Celiac disease is not yet mainstream in endoscopy

Since the early 1990s clinicians have been realizing more and more that the so-called ”typical” picture of celiac disease, i. e., as a diarrheal illness with frequent, foul-smelling bulky stools and weight loss, is in fact the exception [1].

Celiac disease is the most frequent enteropathy in white people all over the world. It is characterized by intolerance to gluten, which causes damage to the small bowel mucosa. Such damage ranges from mild, with only an increase in intraepithelial lymphocytes and crypt hyperplasia, to severe, which involves various degrees of endoscopically relevant lesions such as villous atrophy. Although macroscopic villous atrophy requires histological confirmation, it is an important finding that ideally should be recognized during endoscopy. Other causes of villous atrophy, such as giardiasis, autoimmune enteropathy, HIV infection, and tropical sprue, should be excluded.

The role of conventional endoscopy in the diagnosis of celiac disease has been limited. Although traditional endoscopic signs have been described, these are not sensitive or specific enough for diagnostic purposes [2] [3]. Indeed, so far endoscopic markers are not adequate to enable targeting of biopsy sampling to sites of villous atrophy in the duodenum.

Immersion techniques might also be considered as a follow-up in celiac disease, without taking biopsies [4]. Since 2001, video capsule endoscopy (VCE) has offered an alternative to duodenal biopsies in patients unable or unwilling to undergo conventional gastrointestinal endoscopy. In addition, VCE can be used to further evaluate patients with symptoms suggesting celiac disease who have positive serology (especially endomysial antibodies) but negative histology [5].

Celiac disease should be included in the differential diagnosis of patients with peptic ulcer disease in the stomach and duodenum that is not related to Helicobacter pylori. It has recently been suggested that routine celiac disease serological tests and small-bowel biopsy should be performed in patients with peptic ulcer disease in which neither H. pylori nor nonsteroidal anti-inflammatory drugs are involved [6].

In the past few years, newly developed procedures and technologies have improved endoscopic recognition of the duodenum. These technologies include water immersion techniques, chromoendoscopy, high resolution magnification endoscopy, narrow band imaging, and optimal band imaging [7].

References

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• 3 Shah V H, Rotterdam H, Kotler D P. et al . All that scallops is not celiac disease.  Gastrointest Endosc. 2000;  51 717-720
• 4 Cammarota G, Cuoco L, Cesaro P. et al . A highly accurate method for monitoring histological recovery in patients with celiac disease on a gluten-free diet using an endoscopic approach that avoids the need for biopsy: a double-center study.  Endoscopy. 2007;  39 46-51
• 5 Rondonotti E, Spada C, Cave D. et al . Video capsule enteroscopy in the diagnosis of celiac disease: a multicenter study.  Am J Gastroenterol. 2007;  102 1624-1631
• 6 Levine A, Domanov S, Sukhotnik I, Zangen T, Shaoul R. Celiac-associated peptic disease at upper endoscopy: How common is it?.  Scand J Gastroenterol. 2009;  44 1424-1428
• 7 Banerjee R, Reddy D N. High-resolution narrow-band imaging can identify patchy atrophy in celiac disease: targeted biopsy can increase diagnostic field.  Gastrointest Endosc. 2009;  69 984-985
• 8 Gupta R, Reddy D N, Makharia G K. et al . Indian Task Force for Celiac Disease: current status.  World J Gastroenterol. 2009;  15 6028-6033
• 9 Günther U, Daum S, Heller F. et al . Diagnostic value of confocal endomicroscopy in celiac disease.  Endoscopy. 2010;  42 197-202
• 10 Verbeek W H, von Blomberg B M, Scholten P E. et al . The presence of small intestinal intraepithelial gamma/delta T-lymphocytes is inversely correlated with lymphoma development in refractory celiac disease.  Am J Gastroenterol. 2008;  103 3152
• 11 Matysiak-Budnik T, Coron E, Mosnier J-F. et al . In vivo real time imaging of human duodenal mucosal structures in celiac disease using endocytoscopy.  Endoscopy. 2010;  42 191-196