Importance of duodenal bulb biopsies in children for diagnosis of celiac disease in clinical practice

Abstract

BackgroundThe patchy nature of villous lesion in celiac disease is increasingly being recognized. Current guidelines recommend four endoscopic duodenal mucosal biopsies from the second or more distal part of the duodenum to confirm the diagnosis of celiac disease. The purpose of the study was to investigate the usefulness of duodenal bulb mucosal biopsies in confirming the diagnosis of celiac disease in everyday clinical practice.MethodsAll patients with a positive tissue-transglutaminase antibody requiring biopsy-confirmation of celiac disease over a two-year period were studied. Two endoscopic biopsies were taken from the duodenal bulb and four biopsies from the second (or distal) part of the duodenum.ResultsThirty-five patients were included, mean age 8.1 (± 4.7) years. Thirty-one (88.6%) patients had abnormal distal duodenal biopsies, one had Marsh type 1, one had Marsh type 2 and twenty-nine had Marsh type 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 but abnormal bulb biopsies. Of these, one patient had Marsh type 2 and three had Marsh type 3 lesion. The distal duodenum was also grossly normal in these four patients. The histological diagnosis of celiac disease would not have been possible in these four cases with distal duodenal biopsies only.ConclusionThe lesion in celiac disease in children can be patchy with duodenal bulb mucosa being the only area showing histological changes. The recommendations regarding the site of biopsies should be revised to include biopsies not only from distal duodenum but also from bulb to improve the diagnostic yield.

Duodenal bulb biopsies for diagnosing adult celiac disease: is there an optimal biopsy site?

“…However, recent studies demonstrated that macroscopic changes in celiac disease do occur in the duodenal bulb and in some patients (1.8%-14%) may be the only site of villous atrophy. [13][14][15][16][17][18][19][20] These findings support our group's previous work in which patchy villous atrophy was identified within the duodenum in patients with glutensensitive enteropathy. 20 The rationale in taking duodenal bulb biopsy specimens could be substantiated by a conventional understanding that villous atrophy is most severe proximally where the gluten load is greatest.…”

Narrow band imaging combined with water immersion technique in the diagnosis of celiac disease

“…CD histological damage is often patchy, with some areas of the mucosa not involved at all [15][16][17]. Despite the ESPGHAN guidelines recommendations of taking at least 4 biopsies from the second/third portion of the duodenum and one from the duodenal bulb, this issue remains challenging for both paediatric and adult gastroenterologists.…”

Correlation of Endoscopic and Histological Features in Adults With Suspected Celiac Disease in a Referral Center of Minas Gerais, Brazil

“…First, biopsies must be multiple, preferably between four to six, and at least one from the duodenal bulb by the possibility of irregular involvement of the mucosa, sometimes with histological changes restricted to this region. In clinical practice, biopsies taken in conjunction with the second and/or third portions of the duodenum would have the potential to confirm the histological diagnosis in all cases of CD (3,27) . Technical care is essential in obtaining adequate samples for histological evaluation.…”