Endoscopy and small-bowel biopsy in celiac disease: indications and implications

There is a need to clarify some issues with regard to the indications for endoscopy in the follow-up of patients with celiac disease [1]. To start with, we are not performing routine endoscopy in order to assess or monitor histological recovery in celiac disease. This practice is out of date and it belongs firmly in the last millenium. In 2001 we agreed that further endoscopies are not necessary in patients who show clinical improvement and who respond to a gluten-free diet [2] [3]. Endoscopy is indicated only when a patient is not doing well on a gluten-free diet or in patients who deteriorate despite treatment.

If we look at the indications for endoscopy in unresponsive cases, biopsy is unavoidable in these individuals in order to rule out complications. Endoscopic images might be helpful but are certainly not enough and in some cases are not reliable; performing a biopsy is the most effective and specific way of assessing disease and to stratify the prognosis.

Previous studies show disappointing results for the sensitivity of endoscopy in patients with partial villous atrophy (Marsh IIIc) [4] and we know that presentation with milder mucosal abnormality is very common in patients with celiac disease.

Generally speaking, we should balance any potential (as yet unproved) benefits with the risk of morbidity from invasive follow-up procedures. It would be more desirable to avoid endoscopy completely if possible. We might argue that endoscopy could be avoided in the small subgroup of patients who have classic symptoms and positive serology, but we still find that taking a biopsy seems inevitable in the majority of cases. The central issue is that we are dealing with a condition that commonly presents ”in disguise“ with nonspecific symptoms and signs [5] and that recognizing it can be a real challenge!

References

• 1 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
• 2 United European Gastroenterology . When is a coeliac a coeliac? Report of a working group of the United European Gastroenterology Week in Amsterdam, 2001.  Eur J Gastroenterol Hepatol. 2001;  13 1123-1128
• 3 Rostami K, Mulder CJ et al. Sensitivity of antiendomysium and antiglindin antibodies in untreated celiac disease: disappointing in clinical practice.  Am J Gastroenterol. 1999;  94 888-94
• 4 Dickey W. Endoscopic markers for celiac disease.  Nat Clin Pract Gastroenterol Hepatol. 2006;  3 546-551
• 5 Rostami K. From microenteropathy to villous atrophy: what is treatable?.  Dig Liver Dis. 2003;  35 758-759