Celiac Disease: Ten Things That Every Gastroenterologist Should Know

Amy S. Oxentenko; Joseph A. Murray


Clin Gastroenterol Hepatol. 2015;13(8):1396-1404. 

In This Article

2. Can Celiac Disease Be Recognized Endoscopically?

Gross Endoscopic Views

There are several well-described endoscopic features of CD, including mucosal fold loss, mosaic pattern, scalloping, nodularity, fissuring, and prominent submucosal vascularity (Figure 2A and B). The sensitivity of endoscopic markers varies (59%–94%), yet the specificity is high (92%–100%).[9,10] The pattern of endoscopic markers may differ between adults and children. A mosaic pattern is found commonly in children, and although the frequency of other endoscopic markers of CD increases with age, the mosaic pattern does not.

Figure 2.

Images of the duodenum in CD. (A) Typical changes of villous atrophy characterized by scalloping of the folds, mosaic pattern, and nodularity. (B) Loss of the folds in patient with treated CD.

Water Immersion

Water immersion involves instilling 100–200 mL water into the duodenum after deflation, takes only 30 seconds to perform, has high sensitivity and specificity for detecting total villous atrophy,[11] and may help target duodenal biopsies because of the patchy nature of CD.[12] Combining water immersion with intravenous hyoscine butylbromide may increase the positive predictive value and specificity for CD compared with air insufflation alone (84% vs 99% and 87% vs 99%, respectively).[13]

Other Endoscopic Techniques

Video capsule endoscopy (VCE) may be indicated in patients with CD who are unable to undergo upper endoscopy, have alarm features, or have normal histology but positive celiac serologies.[14] VCE can examine the entire small bowel but lacks sensitivity for partial villous atrophy, is subject to interpretation, and lacks a standardized grading system for CD. The sensitivity of VCE in CD is 89% with specificity of 95%.[15]

Although VCE adds little to the work-up of uncomplicated CD, it is useful when evaluating refractory or atypical features.

Double-balloon endoscopy (DBE) or push enteroscopy may be useful in patients with CD who have patchy small bowel involvement, disease limited to the jejunum, or in those undergoing an evaluation for complications of the disease. Antegrade DBE may uncover ulcerative jejunitis or enteropathy-associated T-cell lymphoma (EATL) and could be considered in CD patients with refractory celiac disease (RCD) type II, ongoing weight loss, continued intussusception despite a sustained GFD, suspicious lesions in the small intestine, or other alarm features.

Chromoendoscopy enhances mucosal features of CD but alone adds little to a skilled endoscopist. However, high-magnification endoscopy with chromoendoscopy may improve accuracy for detecting partial villous atrophy compared with conventional endoscopy.[16] Optical band imaging may also enhance mucosal detail without dye to detect total and partial villous atrophy patterns.[17]

Practical Suggestion

Biopsy for CD is suggested, even in the absence of endoscopic markers. Although novel techniques may enhance visualization of the mucosa, biopsies are still needed. Water immersion is simple and may be useful to target biopsies or evaluate patients without a prior indication for biopsy.