Duodenal Bulb Biopsy Research Articles

PTU-159 Comparison of three commercially available point of care tests for coeliac disease: Abstract PTU-159 Table 1

<h3>Introduction</h3> Coeliac disease (CD) remains underdiagnosed. A rapid point of care test (POCT) may increase uptake of serological testing in appropriate patient groups. 3 POCTs are commercially available in the UK and in continental European pharmacy outlets: Biocard an IgA tissue tranglutaminase (tTG) test (BHR pharmaceuticals); Celiac Quick Test (Biohit Healthcare) detecting IgA, IgG and IgM tTG and Simtomax (Tillotts Pharma) which detects IgA and IgG antibodies against deamidated gliadin peptides (DGP). A fourth POCT has also been developed but not marketed (Xeliac Test Pro, Personal Diagnostics), with availability being solely from the manufacturer and no published data existing supporting its validity. Of the 3 commercially available POCTs, there is a limited evidence base with significant ascertainment bias. For this reason we decided to compare 3 commercially available tests in an endoscopic setting. <h3>Method</h3> Patients referred with a positive endomysial antibody (EMA) for duodenal biopsy to confirm CD were recruited. All patients had repeat serum EMA, tTG and immunoglobulins and were tested simultaneously with the 3 POCTs as per the manufacturers’ instructions. All patients had quadrantic duodenal biopsies from the second part of the duodenum as well as a duodenal bulb biopsy. Demonstration of villous atrophy (VA) was required to diagnose CD. <h3>Results</h3> 82 patients (51.2% female, mean age 41.0) have been recruited. In 10 patients the EMA had normalised on repeat testing. None of these patients had VA on duodenal biopsy. 9 of these patients were referred with a weak EMA and had a negative tTG. One patient had a tTG of 10 times the upper limit of normal, and subsequent gluten challenge revealed a positive EMA and VA. Of the remaining 72 patients 59 new cases of CD were confirmed with the presence of villous atrophy, of the 13 EMA positive patients without VA 8 had Marsh 1 or 2 changes present with the remaining 5 patients having normal histology. Full sensitivity, specificity PPV and NPV for all of the tests compared to VA on duodenal biopsy are shown in Table 1. <h3>Conclusion</h3> In this pilot data set Simtomax appears to be the most sensitive of the POCTs when compared to histology with similar results to serum tTG as screening test. Further work is required in larger cohorts and lower prevalence populations to confirm the utility of these tests in adult CD. <h3>Disclosure of interest</h3> P. Mooney: None Declared, S. Wong: None Declared, M. Burden: None Declared, M. Kurien: None Declared, M. Hadjivassiliou: None Declared, D. Sanders Grant/ Research Support from: BHR pharmaceuticals; Tillotts Pharma for investigator led studies.

PTH-252 Investigation of iron deficiency anaemia. duodenal biopsies – are they worth it?

<h3>Introduction</h3> The prevalence of iron deficiency anaemia (IDA) in adult men and postmenopausal women in the developed world is 2–5%.¹British Society of Gastroenterology (BSG) IDA Guidelines recommend tissue transglutaminase (tTG) antibody as a screening test for coeliac disease. Indications for duodenal biopsies include patients with diarrhoea, weight loss and positive tTG serology. Where coeliac serology is positive, duodenal bulb and D2 biopsies should be taken.²BSG IDA Guidelines do not recommend duodenal biopsy for tTG negative, asymptomatic patients.³However a separate BSG guideline for diagnosis of coeliac disease recommends duodenal biopsies in IDA patients irrespective of Coeliac serology due to the finding of seronegative coeliac disease.² <h3>Method</h3> This audit was carried out to assess adherence to BSG IDA Guidelines for duodenal biopsies in patients referred for IDA investigation with negative tTG antibodies. The study also set out to establish the positive diagnostic yield where biopsies were taken in the same cohort. Patients referred to Newcastle upon Tyne NHSFT adult IDA service between 2011 and 2014 identified as ttG negative and who underwent endoscopy were included. <h3>Results</h3> Two hundred patients were identified, median age 66 (range 19–91); 126 (63%) female and 74 (37%) Male. 114 (57%) patients had duodenal biopsies taken despite tTG being negative and asymptomatic. 28 (19.7%) patients were symptomatic and duodenal biopsies taken, though only 8 (28%) of these patients had 4 biopsy samples and none were from duodenal bulb. Where biopsies were taken, none confirmed coeliac disease. 5/142 (3.5%) patients biopsied had lymphocytic duodenitis but none of them were subsequently diagnosed or treated as coeliac disease. <h3>Conclusion</h3> Duodenal sampling in tTG negative patients did not yield any additional positive diagnosis of coeliac disease. This confirms the recommendations of BSG IDA guidelines. The results of this audit do not appear to support the recommendations made within the BSG coeliac disease guideline for duodenal biopsy being performed regardless of coeliac serology. However, the fact that only 4.9% of patients who had duodenal biopsies taken had duodenal bulb sampled, may limit this conclusion. More efficient use of local endsoscopy and pathology resources can occur by appropriate selection of patients on whom to perform duodenal biopsies. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Guralnik JM, Eisenstaedt RS, Ferrucci L, <i>et al</i>. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anaemia. Blood 2004;<b>104</b>:2263e8 Diagnosis and management of adult coeliac disease: Guidelines from British Society of Gastroenterology June10, 2014(10.1136/gutjnl-2013-306578) BSG Guidelines for the management of Iron deficiency anaemia May 2011

PTU-157 The clinical and phenotypic assessment of ultra-short coeliac disease

Introduction Data suggests that an additional duodenal bulb (D1) biopsy may increase the diagnostic yield for coeliac disease (CD) by up to 10%. However no consensus exists on necessity of D1 biopsy. One reason may be that it is not clear if these patients with Ultra-Short Coeliac Disease (USCD) have the same phenotype or are at risk of the same consequences as conventional CD. We aimed to assess the clinical phenotypes of patients with USCD compared to those with conventional disease. Method All patients attending a specialist CD endoscopy list were invited to take part. All patients had duodenal biopsy taken as routine. Patients had standard quadrantic biopsies taken from the second part of the duodenum (D2) and at least one biopsy taken from D1. Biopsies were analysed separately according to the Marsh classification system. Marsh 3 disease was required to diagnose CD. Patients had concurrent tissue tranglutaminase (tTG) and endomysial antibodies (EMA) and total IgA. All patients with VA were followed up in the CD specialist clinic where routine haematology, biochemistry, HLA typing and DXA scans were requested. Presenting symptoms and immunology were compared for all presentations. Haematology and biochemistry results were compared to a control group of patients that had CD excluded with normal serology and histology. Results 1378 new presentations (62% female; mean age 50.3) underwent duodenal biopsy. 268 (19.4%) new diagnoses of CD were made (66% female; mean age 41.6). CD patients were significantly younger than controls (p P 0.0001). Decision tree analysis to identify USCD showed the absence of diarrhoea was the single discriminating factor (Adj P = 0.018). Rates of osteoporosis (p = 0.78) and anaemia (p = 0.14) were equal. Ferritin deficiency ( P = 0.007) and folate deficiency ( P = 0.003) rates were higher in conventional CD than USCD and controls. On multivariate analysis, patients with USCD were younger than those with conventional CD 36.6 vs. 42.1 (AOR 0.97 (0.94–0.998) P = 0.03), had lower tTG titres (AOR 0.89 (0.81–0.98) P = 0.02) and had higher folate levels (AOR 1.17 (1.01–1.36) P = 0.03) compared to conventional disease. Conclusion USCD appears to represent early disease with younger age and lower tTG titres and may represent a milder form of CD with lower rates of diarrhoea and folate deficiency. Long term follow up of patients with USCD is required to fully assess the clinical impact of diagnosis. Disclosure of interest None Declared.

Sa1307 Comparison of Three Commercially Available Point of Care Tests for Celiac Disease

Introduction Coeliac disease (CD) remains underdiagnosed. A rapid point of care test (POCT) may increase uptake of serological testing in appropriate patient groups. 3 POCTs are commercially available in the UK and in continental European pharmacy outlets: Biocard an IgA tissue tranglutaminase (tTG) test (BHR pharmaceuticals); Celiac Quick Test (Biohit Healthcare) detecting IgA, IgG and IgM tTG and Simtomax (Tillotts Pharma) which detects IgA and IgG antibodies against deamidated gliadin peptides (DGP). A fourth POCT has also been developed but not marketed (Xeliac Test Pro, Personal Diagnostics), with availability being solely from the manufacturer and no published data existing supporting its validity. Of the 3 commercially available POCTs, there is a limited evidence base with significant ascertainment bias. For this reason we decided to compare 3 commercially available tests in an endoscopic setting. Method Patients referred with a positive endomysial antibody (EMA) for duodenal biopsy to confirm CD were recruited. All patients had repeat serum EMA, tTG and immunoglobulins and were tested simultaneously with the 3 POCTs as per the manufacturers’ instructions. All patients had quadrantic duodenal biopsies from the second part of the duodenum as well as a duodenal bulb biopsy. Demonstration of villous atrophy (VA) was required to diagnose CD. Results 82 patients (51.2% female, mean age 41.0) have been recruited. In 10 patients the EMA had normalised on repeat testing. None of these patients had VA on duodenal biopsy. 9 of these patients were referred with a weak EMA and had a negative tTG. One patient had a tTG of 10 times the upper limit of normal, and subsequent gluten challenge revealed a positive EMA and VA. Of the remaining 72 patients 59 new cases of CD were confirmed with the presence of villous atrophy, of the 13 EMA positive patients without VA 8 had Marsh 1 or 2 changes present with the remaining 5 patients having normal histology. Full sensitivity, specificity PPV and NPV for all of the tests compared to VA on duodenal biopsy are shown in Table 1. Conclusion In this pilot data set Simtomax appears to be the most sensitive of the POCTs when compared to histology with similar results to serum tTG as screening test. Further work is required in larger cohorts and lower prevalence populations to confirm the utility of these tests in adult CD. Disclosure of interest P. Mooney: None Declared, S. Wong: None Declared, M. Burden: None Declared, M. Kurien: None Declared, M. Hadjivassiliou: None Declared, D. Sanders Grant/ Research Support from: BHR pharmaceuticals; Tillotts Pharma for investigator led studies.

Su1774 The Role of Duodenal Bulb Biopsies in the Diagnosis of Celiac Disease

Celiac disease is an autoimmune disorder in which ingestion of gluten causes intestinal inflammation and a variety of gastrointestinal symptoms. Gold standard for diagnosis of celiac disease is upper endoscopy with biopsies. Recent guidelines have recommended routine biopsies should include samples from the duodenal bulb. Our aim was to evaluate the diagnostic utility of duodenal bulb biopsies in the diagnosis of celiac disease.

Duodenal bulb biopsy for the diagnosis of coeliac disease

Duodenal bulb biopsy for the diagnosis of coeliac disease

Separate Duodenal Bulb Biopsies Increase Detection of Abnormal Histology but Do Not Increase Diagnostic Yield of Celiac Disease in All-comers to Endoscopy

Purpose: Celiac disease (CD) detection is increased when separate duodenal bulb and distal duodenal samples are obtained in a high pre-test probability population (i.e., patients with positive serology or established CD). This study examines whether CD detection is increased by sampling the duodenal bulb in a low pre-test probability population. Methods: Patients who underwent separate sampling of the bulb during endoscopy at 3 Mayo Clinic sites (Rochester, MN; Scottsdale, AZ; Jacksonville, FL) between January 1, 2011 and December 31, 2011 were included. Records were reviewed for age, gender, pathology, serology, biopsy indication, and adherence to a gluten free diet (GFD) for 4 weeks prior to biopsy. Histology consistent with CD included Marsh stages 1, 2, and 3. Statistical analysis was performed using Χ2 test. P values were two-sided and considered significant if < 0.05. Results: Final analysis included 737 patients - 464 (63%) female, mean age 50 years (range 2-88). The most common biopsy indications were abdominal pain (47%), diarrhea (36%), nausea (23%), weight loss (17%) and anemia (16%). CD or Dermatitis Herpetiformis was known in 33 (4%) and 72 (10%) were on a GFD. Celiac serology was checked in 331 patients; 32 (9%) had at least one positive celiac serology -- 14/330 (4.2%) for TTG IgA, 13/128 (10%) for TTG IgG, 3/98 (3%) for Endomysial Antibody IgA, 10/91 (11%) for Deamidated gliadin peptide (DGP) IgA, and 6/90 (6.7%) for DGP IgG. A total of 15 patients (2%) in this cohort were newly diagnosed with CD. Villous atrophy (VA) consistent with CD was detected in 22 patients (3%) -- 14 (1.8%) new CD diagnosis and 8 (1%) ongoing CD. In 3 of these patients (0.4%), separate bulb sampling detected a new CD diagnosis (n=1) and ongoing CD activity (n=2) which would have been missed if only the distal duodenum was sampled. Most patients (n = 447, 61%) had normal pathology in the duodenum (Tables 1 and 2). Abnormal histology was detected in 290 patients (39%) and was more commonly detected in the bulb - 262 (36% [95%CI 32-39]) vs 119 (16% (95% CI 14-19%)), p < 0.0001. In all patients with abnormal bulb histology (n = 262), the most frequent abnormality was chronic peptic duodenitis (119, 60%). In patients with a normal distal duodenum, 171 (23%) had abnormal histology isolated to the bulb.Table 1Table 2Conclusion: Abnormal duodenal histology is not uncommon and is more frequently detected in the bulb; the most common histology being chronic peptic duodenitis. In a low pre-test probability patient population (i.e., <10% with positive serology or known CD), individual analysis of the bulb does not sufficiently increase detection of CD (0.4% diagnostic yield) and would not warrant the cost associated with this additional anatomic site biopsy.

OC-060 Does IGA Tissue Transglutaminase Antibody Levels Correlate with Histological findings of Coeliac Disease (CD)?: Abstract OC-060 Table 1

<h3>Introduction</h3> The current gold standard diagnostic test for CD is oesophogastroduodenoscopy (OGD) and duodenal biopsies, aiming to demonstrate the presence of villous atrophy. Given the low sensitivity of endoscopic markers and the patchy distribution of CD within the small bowel, a duodenal bulb biopsy is currently recommended. However, recent studies have raised questions about the need for biopsies in CD, particularly within the paedatric literature, with high anti-tissue transglutaminase antibody (TTG) levels believed to be sufficient. The hypothesis being that high TTG levels correlate closely with definitive CD histology (Marsh 3a-c) giving a high positive predicative value (PPV). This study evaluates TTG levels and histology (inclusive of a bulb biopsy) in adult patients suspected of having CD, with the aim of defining a cut off value for TTG when biopsy may be unnecessary. <h3>Methods</h3> Recruitment occurred between Nov 2008 and July 2012, 523 adult patients (&gt;16 years). All patients had a minimum of 5 duodenal biopsies taken whilst on a gluten containing diet. Furthermore, all patients were tested for IgA TTG, Endomysial Antibody (EMA) and total IgA immunoglobulin at the time of their endoscopy. This study retrospectively reviews the correlation between TTG levels (Aesku Diagnostics, Wendelsheim, Germany) and histological outcomes in these patients, with CD being defined as villous atrophy (Marsh 3a-3c) and a clinical and serological response to a gluten free diet. <h3>Results</h3> Of the 523 adult patients (median age 51 years, range 16–91) recruited, 212 (41%) had positive TTG serology (&gt;15 U/ml). EMA positivity was identified in 31% of the cohort (163/523) with CD diagnosed in 32% (169/523). The sensitivity, specificity, PPV and NPV for TTG was 93.3%, 83.3%, 71.7%, 96.4% respectively and for EMA 93.8%, 98.9%, 97.4% 97.2%. Table 1 shows the PPV for diagnosing CD at differing TTG levels. No cut off level was associated with a PPV of 100%, with the highest PPV value of 97.1% seen when the TTG level was set at 300U/ml (20 × upper normal limit). <h3>Conclusion</h3> Contrary to ESPHGAN guidelines our findings would not support a biopsy avoidance strategy in those with high TTG levels, with patient potentially being wrongly diagnosed. We advocate that duodenal biopsies including a bulb biopsy remain the gold standard diagnostic test in those with suspected CD. <h3>Disclosure of Interest</h3> None Declared

Celiac disease

AbstractPurpose of reviewThe aim of this review was to summarize recent advances in celiac disease (CD) published between 2006 and 2012.Recent findingsCD affects ~ 1% of most populations but remains largely unrecognized. During the past year, research has shown that the prevalence of CD has increased dramatically and not merely because of increased detection. Moreover, undiagnosed CD may be associated with increased mortality. Significant progress has been made in understanding how gliadin peptides can cross the intestinal border and access the immune system. New deamidated gliadin peptide antibodies have better diagnostic accuracy over other tests. The inclusion of duodenal bulb biopsy specimens may increase the rate of CD detection. Finally, refractory CD, although rare, is associated with a poor prognosis. The use of novel highly efficient exogenous prolyl endoproteases enzymes may help patients deal with occasional lapses in their diet or may protect highly sensitive individuals from inadvertent presence of gluten in food products. Nevertheless, the efficiency of this approach still needs precise assessment.ConclusionMortality rates among patients with untreated CD increase two-fold every year as they age (gastrointestinal malignancies) and most can be prevented/reversed with early diagnosis and initiation of a gluten-free diet. CD is a global health problem that requires a multidisciplinary and increasingly cooperative multinational research effort.

774 Diagnostic AID of Additional Duodenal Bulb Biopsies in Adult Celiac Disease

In recent years, increasing number of reports emphasize the benefit of duodenal bulb biopsies (BB) besides distal duodenum biopsies (DDB) for the diagnosis of Celiac Disease (CD) (1,2,3). In this prospective study, for the first time, we aimed to investigate the aid of additional BB on diagnosing of CD based on sufficiency of endoscopic appearance of duodenum for celiac disease, as scalloping or paucity of folds, mosaic pattern (cracked-mud), sawtooth image (layering) of fold edges, nodularity, prominence of submucosal vessels.

Duodenal bulb biopsy in children for the diagnosis of coeliac disease: Experience from Perth, Australia

The study aims to assess the usefulness of duodenal bulb biopsy in the diagnosis of coeliac disease (CD) in a paediatric population. Since February 2009, in our institution, we have routinely included duodenal bulb biopsy in addition to distal duodenal biopsies in children undergoing diagnostic upper gastrointestinal endoscopy. All children diagnosed with CD between February 2009 and May 2011 were identified, and those children who had biopsy finding of CD limited to duodenal bulb were reviewed with regard to clinical, serological and histopathological parameters. Duodenal bulb biopsy reports of those children who did not have CD were also reviewed as control group. A total of 101 children were diagnosed with CD during the study period. The mean age was 8.21 years (±3.63), 33 males and 68 females. There were 8 out of 101 (7.92%) who had histological changes consistent with CD exclusively in the duodenal bulb, with normal histology in the distal duodenum. None of duodenal bulb biopsy was abnormal in the control group. In some children, diagnostic CD changes may be limited to the duodenal bulb only and hence we recommend that duodenal bulb biopsies be included routinely in children suspected with CD to improve the diagnostic yield.

An Unusual Referral for Epigastric Pain, Nausea, Abdominal Bloating, Diarrhea, and Weight Loss

Question: A 30-year-old woman with a past medical history of hypothyroidism presents for evaluation of epigastric discomfort, nausea without emesis, abdominal bloating, and watery, nonbloody diarrhea for 5 months. This was associated with a 15-pound weight loss. Complete blood count, liver function tests, thyroid-stimulating hormone, immunoglobulin (Ig) levels, and IgG/IgA tissue transglutaminase (tTG) were within normal limits. Stool studies for bacterial pathogens, giardia, Clostridium difficile toxin, and ova/ parasites were negative. An upper endoscopy revealed minimal antral erythema and abnormal duodenal bulb (Figure A) with a normal-appearing postbulbar duodenum (Figure B). Biopsies of the stomach, duodenal bulb, and second portion of the duodenum were obtained. What is the diagnosis? Look on page 1692 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Histology revealed a thickened subepithelial collagen band in the stomach (Figure C) and total villous blunting with an increased subepithelial collagen band in the duodenal bulb (Figure D). Conversely, the histologic appearance of the second portion of the duodenum was completely normal (Figure E). Gastric biopsies were negative for Helicobacter pylori. The diagnoses of collagenous gastritis and collagenous sprue were established. Treatment included initiation of a gluten-free diet along with a trial of omeprazole. Collagenous gastritis is an uncommon condition first described in 1989. A recent review defined 2 patient groups based on age and presentation with children and young adults presenting with anemia and abdominal pain and older adults predominantly presenting with diarrhea. In the adult group, 2 cases were associated with celiac disease, whereas an additional 5 individuals were found to have concurrent collagenous or lymphocytic colitis.1Brain O. Rajaguru C. Warren B. et al.Collagenous gastritis: reports and systematic review.Eur J Gastroenterol Hepatol. 2009; 21: 1419-1424Crossref PubMed Scopus (34) Google Scholar Various treatment approaches including acid suppression, corticosteroids, misoprostol, mesalamine, and sulfacrate were tried with mostly disappointing results; interventions therefore mainly focus on concurrent diseases such as gluten-free diet for celiac disease and budesonide for collagenous colitis.2Gopal P. McKenna B.J. The collagenous gastroenteritides: similarities and differences.Arch Pathol Lab Med. 2010; 134: 1485-1489Crossref PubMed Google Scholar Despite a sensitivity in the 90%–98% range of tTG antibodies for the detection of celiac disease, this case demonstrates that a negative IgA/IgG tTG cannot entirely exclude the diagnosis and that duodenal biopsies should still be obtained in the setting of a high clinical suspicion for celiac disease or an abnormal-appearing duodenum on endoscopy. Recent studies have also shown the importance of obtaining ≥1 biopsy from the duodenal bulb to avoid missing the diagnosis of celiac disease. In 126 patients with newly established celiac disease and 85 patients with a previous diagnosis on a gluten-free diet presenting for reevaluation, villous atrophy was limited to the duodenal bulb in 9% and 14% of cases, respectively.3Evans K.E. Aziz I. Cross S.S. et al.A prospective study of duodenal bulb biopsy in newly diagnosed and established adult celiac disease.Am J Gastroenterol. 2011; 106 (1837-1742)Crossref Scopus (84) Google Scholar

Predictors of duodenal bulb biopsy performance in the evaluation of coeliac disease in children

AimsStudies on the role of duodenal bulb biopsy (DBB) in coeliac disease (CD) evaluation have increased in recent years; growing evidence suggests that the disease can present solely in the...

PWE-119 Duodenal bulb biopsies for diagnosing adult coeliac disease: is there an optimal biopsy site?

IntroductionThere has been increasing interest in the role that duodenal bulb biopsies may have in helping to establish the diagnosis of coeliac disease. This study aims to determine whether a...

OC-049 Duodenal bulb biopsies—are they a necessity in coeliac disease?

IntroductionHistorically, Brunner's glands in the bulb were thought to cause histological interpretation difficulties, however recent studies have demonstrated that this area maybe the only site to demonstrate villous atrophy (VA)...

Duodenal bulb biopsies for diagnosing adult celiac disease: is there an optimal biopsy site?

Recent studies highlight the role of duodenal bulb biopsy in the diagnosis of celiac disease. To determine whether a targeted duodenal bulb biopsy in addition to distal duodenal biopsies is the optimal strategy to identify villous atrophy. Prospective cohort study. Tertiary-care referral center. Seventy-seven patients undergoing clinically indicated EGD with duodenal biopsies were recruited. Of these, 28 had newly diagnosed celiac disease and 49 were controls. At endoscopy, 8 duodenal biopsy specimens were taken: 4 from the second part of the duodenum and 4 quadrantically from the bulb (at the 3-, 6-, 9-, and 12-o'clock positions). Increasing the diagnostic yield and detection of the most severe villous atrophy in celiac disease with the addition of a targeted duodenal bulb biopsy. The most severe degree of villous atrophy was detected when distal duodenal biopsy specimens were taken in addition to a duodenal bulb biopsy specimen from either the 9- or 12-o'clock position (96.4% sensitivity; 95% CI, 79.7%-100%). The difference between the 12-o'clock position biopsy and the 3-o'clock position biopsy in detecting the most severe villous atrophy was 92% (24/26) versus 65% (17/26) (P = .02). Small sample and study performed in a tertiary referral center. This study demonstrates the patchy appearance of villous atrophy that occurs within the duodenum. A targeted duodenal bulb biopsy from either the 9- or 12-o'clock position in addition to distal duodenal biopsies may improve diagnostic yields by detecting the most severe villous atrophy within the duodenum.

Continuing Medical Education Exam: June 2012

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely on-line. To complete do the following: 1. Read the CME article in this issue carefully and complete the activity: Kurien K, Evans KE, Hopper AD, et al. Duodenal bulb biopsies for diagnosing adult celiac disease: is there an optimal biopsy site? Gastrointest Endosc 2012;75:1190-6. Chokshi R, Hovis C, Hollander T, et al. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointest Endosc 2012;75:1197-203. Vemulapalli KC, Rex DK. Failure to recognize serrated polyposis syndrome in a cohort with large sessile colorectal polyps. Gastrointest Endosc 2012;75:1206-10. Rondagh EJA, Bouwens MWE, Riedl RG, et al. Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopic cancer prevention. Gastrointest Endosc 2012;75:1218-25. 2. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College and have provided a welcome opportunity for the ACC to cultivate leadership and engage members. Visit the journals Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College. Exams can be saved to be acessed at a later date. ou may create a free personal account to save and return to your work in progress, as well as save and track your completed activities o that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME ctivities can also be found at this site.

A Prospective Study of Duodenal Bulb Biopsy in Newly Diagnosed and Established Adult Celiac Disease

A Prospective Study of Duodenal Bulb Biopsy in Newly Diagnosed and Established Adult Celiac Disease

A Prospective Study of Duodenal Bulb Biopsy in Newly Diagnosed and Established Adult Celiac Disease

Recent reports suggest that the duodenal bulb may be the only site to demonstrate villous atrophy (VA) in celiac disease. However, there is a paucity of data from newly diagnosed adult celiac patients and no data from those patients with established celiac disease. The objective of this study was to compare the histological findings in the duodenal bulb and distal duodenum of patients with adult celiac disease (newly diagnosed or established) against controls. A total of 461 patients were prospectively recruited. Biopsies were graded using the Marsh criteria. In all, 461 patients (300 females and 161 males) with median age 51 years were analyzed. In all, 126 had newly diagnosed celiac disease, 85 established celiac disease, and 250 controls. New diagnosis celiac disease (9%, P<0.0001) and established celiac disease (14%, P<0.0001) were more likely than controls to have VA in the bulb alone. Overall, when comparing the histological lesion of the bulb against the distal duodenum, 31/85 with established celiac disease (P<0.0001) and 21/126 newly diagnosed (P=0.0067) had a discrepancy in the severity of the lesion between the two sites compared with 18/250 controls. In all, 24/31 with established celiac disease and 16/21 newly diagnosed had the more severe lesion in the bulb. VA may be present only in the duodenal bulb. This study suggests that the optimal assessment of patients in whom celiac disease is suspected (with positive serology) and those with established celiac disease requires a duodenal bulb biopsy in addition to distal duodenal biopsies.

Routine duodenal bulb biopsy in coeliac disease: time to change clinical practice?

<h3>Introduction</h3> Historically Brunner9s glands were thought to interfere with interpretation of villous atrophy in the duodenal bulb. Recent reports suggest that the duodenal bulb may be the only site to demonstrate villous atrophy (VA) in coeliac disease (CD). There are few data on the prevalence of lesions in non-coeliac patients. <h3>Methods</h3> We aimed to compare the histological findings in the duodenal bulb and distal duodenum of patients with CD against controls having gastroscopy with duodenal biopsy. Indications included positive coeliac serology, family history, diarrhoea, and iron deficiency anaemia. A total of 461 patients were prospectively recruited. Biopsies were graded using the Marsh criteria by a single pathologist blinded to the clinical information. <h3>Results</h3> 461 patients, (300 female, 161 male) median age 50 years (range 16–89) were analysed. 24 patients had VA in the bulb only, 6 had VA in distal duodenum only (p=0.001) (table 1). 1 control patient with HIV enteropathy had VA at both sites. CD in remission showed greater histological variability than new diagnosis CD (p=0.0018) and controls (p=0.0001) <h3>Conclusion</h3> Villous atrophy may be present only in the duodenal bulb. In this study 11/126 (9%) of new diagnosis CD and 12/85 (14%) of CD in remission demonstrated VA in the bulb alone. We recommend taking a biopsy from the bulb as well as the distal duodenum to diagnose suspected coeliac disease and reassess known cases.