A prospective study to evaluate the role of duodenal bulb biopsy in the diagnosis of celiac disease
- 69 Downloads
Celiac disease (CeD) requires a biopsy from the small intestine to confirm the diagnosis. Conventionally, duodenal bulb (D1) was avoided as a biopsy site due to histological confounding factors at this site. However, sometimes, the bulb mucosa is the only affected site. The aim of the present study was to assess changes in duodenal bulb histology and compare it to distal duodenal histology and to analyze whether the addition of duodenal bulb biopsy increases the diagnostic yield of the CeD.
It was a prospective study comprising of 98 patients of CeD who were symptomatic clinically and had positive anti tissue transglutaminase (tTG) antibody. Endoscopically four mucosal biopsies were taken, two each from the bulb and distal duodenum, and morphology was graded as per modified Marsh grade.
Iron deficiency anemia (40%) was a most common clinical presentation followed by chronic diarrhea (30%). Sixty patients showed same Marsh grade and 38 showed different Marsh grade at both sites. Patients who were showing the difference in the Marsh grade at the two biopsy sites, in place of; descending duodenum showed higher grade in 24 patients while higher mucosal atrophy was documented in the bulb in 14 patients. No patient of CeD had isolated D1 involvement. In eight patients, the correct diagnosis of CeD could be made only because of bulb biopsy.
Majority of the patients had no classical symptoms. Different Marsh grade at the two biopsy sites was documented demonstrating the patchy distribution of CeD. Combining biopsy from both bulb and descending duodenum maximizes the diagnostic yield of the CeD.
KeywordsCeliac disease Duodenal bulb biopsy Marsh grade
Compliance with ethical standards
Conflict of interest
BSD, GKG, SJW, NS, and SN declare that they have no conflict of interest.
The authors declare that the study was performed in a manner conforming to the Helsinki declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and the authors followed the policy concerning informed consent as shown on Springer.com.
- 2.Ludvigsson JF, Rubio-Tapia A, van Dyke CT, et al. Increasing incidence of celiac disease in a North American population. Am J Gastroenterol. 2013;108:818–24.Google Scholar
- 4.Sanders DS, Patel D, Stephenson TJ, et al. A primary care cross-sectional study of undiagnosed adult coeliac disease. Eur J Gastroenterol Hepatol. 2003;15:407–13.Google Scholar
- 14.Mooney PD, Kurien M, Evans KE, et al. Clinical and immunologic features of ultra-short celiac disease. Gastroenterology. 2016;150:1125–34.Google Scholar
- 18.Farrell RJ, Kelly CP. Celiac disease and refractory celiac disease. In: Feldman M, Freidman LS, Brandt LJ. Ed. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, Philadelphia, Saunders Elsevier, 2010; pp1797–820. 9th Edition.Google Scholar
- 19.Mohindra S, Yachha SK, Srivastava A, et al. Coeliac disease in Indian children: assessment of clinical, nutritional and pathologic characteristics. J Health Popul Nutr. 2001;19:204–8.Google Scholar
- 27.Mangiavillano B, Masci E, Parma B, et al. Bulb biopsy for the diagnosis of celiac disease in paediatric patients. Gastrointest Endosc. 2010;72:564–8.Google Scholar
- 28.Levinson-Castiel R, Hartman C, Morgenstern S, et al. Role of duodenal bulb biopsy in the diagnosis of celiac disease in children. J Clin Gastroenterol. 2011;45:26–9.Google Scholar
- 29.Bonamico M, Thanasi E, Mariani P,et al. Duodenal bulb biopsies in celiac disease: a multicenter study. J Pediatr Gastroenterol Nutr. 2008;47:618–22.Google Scholar