Abstract
Although studies of adults with celiac disease (CD) have shown that mucosal histopathological changes may be patchy and variable in severity, limited data exist regarding children. We aimed to assess the prevalence of variable biopsy findings in a cohort of children with CD, and its association with clinical parameters (demographics, 14 symptoms, and 3 associated diseases). 201 consecutive cases of CD diagnosed at Children's Hospital during a 5-year period (2001-5) were analyzed. The diagnosis of CD required a consistent biopsy and either 1. positive serology (endomysial antibody and/or tissue transglutaminase antibody) or 2. clinical response to a gluten-free diet. All biopsies were reviewed by a single pathologist blinded to the clinical data, and scored by Marsh criteria. Mucosal changes were classified as focal if changes consistent with CD and normal mucosa were found within a single biopsy specimen. Patchiness was defined as variation of at least one Marsh grade between separate fragments in a biopsy set. The mean age of the patients was 9.3 ± 5.2 years, 62% were female, and 22% had Type 1 diabetes. An average of 3.6 (2-7) biopsies were obtained per case. In 101 cases, biopsies were obtained from the duodenal bulb in addition to the second portion. 198 cases were graded Marsh 3, and 3 were Marsh 1. Focality was present in biopsies from 39 (19%) cases. Patchiness was found in 105 (52%) cases and at least one normal biopsy was present in 72 (36%). In 8 cases, only the bulb biopsies were consistent with CD. There was no association between patchiness and any of the clinical features examined. In conclusion, duodenal involvement by CD in children is frequently patchy and may even show variable severity within a single biopsy fragment. Such variability could not be predicted on the basis of clinical characteristics. We recommend that multiple endoscopic biopsies be performed on children with suspected CD and that all areas of each biopsy be carefully examined. Furthermore, biopsies of the bulb should be obtained in all cases.
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