (8%); persistent vomiting, 12 (7%); haemorrhage, 10 (6%); caustic substance ingestion, six (4%); and dysphagia, four (2%) children. Positive diagnoses were obtained in 123 (62%) procedures. Coeliac disease (26 cases) was the most common histological diagnosis, followed by gastritis (19 cases), oesophagitis (18 cases), duodenitis (16 cases), duodenal ulcer (11 cases), hiatus hernia (six cases), gastric ulcer (three cases) and oesophageal stricture (two cases). Where specialized paediatric endoscopy units are not feasible, e.g. in developing countries, endoscopic services for children can be safely provided by paediatric endoscopists as part of an adult endoscopy service, provided that suitable resuscitation equipment is available and the necessary modifications to meet the medical and psychological needs of children and their parents are taken into consideration.
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Affiliation(s)
- M O Rawashdeh
- Department of Paediatrics, Faculty of Medicine, University of Science and Technology, Irbid, Jordan
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Bernstein DE, Barkin JS, Reiner DK, Lubin J, Phillips RS, Grauer L. Standard biopsy forceps versus large-capacity forceps with and without needle. Gastrointest Endosc 1995; 41:573-6. [PMID: 7672551 DOI: 10.1016/s0016-5107(95)70193-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic biopsy forceps vary in size and design. The purpose of this prospective randomized study was to compare the quality and quantity of gastric tissue obtained by needle and non-needle versions of standard biopsy forceps and newly designed large capacity forceps. Fifty consecutive patients who underwent endoscopy with gastric biopsy forceps were enrolled in the study. There was no significant difference in the presence of crush artifact between the two forceps, both with and without the presence of a needle. Both needle and non-needle versions of the large capacity biopsy forceps were found to obtain significantly larger sized specimens (p = 0.02) than needle and non-needle versions of the standard biopsy forceps. Overall, there was no significant difference in the depth of specimen obtained when comparing the large capacity forceps to standard forceps. Needle versions of each forceps were found to obtain significantly deeper biopsies than non-needle versions of each forceps. In conclusion, our study found that large capacity forceps obtained larger specimens than standard biopsy forceps. Further clinical trials with a larger study population need to be undertaken to determine the impact of these findings on the determination of diagnoses.
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Affiliation(s)
- D E Bernstein
- University of Miami, School of Medicine/Mt. Sinai Medical Center, Division of Gastroenterology, Miami Beach, FL 33140, USA
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Cummins A, Chu G, Faust L, Chandy G, Argyrides J, Robb T, Wilson P. Malabsorption and villous atrophy in patients receiving enteral feeding. JPEN J Parenter Enteral Nutr 1995; 19:193-8. [PMID: 8551646 DOI: 10.1177/0148607195019003193] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The purpose of this study was to assess the structure and function of the small intestine before and after enteral feeding given via a percutaneous feeding gastrostomy (PEG). It is not known whether this method of feeding provides a good luminal drive to the small intestine. METHODS Studies were performed of patients at the time of PEG placement, in a cross-sectional group after a period of feeding and in a smaller longitudinal subgroup. Enteral feeds were adjusted in volume and caloric content for each patient. Duodenal biopsies were taken during endoscopy for quantitative morphometry, and lactulose-rhamnose permeability tests were performed during the next day. Duodenal fluid was cultured quantitatively in the first study, and disaccharidases determined in the second study. RESULTS The first study of 15 patients, who had enteral feeding for a median (range) period of 13 (8 to 104) weeks, showed partial villous atrophy with normal crypt length, no increase in duodenal bacteriology, and abnormal lactulose-rhamnose sugar permeability due to rhamnose malabsorption. These changes were also present in 38 similar patients before enteral feeding. A second study before enteral feeding showed lowered maltase activity (24 patients), and similar intestinal permeability findings (22 patients). Twelve of these patients were followed longitudinally for 3 months of enteral feeding that maintained but did not improve nutrition, as assessed by body mass index and mid-arm muscle circumference, and there was no change in duodenal morphometry (11 patients), rhamnose malabsorption (4 patients), or disaccharidases (11 patients). CONCLUSIONS These studies suggest villous atrophy was not due to an inflammatory enteropathy but resulted from a poor luminal "drive" associated with the enteral feeding. Enteral feeding maintained but did not improve nutrition status.
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Affiliation(s)
- A Cummins
- Gastroenterology Unit, Queen Elizabeth Hospital, Woodville South, South Australia
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Ladas SD, Tsamouri M, Kouvidou C, Raptis SA. Effect of forceps size and mode of orientation on endoscopic small bowel biopsy evaluation. Gastrointest Endosc 1994; 40:51-5. [PMID: 8163135 DOI: 10.1016/s0016-5107(94)70009-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Endoscopy is increasingly being used to obtain duodenal biopsy specimens in suspected small intestinal malabsorption. We have prospectively evaluated the effect of standard and jumbo biopsy forceps, as well as the mode of orientation of the specimens (naked eye or stereomicroscopy), on duodenal biopsy weight, length, depth, and orientation in 18 consecutive patients. A pair of biopsy specimens was obtained from each patient by each type of forceps in random order. After they had been weighed, one biopsy specimen from each pair was oriented stereomicroscopically and all four were blindly evaluated by two pathologists. The biopsy specimens obtained with the jumbo forceps were significantly larger (15.9 +/- 6.9 mg, mean +/- SD) and longer (0.6 +/- 0.2 cm) than those obtained with the standard forceps (8.0 +/- 1.3 mg, 0.4 +/- 0.2 cm, respectively; p < 0.001). Seventy-two percent of the jumbo biopsy specimens that were oriented with stereomicroscopy included a minimum of four villi in a row, as compared to 44% of the eye-oriented jumbo specimens and less than 39% of the standard specimens, irrespective of the mode of orientation (p = 0.02). These results indicate that the jumbo forceps is superior to the standard, because it produces a larger duodenal mucosal specimen, usually suitable for optimal histologic evaluation when oriented with stereomicroscopy.
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Affiliation(s)
- S D Ladas
- Second Department of Internal Medicine-Propaedeutic, University of Athens, Greece
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47
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Affiliation(s)
- J F Morrissey
- Department of Medicine, University of Wisconsin Medical School, Madison 53792
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48
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Wilson IR, Oxner RB, Frampton CM, Tisch G, Chapman BA, Cook HB. Comparison of endoscopic forceps biopsies and capsule biopsies in determining disaccharidase activity in the duodenum. Gastrointest Endosc 1991; 37:527-30. [PMID: 1936829 DOI: 10.1016/s0016-5107(91)70821-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Endoscopic biopsy is an accepted technique for obtaining samples of small bowel mucosa for histological examination. In this study a comparison between endoscopic forceps biopsies and capsule biopsies in estimating disaccharidase enzyme activity in the small bowel was evaluated. Disaccharidase levels on 168 consecutive small bowel biopsies obtained by either endoscopic biopsy or capsule biopsy were reviewed retrospectively. There was no significant difference in enzyme activity in samples collected by either method. Another 18 patients had simultaneous endoscopic and capsule biopsies from the second part of the duodenum. Again, there was no difference in enzyme activity between samples collected by either technique at the same level in the duodenum. The disaccharidase activity in forceps biopsies taken from the second part of the duodenum is equivalent to those obtained by capsule biopsy.
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Affiliation(s)
- I R Wilson
- Department of Gastroenterology, Christchurch Hospital, New Zealand
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Cummins AG, Penttila IA, Labrooy JT, Robb TA, Davidson GP. Recovery of the small intestine in coeliac disease on a gluten-free diet: changes in intestinal permeability, small bowel morphology and T-cell activity. J Gastroenterol Hepatol 1991; 6:53-7. [PMID: 1883978 DOI: 10.1111/j.1440-1746.1991.tb01145.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Intestinal permeability was assessed before and 1, 2, 4, 8 and 12 weeks after commencing a gluten-free diet (GFD) in eight coeliac subjects. Intestinal morphology was quantified in six coeliac subjects on a normal diet, six coeliac subjects on a GFD, and 21 normal subjects. T-cell activity was measured in the eight coeliac subjects by soluble interleukin-2 receptor (sIL-2R) concentration (normal less than 477 U/mL). Intestinal permeability was increased 10-fold with a geometric mean value of 0.72 on a normal diet, and decreased to 0.17 at 4 weeks (P = 0.04), to 0.07 at 8 weeks (P = 0.010), and to 0.20 at 12 weeks (P = 0.015) of a GFD. Two of the eight subjects showed a poor response to gluten withdrawal. Quantitative intestinal morphology showed no significant improvement after 3 to 6 months of a GFD. Mean +/- s.d. sIL-2R concentrations in the eight subjects were increased 5-fold higher than control values at 1400 +/- 530 U/mL on a normal diet and decreased to 750 +/- 200 U/mL after 12 weeks of a GFD (P = 0.004). We conclude that intestinal permeability improves rapidly in the majority of coeliac subjects after commencing a GFD, although some abnormal permeability and increased T-cell activity persists. This may be due to varying degrees of gluten ingestion resulting in continued immune activation.
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Affiliation(s)
- A G Cummins
- Gastroenterology Unit, Queen Elizabeth Hospital, Woodville, SA
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