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The proposed technique could be a simple, safe, and inexpensive method for easier and less painful colonoscopy; moreover, it might facilitate difficult examinations. Further studies are needed to confirm our data and to ensure that the use of this technique is not liable to damage the scope.

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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We read with interest the article by Tursi et al. [1], dealing with the relationships between the endoscopic signs of celiac disease, histological damage, age of the patients, and the clinical form of the disease. Their conclusions stated that the endoscopic appearance of the duodenum may be predictive of the grade of histological damage, and that in young patients with subclinical or silent celiac disease, there is a greater probability of finding milder endoscopic abnormalities associated with milder histological damage. We agree in part with these conclusions; other authors have suggested that the presence of endoscopic signs in celiac disease increases as villous atrophy becomes more evident [2,3] and that in childhood, some endoscopic signs are more frequent than others [4,5]. However, in our opinion simpler and more useful data can be drawn from the results obtained by the authors, taking into account the distribution of the normal endoscopic appearance of the duodenum among Marsh histological classes (Table 1 in [1]), age groups (Table 2 in [1]), and clinical forms of the disease (Table 3 in [1]).As the authors' Table 1 shows, a normal endoscopic appearance in the duodenum was principally found in Marsh class II (13 of 38 patients, 34 %), less frequently in type IIIa (six of 46 patients, 13 %), and never in type IIIb or IIIc: thus, the sensitivity of all the endoscopic signs in the 144 adult patients with celiac disease was 66 % in Marsh class II, 87 % in type IIIa, and 100 % in types IIIb and IIIc, increasing as histological damage became more evident.In the authors' Table 2, a normal endoscopic appearance of the duodenum was reported in six of 38 patients aged 15 -30 (16 %), in eight of 38 patients aged 30 -45 (21 %), in three of 35 patients aged 45 -60 (9 %), and in two of 33 patients aged over 60 (6 %). The sensitivity of the endoscopic signs was thus 86 %, 79 %, 91 %, and 94 % for these groups, respectively, with an upward trend as the age of patients increased.In Table 3, a normal endoscopic appearance of the duodenum was found in 10 of 28 patients (36 %) with the silent form of celiac disease, in eight of 64 patients (13 %) with the subclinical form, and in one of 52 patients (2 %) with the classical clinical form, showing an increasing sensitivity of the endoscopic signs (64 %, 87 % and 98 %, respectively) when passing from the silent, to the subclinical, and to the classical forms of celiac disease.In our opinion, this could be an additional way of presenting the results of the study -highlighting the ability of all the endoscopic signs to suggest the diagnosis of celiac disease when passing from slight to severe histological damage, from younger to older patients, and from the silent to the subclinical or classical forms of celiac disease. In fact, it is of minor clinical relevance whether any single endoscopic sign is associated with milder or severe histological damage, with younger or older patients, or with different clinical forms. In our view, the true clinical impact of the endoscopic sign...