High definition i-SCAN endoscopy with water immersion technique accurately reflects histological severity of celiac disease

Role of endoscopy in the diagnosis of coeliac disease: a narrative review

Background and Objective

Coeliac disease (CD) is a common autoimmune disorder triggered by gluten consumption in genetically predisposed individuals. CD is characterised by chronic inflammation in the small bowel mucosa with an influx of lymphocytes, followed by crypt hyperplasia and villous atrophy. The gold standard test to diagnose CD is endoscopy with duodenal biopsies. However, variations in practice between endoscopists can lead to missed diagnoses. This review aims to discuss the role of endoscopy in the diagnosis of CD, highlighting the performance measures of endoscopy in CD and the advancement in endoscopic techniques for the optical diagnosis of villous atrophy.

Methods

We searched PubMed and Google Scholar from their inception to December 2023 for relevant articles on the role of endoscopy in CD. Two authors reviewed these references, and relevant studies were included in the discussion section of this review.

Key Content and Findings

We provide an up-to-date assessment of the diagnostic accuracy of endoscopic markers of CD and the performance of enhanced endoscopic imaging to identify villous atrophy during endoscopy. We propose a set of benchmarks for endoscopy in CD and discuss the potential role of artificial intelligence (AI) in the endoscopic diagnosis of CD.

Conclusions

Performing high-quality endoscopy and identifying strategies to reduce inter-endoscopist variations may reduce missed diagnoses. Adopting advanced endoscopic techniques and embracing new technologies such as AI could enhance diagnostic accuracy and improve patient care.

Capsule endoscopy for patients with coeliac disease

Coeliac disease is an autoimmune mediated condition in response to gluten. A combination of innate and adaptive immune responses results in villous shortening in the small bowel (SB) that can be morphologically picked up on capsule endoscopy. It is the only imaging modality that can provide mucosal views of the entire SB, while histology is generally limited to the proximal SB. Radiological modalities are not designed to pick up changes in villous morphology. Areas covered: In this review, we provide a comprehensive analysis on the justified use of small bowel capsule endoscopy (SBCE) in the assessment of patients with coeliac disease; compare SBCE to histology, serology, and symptomatology; and provide an overview on automated quantitative analysis for the detection of coeliac disease. We also provide insight into future work on SBCE in relation to coeliac disease. Expert commentary: SBCE has opened up new avenues for the diagnosis and monitoring of patients with coeliac disease. However, larger studies with new and established coeliac disease patients and with greater emphasis on morphological features on SBCE are required to better define the role of SBCE in the setting of coeliac disease.