A Mosaic Pattern of the Descending Duodenum

Johan Lindholm, MD, PhD; Lars Blomqvist, MD, PhD; Edgar Jaramillo, MD, PhD


December 06, 2001


Endoscopic images of the descending duodenum showed a granular mucosa with scalloped folds; spraying with 0.2% indigo carmine solution revealed a mosaic pattern and the absence of villi. Results of histologic examination of the duodenal biopsies were consistent with findings on endoscopy and revealed villous atrophy with increased numbers of inflammatory cells in the lamina propria (see Figure 2).

Upper gastrointestinal endoscopy with multiple biopsies of the descending duodenum is considered the method of choice to accurately diagnose villous atrophy. Endoscopy is also helpful for excluding other pathology of the upper gastrointestinal tract. In normal patients, the duodenal mucosa appears velvety when observed with an electronic video endoscope (see Figure 3).

Indigo carmine dye spraying techniques can enhance the visualization of the duodenal mucosa (see Figure 4).

Endoscopic findings of the descending duodenum associated with celiac disease may include absence of folds, scalloped folds, visible submucosal blood vessels, mucosal mosaic pattern, and absence of villi. At histology, chronic inflammation of the duodenal mucosa with blunting or absence of villi accompanied by crypt hyperplasia is characteristic.

Although villous atrophy is not exclusive of celiac disease, it is considered a crucial finding. Other causes of blunted villi include tropical sprue, malnutrition, intolerance to cow's milk, soy protein intolerance, and infectious gastroenteritis. However, most of these conditions can be readily excluded on the basis of clinical history and laboratory data.