The Utility of Routine Endoscopic Distal Duodenal Biopsy in Patients with Irritable Bowel Syndrome for Celiac Disease Diagnosis; First Study from Nepal

Mohan Khadka

doi:10.12691/ijcd-6-1-4

Abstract

Aim: To investigate the utility of routine endoscopic distal duodenal biopsy in patients with Irritable Bowel Syndrome (IBS) for the diagnosis of Celiac Disease (CD). Method: This study was conducted at the outpatient Department of Gastroenterology at the Institute of Medicine, Tribhuvan University, Kathmandu, Nepal. One hundred patients with IBS selected by Rome III Criteria were prospectively evaluated from April 2015 through March 2016. Esophagogastroduodenoscopy (EGD) was performed on all patients, with four-quadrant distal duodenal biopsies obtained from each patient. The biopsy sections were studied for Marsh-type histology, a histology characteristic of CD. Patients with Marsh-type histology had Immunoglobulin-A anti-tissue transglutaminase (IgA anti tTG) serology ordered, were recommended to start a gluten-free diet (GFD), and were followed up in clinic in 3-6 weeks. The prevalence of CD (defined as Marsh histology grade I-III with serology positive responding to GFD) was calculated in patients with IBS as a whole and among IBS subtypes. Statistical analysis was done using SPSS version 19 software (Chicago, IL, USA). Results: Of the 100 IBS patients evaluated, 50 patients had abnormal duodenal histology. Among these 50 patients, 13 had Marsh-type histology, and the remaining 37 had non-specific duodenitis. Of the 13 patients with Marsh-type histology, 4 were seropositive for CD and 9 were seronegative. The overall prevalence of CD was 4%. All 4 seropositive and 2 out of 9 seronegative patients responded to GFD in 3 to 6 weeks. Conclusion: Routine endoscopic distal duodenal biopsy is useful for the diagnosis of CD in patients with IBS as it could also detect the disease in patients with negative celiac serology.

Highlights

Irritable bowel syndrome (IBS), as defined by the Rome III criteria, is recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months which is associated with two or more of the followings: improvement with defecation; onset associated with a change in frequency of stool and onset associated with a change in form or appearance of stool and the criteria are fulfilled with symptoms onset 6 months prior to diagnosis [1]
Two decision-analytic models have evaluated the cost-effectiveness of Celiac Disease (CD) evaluation with serology followed by histology in seropositive cases and have concluded that it is beneficial if the prevalence of CD in the general population is greater than 1% [18]
The duration of IBS symptoms ranged from 6 months to 10 years, with median of 12 months

Summary

Introduction

Irritable bowel syndrome (IBS), as defined by the Rome III criteria, is recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months which is associated with two or more of the followings: improvement with defecation; onset associated with a change in frequency of stool and onset associated with a change in form or appearance of stool and the criteria are fulfilled with symptoms onset 6 months prior to diagnosis [1]. Two decision-analytic models have evaluated the cost-effectiveness of CD evaluation with serology followed by histology in seropositive cases and have concluded that it is beneficial if the prevalence of CD in the general population is greater than 1% [18]. Based on this evidence, the American College of Gastroenterology recommends routine serologic screening for CD in subjects with IBS with diarrhea (IBS-D) and mixed IBS (IBS-M) (Grade 1B Recommendation) [19]. The diagnosis of CD may be suspected on clinical grounds or as a result of abnormal serologic tests, biopsy of the small intestine has remained the gold standard test to establish the diagnosis [21]

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