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M Rashid, A MacDonald

Dalhousie University, Division of Gastroenterology, Department of Paediatrics, Halifax, Nova Scotia
Small intestinal biopsies are essential to confirm the diagnosis of celiac disease. The patchy nature of villous lesion in celiac disease is increasingly being recognized. The current guidelines (AGA 2006, NASPGHAN 2005) recommend at least four duodenal mucosal biopsies taken from the second or more distal part of the duodenum for histological examination. Multiple biopsies are needed to limit problems with orientation of the specimens and artifact during staining.
The objective of the study was to investigate the usefulness of duodenal bulb mucosal biopsies in confirming the diagnosis of celiac disease.
Methods: All patients with a positive tissue-transglutaminase antibody requiring biopsy-confirmation of celiac disease over a two-year period were studied. Each patient had two endoscopic biopsies taken from the duodenal bulb and four biopsies from the second (or distal) part of the duodenum. Biopsies from gastric antrum were also taken for any Helicobacter pylori infection. The duodenal histology was studied using routine HandE stain and CD3 staining and counting of villous intraepithelial lymphocytes.
Results: Thirty-five patients (14 males, 21 females) were studied. The mean age was 8.1 (± 4.7 ) years, range 1.3 to 18.7 years. Of the 31 patients with abnormal distal duodenal biopsies, one had Marsh 1, one had Marsh 2 and twenty-nine had Marsh 3 lesion. All but two patients with abnormal distal duodenal biopsies also had abnormal bulb biopsies.
Four (11.4%) patients had normal distal duodenal biopsies (Marsh 0) but abnormal bulb biopsies (one patient had Marsh 2 and the other three had Marsh 3 lesion). Grossly, the duodenal bulb was completely normal in one patient, the other three had mild changes with patchy eythema, nodularity and friability with mosaic pattern respectively. The distal duodenum was grossly normal in these four patients. None had Helicobacter pylori infection. The histological diagnosis of celiac disease would have been missed in these four cases if only distal duodenal biopsies were performed.
Conclusions: Patients with celiac disease can have patchy villous lesions with duodenal bulb mucosa being the only area involved in some cases. The current recommendations regarding the site of biopsies need to be revised to include biopsies not only from distal duodenum but also from the bulb to improve the diagnostic yield.