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Abstract

Internationally, there is increased recognition of undetected adult celiac disease, with duodenal bulb biopsies being an evolving area, potentially helping in establishing a diagnosis (Table 1). We appreciate the comments made by Nenna et al1 and are sorry that we did not comment on their study. Although we agree that controls are incorporated into their study, the specificity of this strategy continues to remain the problem for all of us.Table 1Adult studies of duodenal bulb biopsies in celiac diseaseYearCountrySample sizeControlsVillous atrophy present only in the duodenal bulb2001Austria21212/21 (9.5%)2007United Kingdom56None1/56 (1.8%)2010United States40405/40 (12.5%)2011United Kingdom46125011/126 (8.7%)2012Italy86431/43 (2.3%) Open table in a new tab Accurately assessing specificity involves undertaking the same biopsy strategy on antibody-negative patients, with an unassociated human leukocyte antigen type attending for gastroscopy. Given the low prevalence of histologic findings within the bulb in both our control group and in the authors' study, accurately determining the prevalence of histologic lesions within the duodenal bulb within the normal population would require a large, prospective study to be undertaken. Only then may we accurately determine whether or not our strategy results in a high false-positive detection rate of villous atrophy unrelated to celiac disease.We agree with the authors that taking two bulbar biopsies has 100% sensitivity; however, our findings were derived from a small sample size, and we believe that findings need to be replicated in other cohorts. Nevertheless, it is reassuring that the authors' findings, like ours, demonstrate the merits of taking a duodenal bulb biopsy, and we concur with them that this should be reflected in diagnostic guidelines for celiac disease. Internationally, there is increased recognition of undetected adult celiac disease, with duodenal bulb biopsies being an evolving area, potentially helping in establishing a diagnosis (Table 1). We appreciate the comments made by Nenna et al1 and are sorry that we did not comment on their study. Although we agree that controls are incorporated into their study, the specificity of this strategy continues to remain the problem for all of us. Accurately assessing specificity involves undertaking the same biopsy strategy on antibody-negative patients, with an unassociated human leukocyte antigen type attending for gastroscopy. Given the low prevalence of histologic findings within the bulb in both our control group and in the authors' study, accurately determining the prevalence of histologic lesions within the duodenal bulb within the normal population would require a large, prospective study to be undertaken. Only then may we accurately determine whether or not our strategy results in a high false-positive detection rate of villous atrophy unrelated to celiac disease. We agree with the authors that taking two bulbar biopsies has 100% sensitivity; however, our findings were derived from a small sample size, and we believe that findings need to be replicated in other cohorts. Nevertheless, it is reassuring that the authors' findings, like ours, demonstrate the merits of taking a duodenal bulb biopsy, and we concur with them that this should be reflected in diagnostic guidelines for celiac disease. Duodenal bulb for diagnosing adult celiac disease: much more than an optimal biopsy siteGastrointestinal EndoscopyVol. 76Issue 5PreviewWe read with interest the article by Kurien et al1 about the importance of duodenal bulb biopsies in adult patients with celiac disease (CD). The study demonstrates that a targeted duodenal bulb biopsy in addition to distal duodenal biopsies may improve diagnostic yields. It also appears evident that bulb biopsies need to be included in the guidelines for CD diagnosis. Full-Text PDF