Utility of Capsule Enteroscopy in Symptomatic Patients with Celiac Disease

Abstract

Celiac Disease (CD) is associated with proximal small bowel injury. A substantial number of cases with celiac disease will present with persistent or recurrent symptoms despite a gluten-free diet. Aim: To examine the utility of capsule enteroscopy in symptomatic treated celiac disease. Methods: A retrospective, case-control study comparing 47 cases who presented with continued or recurring symptoms of previously biopsy-proven celiac disease with 94 age/sex-matched controls. The controls had undergone capsule enteroscopy for other indications and had celiac disease ruled out by small bowel biopsy. Blinded interpretation of de-identified capsule studies was undertaken in a standardized fashion. Correlation with histologic, serologic, clinical findings was undertaken. Results: An atrophic appearance on capsule was strongly associated with celiac disease as compared to controls with 15/47 cases having atrophy apparent on capsule endoscopy, (p < 0.0001). Erosions or ulcers were identified in 17% of celiac cases and 19% of controls. This difference was not significant. There was a trend for an association between NSAID use (N = 8) and the presence of erosions (p = 0.06). There was no difference in the rate of failure to reach the colon. Small bowel transit time was somewhat slower in the celiac cases (4.4 hours in celiac cases vs. 3.8 hours in controls, p = 0.048). Celiac disease cases who had atrophy on biopsies were more likely to have atrophy identified by capsule. However, only 9/17 cases with histologic atrophy had atrophy visible on capsule. Interestingly, 4 celiac cases had atrophy apparent on capsule that was not evident on biopsy. One control had capsule atrophy but had a completely normal small bowel biopsy (specificity = 98.9%). Lymphoma was detected in one celiac case. Conclusions: Capsule endoscopy cannot replace but may complement endoscopic biopsies in the setting of symptomatically-treated celiac disease. Erosions are as frequent in celiac disease as they are in non-celiac disease controls.