COMMENTARY

Celiac Disease: What Is Your Biopsy Protocol?

David A. Johnson, MD

Disclosures

December 15, 2011

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Hello, I am Dr. David Johnson, Professor of Medicine and Chief of Gastroenterology at the Eastern Virginia Medical School in Norfolk, Virginia.

Celiac sprue: Where do you biopsy and how many [biopsy samples should you take]?

We know that celiac disease can be patchy, and back when I was a fellow and using Rubin's [biopsy] capsules, we were told that we had to biopsy into the jejunum. Primarily [this was related to the] concern about biopsying proximal into the duodenal bulb, and of distortion from the Brunner gland or gastric hyperplasia in the duodenal bulb; [the rationale was] that these might distort the analysis as it relates to celiac sprue and villous atrophy.

We do think that the atrophy should be more pronounced more proximally [because this is] where the gluten concentration in the diet is perhaps more evident, and therefore it would make sense that the proximal small bowel might be more involved than the distal small bowel. Data are emerging that suggest that biopsies of the duodenal bulb may be the only manifestation of celiac disease in a subset of patients.

How many [patients comprise] that subset? Let's take a step back and say, first of all, we are or should be dealing with a very common diagnosis. It is estimated currently that the prevalence of celiac disease approaches 1% of the US population. That is probably much less than what you encounter in your clinic and less than the number of patients with celiac disease that you are following.

We also know that endoscopists do not do a great a job of making this diagnosis of celiac disease, possibly because they most frequently and most commonly miss the mark by their biopsy technique. A recent paper was presented at Digestive Disease Week 2011 by investigators at Columbia University in New York, who evaluated the biopsy technique that was being used in a large pathology database.[1] In 2006, the American Gastroenterology Association Consensus Conference and Technical Review suggested that biopsies should be taken from the proximal small intestine and should range from 4 to 6 in number. In 2011, when these investigators looked at the database and saw biopsies submitted when celiac disease was suspected, 35% actually met the criteria for adequate biopsy. Therefore, the biopsies are not being taken correctly.

Another study, from the United Kingdom, was just published in the American Journal of Gastroenterology. [2]Investigators looked at 461 patients; 150 of these had newly diagnosed celiac disease, 85 had a current diagnosis of known celiac disease, and the rest were controls. They evaluated all these patients prospectively. They took 1 biopsy from the duodenum and 4, in quadrant fashion, from the second or third portion of the duodenum. These were then analyzed, albeit not blindly, for villous atrophy.

Overall, in the newly diagnosed celiac patients, 9% only had villous atrophy in the duodenal bulb. In the patients with known [existing] celiac disease who were being followed up, 14% had villous atrophy only in the duodenal bulb. This tells us that a sizable percentage of these patients who are being evaluated for celiac disease may actually be missed.

What should you be doing in your practice? The answer is, you must biopsy the duodenal bulb. You must biopsy at least 4-6 areas; our practice is generally to do 6, and to take [samples] from the second and third portion [of the duodenum] for the rest of the biopsies. We submit the biopsies individually; we do not group the biopsies together with a multiple biopsy technique. [Submitting the samples individually] allows the villous surface to be better oriented. Mat these on a piece of histology paper. As you do this, it makes the pathology interpretation much [more accurate]. Start doing duodenal bulb biopsies if you are not already doing that, and the prevalence will increase considerably. We need to do that given the underlying problems that are at least suspected in the current population of 1%. And biopsy the duodenal bulb: Take 4-6 biopsy samples, and I predict that you will see a significant increase in the diagnosis of celiac disease.

I'm Dr. David Johnson. Thanks for listening.

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