Capsule Endoscopy Useful for Evaluating Equivocal Celiac Disease

By Will Boggs MD

January 29, 2020

NEW YORK (Reuters Health) - Small-bowel capsule endoscopy (SBCE) is useful for evaluating patients with equivocal celiac disease, researchers in the UK report.

Seronegative villous atrophy (SNVA) - villous atrophy in the absence of positive celiac serology - can result from IgA deficiency or low gluten intake in patients with celiac disease (CD), but can also be secondary to drugs, infections or immune-mediated conditions.

Dr. Stefania Chetcuti Zammit of Royal Hallamshire Hospital, in Sheffield, and colleagues investigated the role of SBCE in 177 patients with SNVA or equivocal CD and evaluated whether SBCE findings could predict outcomes.

Overall, 55 patients (31.1%) had no identifiable cause for SNVA (SNVA-UO); 35 patients (19.8%) were classified as having CD based on a histological response to a gluten-free diet (SNVA-CD); 37 patients (20.9%) had other identifiable causes of SNVA; and 50 patients (28.2%) had raised intraepithelial lymphocytes (IELs) and/or crypt hyperplasia (Marsh class 1 or Marsh class 2).

The diagnostic yield of SBCE was 40.0% in patients with SNVA-UO; 51.4% in patients with SNVA-CD; 27.0% in patients with alternative identifiable causes of SNVA; and only 14.0% in patients with Marsh 1 or 2, the researchers report in Gastrointestinal Endoscopy.

Among patients with villous atrophy, a positive SBCE was associated with a more severe histological pattern on duodenal biopsies and, in patients with SNVA-CD, with more adverse events.

Among patients with SNVA-UO and SNVA-CD, more extensive small-bowel involvement was associated with worse survival than was normal or only proximal involvement on SBCE.

"In patients with SNVA-UO, positive findings on SBCE and more extensive disease can predict those with persistent SNVA who will require treatment with immunosuppressants," the authors conclude. "In SNVA-CD, the same pattern is true for patients who eventually develop CD-related adverse events. In both SNVA-CD and SNVA-UO, more extensive disease on SBCE is indicative of a poorer prognosis. These patients need to be monitored more closely and alternative therapy such as steroids and immunosuppressants considered if adverse events develop."

Dr. Suzanne K. Lewis of Columbia University, College of Physicians and Surgeons, in New York City, who studies celiac disease, told Reuters Health by email, "This study shows that SBCE should be considered early in the evaluation of patients with SNVA, since they demonstrated it can be used to predict future disease severity and also can help with identifying another diagnosis, such as Crohn's disease. This clearly would impact on the management of these patients."

"Current guidelines don't support the use of SBCE for monitoring celiac disease," said Dr. Lewis, who was not involved in the new research. "This study is important in that it demonstrates a role for SBCE in seronegative celiac disease because this is a group with a higher mortality and at risk for complications. Monitoring with repeat SBCE can identify progressive disease and complications early and guide treatment."

"It also confirms the value of SBCE in patients with SNVA of unknown etiology with extensive small-bowel villous atrophy," she added. "For patients with raised IELs +/- crypt hyperplasia, as well as all patients with SNVA in general, a thorough history and clinical evaluation are important to eliminate other potential causes, such as medications, infections, and autoimmune and inflammatory causes, including Crohn's disease. SBCE can be useful to detect distal disease from other causes."

Dr. Zammit did not respond to a request for comments.

SOURCE: Gastrointestinal Endoscopy, online January 7, 2020