Duodenal Injury Research Articles

Combined stomach and duodenal perforating injury following blunt abdominal trauma: a case report and literature review

BackgroundGastrointestinal injury following blunt abdominal trauma is uncommon; a combined stomach and duodenal perforating injury is even more rare. Because these two organs are located in different spaces in the abdomen, such injuries are difficult to identify.Case presentationA young woman involved in a motor vehicle crash presented to our emergency department with concerns of severe peritonitis. Contrast-enhanced computed tomography of the abdomen revealed pneumoperitoneum and retroperitoneal hematoma in zone 1. An emergency laparotomy was performed, revealing a stomach-perforating injury, which was resolved with primary repair. No obvious injury was observed on retroperitoneal exploration. However, peritonitis presented again on the second postoperative day, and a second laparotomy was performed, revealing a duodenum-perforating injury in its third portion. We performed primary repair with multi-tube-ostomy. The patient recovered well without permanent tube placement or internal bypass.ConclusionsAssessing associated injuries in blunt abdominal trauma is crucial because they may be fatal if timely intervention is not undertaken. These types of complicated injuries require a feasible surgical strategy formulated by experienced surgeons, which gives the patient a better chance of survival.

Surgical Management of Penetrating Duodenal Injury: Role of Primary Repair

To evaluate the outcome of primary repair in penetrating duodenal injuries. Descriptive study. Adana City Training and Research Hospital, Adana, Turkey, between March 2011 and September 2018 Methodology: Patients with penetrating duodenal injury, who underwent primary repai, were reviewed retrospectively. The patients who had early death, grade 1 duodenum injuries and operative procedures except primary repair, were excluded from the study. Age, gender, mechanism of penetrating injury, grade of the duodenal injury, associated intra-abdominal injuries, length of intensive care unit and hospital stay, duodenum-related mortality and morbidity were analysed. Fisher's exact test was used to compare the outcomes between survivor and non-survivor groups. Data of 26 patients with primary repair (5 females, 21 males) were reviewed. The mean age was 33.11 ±12.07 years; and gunshot (n=19, 73.1%) was the most common cause of the duodenal injury. Twenty-five had a total of 103 (3.9 injuries per patient) associated intra-abdominal organ injuries. 20 (76.9%) patients had grade 2 duodenal injuries; and the most injured portion of the duodenum was segment IV (n: 9, 34.6%). Three (11.5%) patients had duodenal leakage and postoperative complication rate was 53.8%. Duodenum-related mortality (DRM) was 3.8% (n:1) and overall mortality was 19.2% (n:5). The anatomic localisation of duodenal injury and associated vascular trauma were significantly different between survivor and non-survivor groups (p: 0.038, and p: 0.034, respectively). Associated intra-abdominal organ and vascular injuries were predictive factors of overall mortality in duodenal injuries. Duodenum-related mortality was low, for this reason minimally invasive procedures such as primary repair will be more accurate in surgical management of penetrating duodenal injuries. Key Words: Duodenal injury, Primary repair, Surgical management.

Genome-Wide Transcriptomic Analysis of Intestinal Mucosa in Celiac Disease Patients on a Gluten-Free Diet and Postgluten Challenge

Background & AimsGluten challenge studies are instrumental in understanding the pathophysiology of celiac disease. Our aims in this study were to reveal early gluten-induced transcriptomic changes in duodenal biopsies and to find tools for clinics.MethodsDuodenal biopsies were collected from 15 celiac disease patients on a strict long-term gluten-free diet (GFD) prior to and post a gluten challenge (PGC) and from 6 healthy control individuals (DC). Biopsy RNA was subjected to genome-wide 3’ RNA-Seq. Sequencing data was used to determine the differences between the three groups and was compared to sequencing data from the public repositories. The biopsies underwent morphometric analyses.ResultsIn DC vs. GFD group comparisons, 167 differentially expressed genes were identified with 117 genes downregulated and 50 genes upregulated. In PGC vs. GFD group comparisons, 417 differentially expressed genes were identified with 195 genes downregulated and 222 genes upregulated. Celiac disease patients on a GFD were not “healthy”. In particular, genes encoding proteins for transporting small molecules were expressed less. In addition to the activation of immune response genes, a gluten challenge induced hyperactive intestinal wnt-signaling and consequent immature crypt gene expression resulting in less differentiated epithelium. Biopsy gene expression in response to a gluten challenge correlated with the extent of the histological damage. Regression models using only four gene transcripts described 97.2% of the mucosal morphology and 98.0% of the inflammatory changes observed.ConclusionsOur gluten challenge trial design provided an opportunity to study the transition from health to disease. The results show that even on a strict GFD, despite being deemed healthy, patients reveal patterns of ongoing disease. Here, a transcriptomic regression model estimating the extent of gluten-induced duodenal mucosal injury is presented.

The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis.

Trauma pancreaticoduodenectomy (TP) remains a challenging operation with morbidity and mortality rates as high as 80% and 50%. Many trauma surgeons consider it surgical dogma to avoid performing a TP during the index operation for patients with severe pancreatic or duodenal injuries. However, there is no modern analysis evaluating this belief. Therefore, we hypothesized no difference in risk of mortality between patients with severe pancreatic or duodenal injury undergoing a TP for penetrating trauma to propensity-matched controls undergoing laparotomy without TP. The Trauma Quality Improvement Program (2010–2016) was queried for adults with severe penetrating pancreatic or duodenal injuries undergoing laparotomy. A 1:2 propensity-matching including demographics/comorbidities, injury severity score, vitals on admission, Glasgow Coma Scale and concomitant injuries for laparotomy with or without TP was performed. Risk of mortality was reported using a univariable logistic regression model. Of 2182 patients with severe pancreatic or duodenal injuries undergoing laparotomy, 54 (2.5%) underwent TP and 2128 (97.5%) underwent laparotomy without TP. There were no differences in propensity-matching characteristics. Patients undergoing TP had a similar mortality rate (20.0% vs. 28.7%, p = 0.302) but a longer length of stay (LOS) (27.5 vs. 16.5 days, p = 0.017). The TP group had a similar associated risk of mortality (OR = 0.62, p = 0.302) but higher risk of major complications (OR 3.44, CI 1.35–17.47, p = 0.015). In appropriately selected penetrating trauma patients with severe pancreatic/duodenal injuries, TP is associated with a similar risk of mortality compared to laparotomy without TP. However, TP patients did have an increased associated risk of major complications and longer LOS.

Complete transection of third part of duodenum following blunt injury abdomen: a rare case report

Blunt injury abdomen (BIA) is an ever-increasing problem. Isolated injury to duodenum following BIA is rare (1-4%). It can be a challenge to the surgeon and failure to manage it properly can lead on to devastating results. Blunt duodenal injury can occur in isolation or with pancreatic injury. We report a case of an isolated transection of third part of the duodenum following BIA. Initial clinical changes in isolated duodenal injury may be subtle before life-threatening peritonitis develops. High index of suspicion, knowledge of mechanism of injury, physical examination and proper imaging techniques are the key in early detection of duodenal injury.

Isolated Pyloroduodenal Transection in Children: a Spectrum of Presentation of an Uncommon Entity

Isolated duodenal injuries are not commonly seen in children who sustain abdominal trauma, and a complete pyloroduodenal disruption is quite rare. While techniques of duodenal diverticulization are employed widely in adults, the application of intubated diversion with primary repair works just as well in children. Two cases of isolated pyloroduodenal transection have been chronicled. To the best of our knowledge, one of these is the first case of successfully treated complete pyloroduodenal disjunction in pediatric literature. Case 1: A 10-year-old boy sustained multiple injuries after a road traffic accident and presented to us 48-h post-incident. Imaging suggested a duodenal injury. Exploratory laparotomy revealed a complete pyloroduodenal transection without associated pancreatic/ductal injuries. Primary repair with intubated diversions and a feeding jejunostomy was done. The child recovered completely. Case 2: A 5-year-old girl with delayed presentation following a road traffic accident required cardiopulmonary resuscitation and inotropic support prior to exploratory laparotomy. Findings included a large retroperitoneal hematoma involving zone 1 and 2, a right hepatic laceration, gastroduodenal disruption, and impending venous gangrene of the bowel. Intraoperative cardiac arrest necessitated rapid damage control surgery. Unfortunately, the child did not survive the injury. We wish to emphasize not only the need for early diagnosis and the customization of the surgery depending on the site and extent of injury but also the necessity of the rapid establishment of enteral nutrition to enhance recovery.

Prior viral illness increases heat stroke severity in mice.

What is the central question of this study? We hypothesized that prior illness would increase the susceptibility to and severity of heat stroke (HS). What is the main finding and its importance? We provide the first experimental evidence, using a mouse model of HS, that recent viral illness increases the severity of HS. Our data indicate that this effect is not attributable to the exacerbation of hyperthermia but is a consequence of ongoing coagulation and systemic inflammatory reactions. Our data suggest that measurement of platelets, cytokines and chemokines before heat exposure might be indicative of susceptibility to HS, with coagulation and inflammation being potential targets for intervention that could improve recovery. It is hypothesized that prior illness exacerbates heat stroke (HS) in otherwise healthy organisms by augmenting hyperthermia during heat exposure or deactivating cellular pathways that protect against organ injury. To test these hypotheses, we injected telemetered male C57BL/6J mice with lipopolysaccharide (LPS; 50µgkg-1 i.p.) or polyinosinic:polycytidylic acid (PIC; 100µg i.p.) as a bacterial or a viral mimic, respectively, with saline (SAL; equivalent volume) as a control. Mice recovered for 48 or 72h before HS (maximal core temperature=42.4°C). Platelet counts, cytokines, chemokines and organ injury were determined 48 or 72h after injection (without heating) or at maximal core temperature and at 1day of recovery from HS. In the absence of heat, PIC induced more robust signs of sickness and increased cytokines and chemokines (TNF-α, RANTES, IP-10 and MIP-1β) at 48h, which was not observed with LPS (P<0.05). Responses of both groups recovered by 72h, although low platelet counts persisted after PIC (P<0.05). Heat-induced hyperthermia was similar among mice injected with SAL, LPS and PIC; however, PIC-injected mice displayed more severe responses during recovery from HS, with reduced survival (48h, 70 versus 100%; P<0.05), deeper and longer post-HS hypothermia, greater reductions in platelets, elevated RANTES, IP-10, IL-6 and TNF-α and greater duodenal injury (P<0.05). By 72h, survival from HS was no longer reduced in PIC-injected mice, although hypothermia, the reduction in platelets and elevated cytokines persisted. Our data indicate that prior illness exacerbates the severity of HS in the absence of signs of illness at the time of heat exposure and suggest that this is attributable to persistent coagulation and inflammatory reactions that might be targets for intervention to improve recovery.

The Safety and Effectiveness of Laparoscopic versus Open Surgery for Congenital Hypertrophic Pyloric Stenosis in Infants.

BackgroundThis study aimed to investigate the safety and effectiveness of laparoscopic pyloromyotomy for infants with congenital hypertrophic pyloric stenosis.Material/MethodsThe clinical data of 233 infants with congenital hypertrophic pyloric stenosis who were treated at our hospital from January 2013 to January 2018 were analyzed retrospectively. The patients were divided into 2 groups: the laparoscopic group (group A, n=126) and the conventional operation group (group B, n=107).ResultsLaparoscopic surgery was successfully performed in all patients in the laparoscopic group, and none of the surgeries were converted to open surgery. Compared with traditional surgery, laparoscopic surgery has obvious advantages in operation time (29.8±12.9 minutes versus 37.2±17.5 minutes, P=0.012), postoperative feeding time (10.3±2.2 hours versus 15.2±4.1 hours, P=0.035), postoperative hospitalization time (2.8±0.7 days versus 3.5±1.9 days, P=0.013), incision length (0.9±0.2 cm versus 3.3±0.8 cm, P=0.002) and poor wound healing (0 versus 6, P=0.007). No complications, such as bleeding, gastric perforation, duodenal injury, abdominal infection or recurrent vomiting, were observed in the 2 groups. The growth and development (weight and height) of the infants in both groups were normal.ConclusionsLaparoscopic pyloromyotomy has the same safety and effectiveness as the traditional operation and has the advantages of less trauma, faster recovery and cosmetically pleasing incisions.

Pathologic Manifestations of Gastrointestinal and Hepatobiliary Injury in Immune Checkpoint Inhibitor Therapy.

Immune checkpoint inhibitors (CPIs), including cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) inhibitors and the programmed death receptor-1 (PD-1)/programmed death ligand-1 (PD-L1) inhibitors, are being increasingly used for treating many advanced malignancies. However, CPI therapy is also associated with gastrointestinal and hepatobiliary adverse effects. To review the adverse effects of CPI therapy on the gastrointestinal tract and hepatobiliary system. To describe histopathologic patterns and discuss differential diagnostic considerations in the diagnosis of CPI injuries. Published peer-reviewed literature in the English language and personal experience in the diagnosis of CPI injuries. The pathologic manifestations of CPI therapy-induced gastrointestinal and hepatobiliary injury are broad. The patterns of esophageal CPI injury include lymphocytic inflammation and ulcerative esophagitis, while those of gastric injury include chronic active gastritis, lymphocytic gastritis, focal enhancing gastritis, and periglandular inflammation. The duodenal injury may present as duodenitis with villous blunting and granulomas. We also noticed active colitis, microscopic colitis, chronic active colitis, increased apoptosis, ischemic colitis, and nonspecific inflammatory reactive changes in colonic injuries. The reported histologic features of hepatobiliary injuries are panlobular hepatitis, centrilobular necrosis, portal inflammation with bile duct injury, steatosis, nodular regenerative hyperplasia, and secondary sclerosing cholangitis. In summary, we discuss the pathologic features and differential diagnosis of CPI therapy-induced gastrointestinal and hepatobiliary injury. Recognition of CPI injury is important to determine the proper management that often includes cessation of CPI therapy, and administration of steroids or other immunosuppressive agents, based on severity of injury.

Experience of laparoscopic drainage of posttraumatic intramural hematomas of duodenum in children

Purpose . To demonstrate that it is possible to perform minimally invasive laparoscopic interventions in children with extremely rare duodenal traumas resulting in a traumatic intramural duodenal hematoma. At the present stage, timely diagnostics and treatment of traumatic duodenal injuries resulting in a traumatic intramural duodenal hematoma relate to one of complex and rather complicated surgical issues. In the structure of all abdominal damages, the rate of duodenal traumas currently constitutes 1.2% only [1]. Single treatment cases of children with this pathology are described in the world medical literature. That’s why we decided to present our own observations devoted to this pressing issue of pediatric surgery. Materials and methods . We presented 2 rare clinical observations of posttraumatic intramural duodenal hematomas in children who had successful mini-invasive laparoscopic interventions. The mini-invasive surgical interventions were done using laparoscopic equipment by Karl Storz. Results . As shown in these clinical observations, recovery of duodenal posttraumatic hematoma using mini-invasive surgeries in children is possible and highly effective. Conclusions . Posttraumatic duodenal hematoma is treated with minimally invasive surgeries, high bowel obstruction is arrested as soon as possible, early enteral nutrition is initiated and the patient becomes active in the early postoperative period.

Traumatic Duodenal Injury: Current Management Update

Although duodenal injuries are a rare entity of all trauma, they carry high risk of morbidity and mortality. The management of duodenal injuries should encompass a multidisciplinary approach. Optimal operative management of duodenal injuries has evolved in the last few decades. Isolated duodenal injuries are rare due to its proximity to major vascular and organ structures. Immediate mortality from duodenal injuries is due to hemorrhage from major vascular injuries. Non-operative management of isolated low-grade classification of duodenal injuries is accepted with close clinical and laboratory monitoring of patients. When operative management is necessary, recent evidence suggests simple repair over complex reconstructions that carry less morbidity and improved outcomes. When dealing with injuries to the duodenopancreas complex, reconstruction of the pancreaticobiliary system should involve expertise of hepatobiliary surgeons. Management of duodenal injuries and its complications should engage a multidisciplinary approach. Damage control techniques should be utilized in patients in extremis with associated major vascular injuries. Low-grade duodenal injuries may be monitored closely with clinical examinations and laboratory values. When duodenal repair is needed, conservative repair techniques over complex reconstructions should be utilized.

Duodenal Injury in the Dakotas: A 15-Year Review of Duodenal Injury in the Level II Trauma Centers of North and South Dakota

Duodenal Injury in the Dakotas: A 15-Year Review of Duodenal Injury in the Level II Trauma Centers of North and South Dakota

Partial Resection of the Second Portion of the Duodenum for Traumatic Duodenal Injury Caused by a Wire in a Child

Partial Resection of the Second Portion of the Duodenum for Traumatic Duodenal Injury Caused by a Wire in a Child

Delayed manifestation of Isolated Intramural Hematoma of the duodenum resulting from Blunt abdominal Trauma

Duodenal injury following blunt abdominal trauma is a relatively unusual complication, and it may sometimes be difficult to distinguish a duodenal hematoma from duodenal perforation. According to recent reports, intramural hematomas typically resolve spontaneously with conservative treatment. Surgery, however, is occasionally necessary in some cases if the diagnosis is delayed, conservative therapy fails, or a high degree of suspicion of duodenal injury persists. We experienced a case of delayed manifestation of a duodenal intramural hematoma that was surgically treated. Keywords: Hematoma; Blunt abdominal trauma; Duodenum

Grade IV traumatic pancreatic injury with primary duodenum malignant lymphoma following pancreatoduodenectomy: a case report

BackgroundTraumatic pancreatic injury with a main pancreatic duct injury has a high incidence of mortality and requires a prompt and appropriate treatment. However, the best approach, and treatment options, which may be limited, remains controversial especially for the elderly patients. Herein, we present a case of traumatic pancreatic injury in an elderly patient for whom pancreatoduodenectomy was safe and effective.Case presentationAn 87-year-old man was diagnosed with a traumatic pancreatic injury with a main pancreatic duct injury. In addition, the horizontal segment of the duodenum was largely eradicated. There were no comorbidities, and his vital signs were stable. A pancreatoduodenectomy was performed. The postoperative course was uneventful, and he was discharged. Pathological examination revealed a primary follicular lymphoma of the duodenum.ConclusionsThis case demonstrated that pancreatoduodenectomy could be performed safely for a severe pancreatic injury in an elderly patient. However, special attention should be paid to select the optimal surgical procedure. Further, this was a rare case, as initially a primary follicular lymphoma of the duodenum was suspected as a duodenal injury coexisting with a traumatic pancreatic injury because of the increased duodenal thickness.

Modified delta-shaped gastroduodenostomy consisting of linear stapling and single-layer suturing with the operator positioned between the patient's legs: A technique preventing intraoperative duodenal injury and postoperative anastomotic stenosis.

BackgroundThe drawback of the delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG) is the presence of intraoperative duodenal injury and postoperative anastomotic stenosis, which can occur due to a relatively short duodenal bulb diameter.Materials and methodsFrom June 2013 to June 2019, 35 patients with gastric cancer underwent TLDG with a modified DSG consisting of linear stapling and single-layer hand suturing in our institution. All anastomotic procedures were performed by the right hand of the operator positioned between the patient’s legs. Linear stapling of the posterior walls of the remnant stomach and duodenum without creating a gap was performed using a 45-mm linear stapler, considering the prevention of intraoperative duodenal injury. The stapler entry hole was closed using a single-layer full-thickness hand suturing technique with knotted sutures and a knotless barbed suture. We described the clinical data and outcomes in the present retrospective patient series.ResultsNo intraoperative duodenal injury occurred in any of the 35 patients. The median staple length at linear stapling of the posterior walls of the remnant stomach and duodenum was 41.7 ± 4.2 (30–45) mm, and 2 patients (5.7%) had a staple length of 30 mm. There were no incidences of postoperative anastomotic stenosis.ConclusionsWe suggest that a modified DSG consisting of linear stapling and single-layer hand suturing performed by an operator positioned between the patient’s legs can be one option for B-Ⅰ reconstruction following TLDG because it can aid in preventing both intraoperative duodenal injury and postoperative anastomotic stenosis.

TACTICS OF SURGICAL TREATMENT FOR ISOLATED DUODENAL INJURY

Currently the diagnosis and surgical treatment of isolated duodenal injury is one of the most rare and, consequently, a complicated and completely unsolved problem in emergency surgery. In order to analyze the results of surgical treatment and to justify the optimal amount of intervention in the patients with isolated duodenal injury we have performed a study, wherein the cases of an open injury of the cut−stab character, the effects of a blow on the anterior abdominal wall have been considered. The admission time of patients generally made 6 hours. Examination radiography of abdominal organs with DeBakey − Henelt test, phagogastroduodenoscopy was performed. In cases of unexplained clinical picture the diagnostic video laparoscopy was urgently used. The factors, affecting an outcome of treating the isolated duodenal injury were as follows: the time of hospitalization of patients, size and localization of the bowel defect, timely diagnosis and choice of the surgery volume as well as the post−surgery complications. A thorough revision of a retroperitoneal space, being the one of the symptoms of the Winiwarter−Laffite triad, was accomplished. In injuries of the first and second degree, duration of an injury of no longer than 6 hours, it is necessary to close the defect of the duodenum by two−row sutures with a nasogastroduodenal intubation. At admission of the patients at later terms or with the injuries of the third degree it is expedient to exclude a passage of food on a gut by imposing a gastroenteroanastomosis with Brownian complicity and a decompression of bilious ways. On the basis of our findings the diagnostic and surgical algorithms, depending on admission time of patients to a hospital, size and localization of duodenum wall defect were designed. Key words: duodenal injury, tactics of surgical treatment, results of surgical treatment.

Complicated Abdominal Seat Belt Injuries in Children

Background: The proper use of security accessories in cars has resulted in the reduction of morbidity and mortality both in adults and children. Improper use of abdominal seat belt is associated in some cases with severe abdominal injuries. Objectives: Investigation of the treatment outcomes of children who suffered complicated abdominal seat belt injuries between 1998 and 2013. Methods: We present five cases of children aged 6-14 years, who suffered complicated abdominal injuries due to improper use of the seat belt. Abdominal injuries included injuries to the liver, spleen, small bowel (duodenum, jejunum, and ileum), colon and aorta, mesenterial bleeding, retroperitoneal bleeding, bowel obstruction and pelvic fractures. Results: Three children were operated on within a few hours of admission due to peritoneal irritation, hemodynamic instability after fluid resuscitation, bowel injuries including perforation and bowel ischemia. Two children who were hemodynamically stable, were operated on after few days. One of them had a diagnosis of aortic injury and the other, bowel obstruction. The first child was treated in two stages: i. repair of duodenal rupture, and ii. repair of the aortic injury by using interposition Gore-Tex graft. For the child with bowel obstruction, segmental resection and primary anastomosis were performed. The operation and postoperative periods for all children were uneventful, and all five children are healthy today. Conclusion: 1) The abdominal seat belt should always be used in conjunction with the chest seat belt. 2) An abdominal seat belt sign should always raise the possibility of complicated abdominal injuries. 3) Gastrointestinal tract injuries are common in this setting. 4) Aortic injury is rare; however, it can easily be missed initially. 5) Abdominal aortic trauma is associated with duodenal injuries in almost all cases.

Changes in Serum Concentration of VEGF Angiogenesis Factor and I-FABP Intestinal Barrier Biomarker in Different Outcomes of Treatment of Patients with Duodenal Injury

Changes in Serum Concentration of VEGF Angiogenesis Factor and I-FABP Intestinal Barrier Biomarker in Different Outcomes of Treatment of Patients with Duodenal Injury

Baseline quantitative histology in therapeutics trials reveals villus atrophy in most patients with coeliac disease who appear well controlled on gluten‐free diet

BackgroundThe prevalence and severity of duodenal injury in coeliac disease patients controlled on a gluten‐free diet is unclear.AimsTo use quantitative histology to assess duodenal injury in treated coeliac disease.MethodsQuantitative histology in pre‐treatment duodenal biopsies collected in clinical trials assessing an investigational immunotherapy for coeliac disease was analysed. Morphometric readings were converted to Marsh classifications.ResultsNinety‐three patients had duodenal biopsies. For well‐oriented sections of second part biopsies, six (6%) patients were classified as Marsh 0 or 1, 30 (33%) as Marsh 2 and 56 (60%) as Marsh 3a or 3b. In second part biopsies from 78 seronegative patients on gluten‐free diet >2 years, 27 (35%) were Marsh 2 and 45 (58%) were Marsh 3a or 3b. Distal compared to proximal duodenal biopsies had significantly higher villus height to crypt depth ratios (median, third part: 2.1 vs bulb: 1.4; P < 0.0001) and higher intraepithelial lymphocyte density (44 vs 30; P = 0.0002). The sum of paired villus height and adjacent crypt depth measurements was correlated strongly with villus height (r s = 0.82, P < 10−10). At least one biopsy was graded Marsh 3a or worse in all 26 patients who had serial biopsies from the bulb, first, second and third part, but was overlooked in 20 patients by subjective histology.ConclusionsQuantitative histology in well‐oriented biopsy sections reveals villus atrophy in the majority of patients with coeliac disease who appear well controlled on gluten‐free diet. Standardisation of biopsy collection, processing and evaluation could substantially improve the value of follow‐up biopsies in coeliac disease.