The insensitivity of endoscopic markers in celiac disease

OBJECTIVES: Celiac disease (CD) is characterized by small intestinal inflammation and mucosal atrophy. Endoscopic markers of villous atrophy are reported to be present in 88-100% of untreated celiac patients. In patients being evaluated for iron deficiency anemia (IDA), we examined whether endoscopic markers could predict histological results consistent with CD. METHODS: One hundred thirteen patients without histories of CD had small bowel biopsies to evaluate IDA using videoendoscopy. Markers suggesting villous atrophy were noted at endoscopy. Biopsy specimens were reviewed for consistency with CD. Endoscopic and histological findings were compared. RESULTS: Seventeen patients were diagnosed with CD, both clinically and histologically. Loss of folds was the most sensitive marker of villous atrophy, present in 47% with CD, with 97% specificity. The mosaic pattern was much less sensitive (12%), with 100% specificity. Nodularity and scalloping had low sensitivities (6%), but specificities of 95% and 100%, respectively. A finding of any endoscopic marker yielded a sensitivity of 59% and specificity of 92% for CD. CONCLUSIONS: Although endoscopic markers have been guides for directing small bowel biopsies in patients suspected of having CD, we found sensitivities of these markers to be low and conclude that they should not be relied upon for detecting CD in patients presenting with IDA.     

Role of small bowel investigation in iron deficiency anaemia after negative endoscopic/histologic evaluation of the upper and lower gastrointestinal tract

BACKGROUND: The usefulness of small bowel investigation in iron deficiency anaemia (IDA) patients is controversial. AIM: To evaluate the presence of small bowel lesions likely to cause IDA in patients with unexplained IDA after negative gastroscopy with biopsies and colonoscopy (CS). METHODS: A total of 117 outpatients, referred for unexplained IDA, underwent gastroscopy with biopsies and colonscopy. In 17 (14.5%) patients, endoscopic/histological investigations were negative. Of these patients, 13 underwent small bowel follow-through (SBFT) and if necessary to confirm the diagnosis, further gastrointestinal (GI) investigations. RESULTS: Small bowel lesions likely to cause IDA were found in five (38%) patients. Four of these lesions were detected by SBFT, two of them were malignant. These findings, confirmed at surgery and ileoscopy (IS), led to the final diagnoses ofjejunal and ileal adenocarcinoma, idiopathic ileal ulcers and ileal Crohn's disease. In one case, after negative SBFT, jejunal angiodysplasia was detected by video capsule endoscopy (VCE). Faecal occult blood test (FOBT) was positive in four (31%) patients, all of whom presented lesions likely to cause IDA, detected in three cases by SBFT and in one case by VCE. CONCLUSIONS: This study shows the importance of investigating the small bowel in IDA patients after negative upper and lower GI endoscopy, particularly if FOBT is positive.     

Cost effectiveness of routine duodenal biopsies in iron deficiency anemia

AIM To investigate the cost effectiveness of routine small bowel biopsies(SBBs) in patients with iron deficiency anemia(IDA) independent of their celiac disease(CD) serology test results.METHODS We used a state transition Markov model. Two strategies were compared: routine SBBs during esophagogastroduodenoscopy(EGD) in all patients with IDA regardless their celiac serology status(strategy A) vs SBBs only in IDA patients with positive serology(strategy B). The main outcomes were quality adjusted life years(QALY),average cost and the incremental cost effectiveness ratio(ICER). One way sensitivity analysis was performed on all variables and two way sensitivity analysis on selected variables were done. In order to validate the results,a Monte Carlo simulation of 100 sample trials with 10,and an acceptability curve were performed.RESULTS Strategy A of routine SBBs yielded 19.888 QALYs with a cost of $218.10 compared to 19.887 QALYs and $234.17 in strategy B. In terms of cost-effectiveness,strategy A was the dominant strategy,as long as the cost of SBBs stayed less than $67. In addition,the ICER of strategy A was preferable,providing the cost of biopsy stays under $77. Monte Carlo simulation demonstrated that strategy A yielded the same QALY but with lower costs than strategy B. CONCLUSION Our model suggests that EGD with routine SBBs is a cost-effective approach with improved QALYs in patients with IDA when the prevalence of CD is 5% or greater. SBBs should be a routine screening tool for CD among patients with IDA,regardless of their celiac antibody status.     

Prevalence and Predictive Signs for Gastrointestinal Lesions in Premenopausal Women with Iron Deficiency Anemia

Introduction The reported rates of gastrointestinal (GI) lesions among pre-menopausal women with iron deficiency anemia (IDA) vary considerably. Aim To assess the prevalence of significant gastrointestinal lesions among symptomatic and asymptomatic pre-menopausal women with IDA, and to shed light on potential predictors of their presence. Methods Clinical, endoscopic, and histological data was collected from 116 pre-menopausal women with IDA. All women underwent upper and lower gastrointestinal tract endoscopies, duodenal biopsies, and small bowel evaluation with small bowel series or computed tomography. Results The mean age was 33 years (range: 18–45). Clinically, significant lesions were demonstrated in 30%, the majority in the upper gastrointestinal tract. Helicobacter pylori gastritis was the most common finding (16%). Celiac disease was detected in 6%. No malignant lesions were detected. The prevalence of lesions was highest among women with symptoms of heartburn and regurgitation. The presence of upper gastrointestinal symptoms (OR: 3.67, 95%CI: 2.14–5.03; P = 0.002), MCV lower than 70 pg (OR: 1.88, 95%CI: 1.27–3.91; P = 0.04), and hemoglobin levels less than 10 g/dl (OR: 1.71, 95%CI: 1.19–4.07; P = 0.05) were associated with an increased likelihood of significant gastrointestinal lesions; history of heavy menstrual blood loss was associated with negative findings (OR: 0.46, 95%CI: 0.27–0.69; P = 0.002). Conclusions Upper GI findings, mainly HP gastritis and celiac disease, were the most common pathologic findings. Initial evaluation of IDA in premenopausal women may include urea breath test and celiac serology. Further endoscopic evaluation can be reserved for those women who are found to be negative in the initial evaluation, as well as in cases of failure of IDA remission after successful HP eradication.     

Prospective evaluation of gastrointestinal tract in patients with iron-deficiency anemia

Gastrointestinal bleeding is believed to cause iron-deficiency anemia (IDA). The information concerning ideal evaluation of the gastrointestinal tract and exact findings in patients with IDA is scant. The aim of this study was to prospectively evaluate patients with IDA for gastrointestinal lesions potentially causing IDA at a US Army Teaching Medical Center with Gastroenterology Fellowship. Seventy patients with IDA had esophagogastroduodenoscopy (EGD) and colonoscopy, and if this evaluation was unremarkable, then small bowel biopsy was obtained at EGD to evaluate for celiac disease. Enteroclysis was done if endoscopic evaluation was negative. At endoscopy, at least one lesion potentially accounted for the IDA in 50 (71%) patients. At colonoscopy, 21 (30%) patients had 22 lesions (four colon cancer, seven adenoma>1 cm, six vascular malformation, four severely bleeding hemorrhoids, one ileal Crohn's); at EGD, 39 (56%) patients had 43 lesions (11 gastric erosion, 10 esophagitis, four vascular malformation, four celiac disease, three gastric cancer, three gastric ulcer, three duodenal ulcer, two gastric polyp>1 cm, one duodenal lymphoma, one esophageal cancer, and one duodenal Crohn's). Twelve (17%) patients had both upper and lower gastrointestinal tract lesions. Twenty-four of 32 (75%) patients with positive fecal occult blood test had potentially bleeding lesions compared to 24 of 38 (63%) patients with negative fecal occult blood test (P>0.05). Six of nine patients with malignancy had positive fecal occult blood test. Twenty patients with normal endoscopy and small bowel biopsy had normal enteroclysis. It is concluded that the combination of colonoscopy and EGD identifies potential bleeding sources in most patients with IDA. In the absence of a potential bleeding lesion, small bowel biopsy at EGD is essential to diagnose celiac disease.The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense.     

A Blinded Pilot Comparison of Capsule Endoscopy and Small Bowel Histology in Unresponsive Celiac Disease

This study compares video capsule endoscopy (VCE) with histological specimens of proximal small bowel in patients with celiac disease who have failed to respond to a gluten-free diet. Patients with nonresponsive celiac disease underwent capsule endoscopy, and concordance between endoscopy and histology was then calculated using the kappa statistic. In 19 patients, endoscopy videos were reported as normal in ten (53%) case, as having mild changes in three (16%) cases, and as having moderate-severe changes in six (31%) cases. Two (11%) had acute ulcers. No small bowel tumors were seen. Endoscopy demonstrated concordance with histological changes in 14 of the 18 patients with histology available (78% concordance). The kappa statistic suggested a substantial degree of concordance between histology and endoscopic findings. Endoscopy with distal duodenal biopsies is superior to VCE in detecting proximal, nonresponsive celiac disease, but more distal lesions may be missed such that the strength of VCE lies in its ability to visualize the entire small bowel.     

Detection of adult celiac disease using duodenal screening biopsies over a 30-year period

BACKGROUND:

Serological studies suggest that celiac disease may be present in approximately 0.5% to 1% of the North American population. Screening data based on small intestinal biopsy performed during routine endoscopic evaluations are not available.

METHODS:

Patients referred between January 1982 and December 2011 for evaluation of gastrointestinal symptoms and requiring elective investigative upper endoscopic evaluation underwent duodenal biopsies to determine whether changes of adult celiac disease were present.

RESULTS:

A total of 9665 patients, including 4008 (41.5%) males and 5657 (68.5%) females, underwent elective endoscopies and duodenal biopsies. Of these, 234 (2.4%) exhibited changes of celiac disease including 73 males (1.8%) and 161 females (2.8%). During the first 20 years, the number of biopsy-positive patients in five-year intervals progressively decreased and, subsequently, during the next 10 years, the number progressively increased.

CONCLUSIONS:

Celiac disease is far more common in specialist practice than has been suggested in the evaluation of healthy populations using serological screening studies. Endoscopic duodenal biopsy is an important method of identifying underlying celiac disease and should be routinely considered in all patients undergoing an elective endoscopic evaluation. Noninherited factors, possibly environmental, may play a role in the appearance of biopsy-defined celiac disease and alter detection over time.     

The value of duodenal biopsy within routine upper endoscopy: a prospective study in 1000 patients

BACKGROUND AND AIM: Several gastrointestinal diseases are localised in the small bowel and are confirmed by duodenal biopsies upon upper gastrointestinal endoscopy. However, the clinical value of routine duodenal biopsies during endoscopy has not been satisfactorily defined and was assessed in the current study. METHODS: In 1000 consecutive patients duodenal biopsies were performed during routine upper gastrointestinal endoscopy. Endoscopic diagnoses, symptoms and the prevalence of anaemia were correlated with the histological diagnoses. RESULTS: Coeliac disease and giardiasis was diagnosed in 18 and two patients, respectively (2.0 % of all cases). In 11 (55 %) patients the diagnosis was already made macroscopically during endoscopy. The sensitivity for endoscopic diagnosis of coeliac disease MARSH III was 84.6 %. There was no correlation between clinical symptoms, the prevalence of anaemia and the diagnosis of coeliac disease or giardiasis in our cohort. CONCLUSION: Endoscopic diagnosis of advanced celiac disease (MARSH III) can be made with high sensitivity and specifity. Nevertheless, duodenal biopsy is necessary for the diagnosis of early coeliac disease or giardiasis. However, the routine duodenal sampling of normal mucosa during gastrointestinal endoscopy cannot be recommended.     

Diagnostic and therapeutic impact of double-balloon enteroscopy (DBE) in a series of 100 patients with suspected small bowel diseases

BACKGROUND: Double-balloon enteroscopy is a newly developed endoscopic method allowing non-surgical full-length exploration of the small bowel, biopsies sample and endoscopic treatment of previously inaccessible lesions. AIM: To prospectively assess the diagnostic and therapeutical impact of double-balloon enteroscopy in patients with suspected or documented small bowel disease. PATIENTS AND METHODS: One hundred consecutive patients referring to our centre for suspected small bowel disease underwent double-balloon enteroscopy. Starting insertion route (anal or oral) of double-balloon enteroscopy was chosen according to the estimated location of the suspected lesions basing on the clinical presentation and on the findings, when available, of previous endoscopic or radiological investigations. Major indications for the procedures were acute recurrent or chronic mid-gastrointestinal bleeding (n=71), suspected gastrointestinal tumours (n=10), suspected Crohn's disease (n=6), chronic abdominal pain and/or chronic diarrhoea (n=8), refractory celiac disease (n=5). RESULTS: One hundred and eighteen double-balloon enteroscopy procedures were carried out. Oral and anal route double-balloon enteroscopies were performed in 54 and 28 patients, respectively, while 18 patients underwent a combination of both approaches. Overall diagnostic yield of double-balloon enteroscopy resulted 69%. Most common pathological findings included angiodysplasias (n=39), ulcerations and erosions of various aetiologies (n=21), tumours (n=7) and ileal stenosis in patients with Crohn's disease suspicion (n=2). In the 65% of the patients examined, double-balloon enteroscopy findings influenced the subsequent clinical management (endoscopic, medical or surgical treatment). No major complications related to the procedure occurred. CONCLUSIONS: Our prospective analysis shows that double-balloon enteroscopy is a useful, safe and well-tolerated new method with a high diagnostic and therapeutic impact for the management of suspected or documented small bowel diseases.     

Collagenous colitis as the presenting feature of biopsy-defined celiac disease

BACKGROUND: Prior case reports have linked celiac disease with collagenous colitis, but serological and retrospective pathologic survey studies of small intestinal biopsies have produced conflicting results. METHODS: In this report, consecutive patients with chronic diarrhea and the initial finding of collagenous colitis were evaluated to determine if occult celiac disease was also present. All 36 patients with no exclusions were offered upper endoscopy and biopsies. If the changes of untreated celiac disease were detected in the small intestinal biopsies, then a gluten-free diet was instituted. Diet response was based on resolution of diarrhea and normalization of repeated small intestinal biopsies. RESULTS: Eight patients, or over 20%, had severely abnormal small bowel biopsy changes characteristic of untreated celiac disease. In some, lymphocytic or collagenous gastritis were also detected with or without celiac disease. All 8 patients were treated with a gluten-free diet alone and, in all, diarrhea improved and small intestinal biopsies normalized. In 5, however, repeated colonic biopsies showed persistent collagen deposits. Autoimmune thyroid disease or neoplastic diseases, like lymphoma known to be associated with celiac disease were also noted in this cohort with collagenous colitis, often in the absence of celiac disease. CONCLUSIONS: This study indicates that collagenous colitis may be the presenting clinical and pathologic feature of celiac disease. Diagnosis of collagenous colitis should lead the clinician to consider exclusion of underlying occult celiac disease.     

Diagnosis of small bowel malabsorption syndromes in adults

Patients with malabsorption represent a small proportion of presentations with chronic diarrhea. In spite of some progress, the last twenty years were not very innovating in malabsorption investigations. Supporting history may direct investigations toward either the small bowel or pancreas. Serological testing for celiac disease will determine most cases without invasive investigation, but individuals suspected to have small bowel malabsorption, despite negative celiac serology, should have endoscopic distal duodenal biopsies taken to exclude other rare forms of small bowel enteropathy. This strategy has largely supplanted many older tests of small bowel function.     

The value of double-balloon enteroscopy in patients with refractory celiac disease

OBJECTIVE: Patients with refractory celiac disease can develop enteropathy-associated T-cell lymphoma (EATL) or ulcerative jejunitis. Double-balloon enteroscopy allows examination of the small bowel. We prospectively assessed the value of this technique in patients with refractory celiac disease in a tertiary referral center. METHODS: Small bowel enteroscopy was performed in a total of 21 consecutive patients for lesions like ulcerations (high risk). Biopsy specimens were taken from such lesions and from examined small bowel at three different levels of scope insertion depth. Tissue specimens were evaluated for the modified Marsh classification and for the presence of EATL. RESULTS: Twenty-four procedures were successfully performed without complications. EATL was found in five patients (24%, 95% CI 10-45%) as circumferential, discrete, or confluent ulcerations. In three of them, Marsh III was found while in the other two patients with EATL Marsh I was found. Another two patients (9%, 95% CI 2-28%) had ulcerative jejunitis in the absence of EATL and histology was compatible with Marsh III. In the remaining 14 patients (54%, 95% CI 35-73%), no high-risk lesions were found. Double-balloon enteroscopy could exclude the presence of EATL in four patients that was suggested by abdominal computerized tomography. CONCLUSIONS: Complications of refractory celiac disease like ulcerative jejunitis or EATL could efficiently be detected or excluded by double-balloon enteroscopy. This technique should be reserved for patients with refractory celiac disease or patients with a past history of EATL.     

Risk of Duodenal Adenoma in Celiac Disease

Background: There is a 60- to 80-fold increased risk of small-bowel adenocarcinoma in patients with celiac disease. While the adenoma-carcinoma sequence appears to operate in the small bowel as in the large bowel, the risk of duodenal adenomas in celiac patients is unknown. Methods: The records of 381 patients (245 F, 136 M) with biopsy-proven celiac disease were reviewed to determine the prevalence of duodenal adenoma found during esophagogastroduodenoscopy (EGD). We conducted an extensive literature review to find data for estimates of the prevalence of duodenal adenoma in a comparable general population; we used data from a study at another New York City medical center of 7346 EGDs conducted between 1976 and 1982 (Ghazi et al., 1984). We estimated the relative risk, expressed as a standard morbidity ratio (SMR), by calculating the observed to expected (O/E) ratio. Results: Duodenal adenomas were found in 3 celiac patients (0.78%), with 24 adenomas (0.33%) in the reference population, giving an SMR of 2.39 (95% CI 0.67-8.48). Conclusion: We did not find a significantly increased risk of duodenal adenoma in celiac patients compared to a non-celiac endoscoped population. Thus, despite the previously described elevated risk of small-bowel adenocarcinoma in these patients, routine endoscopic examination of the duodenum may not be adequate for screening.     

Risk of duodenal adenoma in celiac disease

BACKGROUND: There is a 60- to 80-fold increased risk of small-bowel adenocarcinoma in patients with celiac disease. While the adenoma-carcinoma sequence appears to operate in the small bowel as in the large bowel, the risk of duodenal adenomas in celiac patients is unknown. METHODS: The records of 381 patients (245 F, 136 M) with biopsy-proven celiac disease were reviewed to determine the prevalence of duodenal adenoma found during esophagogastroduodenoscopy (EGD). We conducted an extensive literature review to find data for estimates of the prevalence of duodenal adenoma in a comparable general population; we used data from a study at another New York City medical center of 7346 EGDs conducted between 1976 and 1982 (Ghazi et al., 1984). We estimated the relative risk, expressed as a standard morbidity ratio (SMR), by calculating the observed to expected (O/E) ratio. RESULTS: Duodenal adenomas were found in 3 celiac patients (0.78%), with 24 adenomas (0.33%) in the reference population, giving an SMR of 2.39 (95% CI 0.67-8.48). CONCLUSION: We did not find a significantly increased risk of duodenal adenoma in celiac patients compared to a non-celiac endoscoped population. Thus, despite the previously described elevated risk of small-bowel adenocarcinoma in these patients, routine endoscopic examination of the duodenum may not be adequate for screening.     

Intestinal disaccharidase deficiency without villous atrophy may represent early celiac disease

BACKGROUND: Intestinal disaccharidase activities are decreased in untreated celiac disease and also in other conditions without villous atrophy. Of 908 patients examined for suspected malabsorption, 37 (4.1%) had generalized disaccharidase deficiency without villous atrophy. The aim was to determine if generalized disaccharidase deficiency without villous atrophy represented latent celiac disease. METHODS: Case notes and histology of the 37 patients were reviewed. History and blood investigations including antigliadin and endomysial antibodies were checked. Where celiac disease was suspected, endoscopic duodenal biopsies for histology and disaccharidase estimation were repeated. RESULTS: Of the initial 37 patients, 6 patients had had repeat endoscopic biopsies; one having celiac disease. A further 18 patients were reviewed. The remainder declined further investigation. Eight had repeat endoscopic duodenal biopsies; one had celiac disease. Two with positive celiac serology also had enteroscopy with jejunal biopsies; both had celiac disease. CONCLUSIONS: At least 11% of patients with generalized disaccharidase deficiency without villous atrophy develop celiac disease. Enteroscopic biopsies from distal duodenum and proximal jejunum should be considered as the next investigation if endomysial or antigliadin antibodies are positive.     

Video capsule enteroscopy in the diagnosis of celiac disease: a multicenter study

OBJECTIVES: Duodenal biopsy is the current gold standard for diagnosis of celiac disease. Videocapsule endoscopy examines the entire small bowel and allows visualization of mucosal villi. We evaluated the potential of videocapsule endoscopy in assessing the severity and extent of mucosal changes in patients with suspected celiac disease. METHODS: Consecutive patients with signs/symptoms suggesting celiac disease and positive anti-gliadin and/or anti-endomysial and/or anti-tissue transglutaminase antibodies underwent upper gastrointestinal endoscopy and videocapsule endoscopy. Duodenal biopsies were classified according to modified Marsh's criteria. Capsule findings were evaluated for the presence of lesions compatible with celiac disease (scalloping of duodenal folds, fissures, flat mucosa, and mosaic appearance). RESULTS: Forty-three patients were studied. Duodenal histology was normal in 11 and compatible with celiac disease in 32. Using duodenal histology as the gold standard, the performance characteristics of capsule endoscopy for the diagnosis of celiac disease were: sensitivity 87.5% (95% CI 76.1-98.9%), specificity 90.9% (95% CI 81.0-100%), positive predictive value 96.5% (95% CI 90.1-100%), negative predictive value 71.4% (95% CI 55.8-87%), positive and negative likelihood ratios 9.6 and 0.14, respectively. Eighteen patients had mucosal changes extending beyond the duodenum, involving the entire small bowel in three. These patients tended to have more severe symptoms, but the difference was not statistically significant. Interobserver agreement for the diagnosis of celiac disease by capsule endoscopy ranged between 79.2 and 94.4%; kappa values ranged between 0.56 and 0.87. CONCLUSIONS: Videocapsule endoscopy shows good sensitivity and excellent specificity for the detection of villous atrophy in patients with suspected celiac disease.     

The symptomatic and histologic response to a gluten-free diet in patients with borderline enteropathy

GOALS: A clinical problem is posed by patients with symptoms suggestive of gluten sensitivity (diarrhea, weight loss, unresponsive iron-deficiency anemia, etc.); however, small intestinal biopsies reveal only minor abnormalities, such as lymphocytosis with or without crypt hyperplasia (Marsh I-II). Our aim was to assess the benefit of a gluten-free diet (GFD) in patients with these small bowel mucosal abnormalities. STUDY: We studied 35 patients (11 men, 24 women; mean age, 28 years; range, 22-51 years) referred to us for gastrointestinal symptoms or unexplained or unresponsive diseases. Because celiac disease was suspected to be the underlying pathology, small intestinal biopsies were taken. These revealed only minor abnormalities: 11 patients showed Marsh I type lesions, whereas 24 patients demonstrated Marsh II type lesions. Although the histologic lesions were inconsistent for celiac disease and a suspicion of a borderline celiac disease persisted, all patients were motivated to adhere to GFD.RESULTS Only 23 patients adhered to our advice and followed a GFD; follow-up biopsies were taken after 8 to 12 months. In the Marsh I lesion group (seven patients), five patients showed mucosal normalization to Marsh 0 and two showed persistence of Marsh I lesions. In the Marsh II lesion group (16 patients), 9 patients revealed mucosal normalization, 5 improved to a Marsh I lesion, and 3 revealed persistence of Marsh II lesions. A dramatic clinical improvement in symptoms was noted in all patients who were on a GFD, with symptoms virtually disappearing in all patients. Seven patients who refused GFD were reevaluated 8 to 12 months later. Symptoms and histologic lesions were unchanged in six, all of whom refused again to adhere to a GFD. One of the seven with Marsh I lesions had a worsening of symptoms and of histologic lesions (from Marsh I to Marsh IIIa); so, this last patient adhered to a GFD. CONCLUSIONS: Symptoms disappeared after GFD in patients suspected to have celiac disease but with slight histologic lesions. Although Marsh I-II lesions cannot be classified as celiac lesions (ESPGAN criteria), the patients' symptoms at presentation and the clear improvement of symptoms when on GFD, with or without improvement of histologic lesions, supports the assumption that these patients are sensitive to gluten and may justify treatment with a GFD.     

The prevalence of unrecognized adult celiac disease in Central Anatolia

BACKGROUND: The aim of this study is to assess the prevalence of unrecognized adult celiac disease in Central Anatolia of Turkey and establish if prevalence figures are similar to other reports in the international literature. METHODS: Subjects were randomly selected from patients at the time of blood sampling because of a routine examination or suspicion of some disorder other than celiac diseases and were screened with anti-tissue transglutaminase IgA and serum IgA measurements. Duodenal biopsies were taken from the patients who were found positive for anti-tissue transglutaminase IgA and had low IgA levels. RESULTS: A total of 906 subjects between 20 and 59 years of age were included. Small bowel biopsies were performed for 55 of the 906 participants. Fifty-two of 55 participants taken biopsies had anti-tissue transglutaminase IgA levels greater than 15 IU/mL and 3 of them had low IgA levels. Celiac disease was diagnosed as 9 of 906 (0.99%). The majority of the patients with celiac disease had nonspecific gastrointestinal symptoms. There was no correlation between the titers of anti-tissue transglutaminase IgA and the severity of histopathologic findings. CONCLUSIONS: In this study, we found that unrecognized adult celiac disease in Central Anatolia affects approximately 1% of the population, and the major constellation of symptoms are nonspecific gastrointestinal related. Serologic data are not adequate for a definite diagnosis, but the anti-tissue transglutaminase IgA test has high diagnostic value and may be used as screening tool. Confirmation with intestinal biopsy is required for a definite diagnosis.     

Push and Sonde Enteroscopy for the Diagnosis of Obsccre Gastrointestinal Bleeding

Objective: The combination of push and sonde enteroseopy permits endoscopic evaluation to extend the distal small bowel. Our objective was to determine the yields of both push and sonde enteroscopy in patients with obscure GI bleeding. Methods: We retrospectively reviewed 553 small bowel examinations performed with an orally passed 135-cm pediatric colonoscope in combination with a 2750-cm per nasal sonde enteroscope to investigate the small bowel for sources of gastrointestinal bleeding of obscure origin. Results: The examination reached the distal Jejunum or beyond in over 90% of patients undergoing both push and sonde enteroscopy. The yield of these combined studies was 58% for identifying a possible source of gastrointestinal blood loss. In 40% of the examinations, the abnormality was found distal to tbe limits of routine upper gastrointestinal en-doscopy. In 26% of all examinations, the lesion was detectable only by sonde enteroscopy. The most common small bowel findings were mucosal vascular lesions (31% of all exams) and tumors (6%). No major endoscopic complications occurred, and patients tolerated the procedures well. Conclusions: The combination of push and sonde enteroscopy is a valuable tool in the evaluation of obscure gastrointestinal bleeding and may provide useful information necessary to formulate treatment plans aimed at cessation of bleeding.     

Intestinal Disaccharidase Deficiency Without Villous Atrophy May Represent Early Celiac Disease

Background: Intestinal disaccharidase activities are decreased in untreated celiac disease and also in other conditions without villous atrophy. Of 908 patients examined for suspected malabsorption, 37 (4.1%) had generalized disaccharidase deficiency without villous atrophy. The aim was to determine if generalized disaccharidase deficiency without villous atrophy represented latent celiac disease. Methods: Case notes and histology of the 37 patients were reviewed. History and blood investigations including antigliadin and endomysial antibodies were checked. Where celiac disease was suspected, endoscopic duodenal biopsies for histology and disaccharidase estimation were repeated. Results: Of the initial 37 patients, 6 patients had had repeat endoscopic biopsies; one having celiac disease. A further 18 patients were reviewed. The remainder declined further investigation. Eight had repeat endoscopic duodenal biopsies; one had celiac disease. Two with positive celiac serology also had enteroscopy with jejunal biopsies; both had celiac disease. Conclusions: At least 11% of patients with generalized disaccharidase deficiency without villous atrophy develop celiac disease. Enteroscopic biopsies from distal duodenum and proximal jejunum should be considered as the next investigation if endomysial or antigliadin antibodies are positive.