Reliability of the "immersion technique" during routine upper endoscopy for detection of abnormalities of duodenal villi in patients with dyspepsia

BACKGROUND: Upper endoscopy is not routinely performed to directly detect abnormalities of the duodenal villi. The reliability of the immersion technique for assessment of duodenal villi was evaluated in a series of patients with dyspepsia. METHODS: A total of 396 patients who were to undergo standard EGD for dyspeptic symptoms were enrolled. Patients with suspected malabsorption were excluded. By performing a "modified immersion technique," duodenal villi were scored as the following: definitely present, partially present, or definitely absent. Three duodenal biopsy specimens were obtained from each patient, and villi also were scored histologically as the following: normal, partial villous pattern, or total villous atrophy. RESULTS: Sensitivity, specificity, and positive and negative predictive values of the modified immersion technique for detection of total villous atrophy were 100%, 99.7%, 85.7%, and 100%, respectively. Sensitivity, specificity, and positive and negative predictive values of modified immersion technique for detection of partial villous patterns were 75%, 99.5%, 60%, and 99.7%, respectively. Sensitivity, specificity, and positive and negative predictive values for modified immersion technique detection of any villous abnormality (partial or total villous atrophy) were 90.9%, 99.5%, 83.3%, and 99.7%, respectively. CONCLUSIONS: During standard EGD, duodenal evaluation by modified immersion technique can reliably detect abnormalities of duodenal villi. This simple diagnostic technique may be performed routinely during endoscopic exploration of duodenum.     

Lack of endoscopic visualization of intestinal villi with the "immersion technique" in overt atrophic celiac disease

BACKGROUND: The endoscopic appearance of the duodenal folds can predict the presence of celiac disease. However, endoscopic alterations can be minimal and the disease can have a "patchy" distribution histopathologically. The observation that intestinal villi can be better visualized when the duodenum is filled with water led to the development of an endoscopic "immersion technique" to assess celiac disease. METHODS: Endoscopy with duodenal biopsies was performed in 20 patients with malabsorption syndrome (positive for antiendomysial antibodies) and in 30 patients with reflux-like symptoms (negative for antiendomysial antibodies). Duodenal hypotonia was induced pharmacologically, water was introduced, and the mucosa was observed for the presence of villi. Photographs were obtained for subsequent analysis. The endoscopic appearance was classified from 1 (folds certainly present) to 4 ("scalloped valvulae"); villous structures were classified from 1 (definitely present) to 3 (definitely absent). RESULTS: Celiac disease was confirmed histopathologically in all patients with positive antiendomysial antibodies. The endoscopic appearance of the duodenum with air insufflation alone had a positive predictive value for the diagnosis of celiac disease of 84% and a specificity of 87%. Visualization of villi with the "immersion technique" had a higher positive predictive value (99%) and specificity (99%). CONCLUSIONS: A lack of visualization of intestinal villi in the descending duodenum with the "immersion technique" may increase the diagnostic accuracy of endoscopy for celiac disease. This technique could also be useful for targeting duodenal biopsies.     

Image-Enhanced Endoscopy with I-scan Technology for the Evaluation of Duodenal Villous Patterns

Background

I-scan technology is the newly developed endoscopic tool that works in real time and utilizes a digital contrast method to enhance endoscopic image.

Aims

We performed a feasibility study aimed to determine the diagnostic accuracy of i-scan technology for the evaluation of duodenal villous patterns, having histology as the reference standard.

Methods

In this prospective, single center, open study, patients undergoing upper endoscopy for an histological evaluation of duodenal mucosa were enrolled. All patients underwent upper endoscopy using high resolution view in association with i-scan technology. During endoscopy, duodenal villous patterns were evaluated and classified as normal, partial villous atrophy, or marked villous atrophy. Results were then compared with histology.

Results

One hundred fifteen subjects were recruited in this study. The endoscopist was able to find marked villous atrophy of the duodenum in 12 subjects, partial villous atrophy in 25, and normal villi in the remaining 78 individuals. The i-scan system was demonstrated to have great accuracy (100 %) in the detection of marked villous atrophy patterns. I-scan technology showed quite lower accuracy in determining partial villous atrophy or normal villous patterns (respectively, 90 % for both items).

Conclusions

Image-enhancing endoscopic technology allows a clear visualization of villous patterns in the duodenum. By switching from the standard to the i-scan view, it is possible to optimize the accuracy of endoscopy in recognizing villous alteration in subjects undergoing endoscopic evaluation.     

A comparison study between Magniview and high definition white light endoscopy in detecting villous atrophy and coeliac disease: A single centre pilot study

Background and aimsCoeliac disease may be missed at gastroscopy. We aimed to assess the sensitivity of Pentax optical zoom technology endoscopes in detecting duodenal villous atrophy and the ease of image interpretation by non-coeliac specialists.MethodAll patients attending for a gastroscopy were assessed for endoscopic villous atrophy in part one and two of the duodenum with high definition white light endoscopy and magnification endoscopy. Endoscopic findings of the duodenum were compared to histology as the reference standard.A short training video of varying degrees of villous atrophy seen by magnification endoscopy was used to train individuals. They were then assessed for the ability to differentiate between normal duodenum and villous atrophy.ResultsTwo hundred and fifty patients were prospectively recruited (145 females, 58%; age range 16–84, median age 50.5). Ninety-six patients had villous atrophy on histology (38.4%) 154 were controls. Magnification endoscopy had a higher sensitivity in detecting villous atrophy compared to high definition white light endoscopy (86.4% versus 78.4%, p = .0005).9/10 individuals undertaking magnification endoscopy training correctly identified all cases of villous atrophy.ConclusionMagnification endoscopy has superior diagnostic sensitivity in detecting villous atrophy compared to high definition white light endoscopy and the potential to be easily adopted by all endoscopists.     

Prevalence of celiac disease and its endoscopic markers among patients having routine upper gastrointestinal endoscopy

OBJECTIVE: The aim of this study was to determine the prevalence of duodenal villous atrophy (VA) among patients undergoing routine upper gastrointestinal (GI) endoscopy and the value of endoscopic markers for VA in selecting patients for duodenal biopsy. METHODS: One hundred and fifty adult patients with upper GI symptoms or iron-deficiency anemia had inspection and biopsy of the second part of the duodenum during endoscopy. Endoscopic markers for VA sought were mosaic or nodular mucosa, scalloping of duodenal folds, and reduction in number or absence of duodenal folds. RESULTS: Endoscopic markers were seen in seven patients (5%): scalloped folds with mosaic pattern mucosa (three patients), scalloped folds, reduced in number with mosaic pattern mucosa (three patients), and nodular mucosa with reduction in fold numbers (one patient). All seven patients had partial, subtotal, or total VA. One of 143 patients with no endoscopic abnormality had patchy VA. The prevalence of VA was thus 1:19 (8 of 150). Endoscopic markers had a sensitivity of 87.5% (7 of 8), specificity of 100% (142 of 142), positive predictive value of 100% (7 of 7), and negative predictive value of 99% (142 of 143). Of the eight patients with VA, the indications for endoscopy were upper GI symptoms in seven patients (two with anemia) and anemia without GI symptoms in one. After 6 months of dietary gluten exclusion, improvement by at least one criterion was documented in all eight patients. CONCLUSIONS: Careful inspection of the duodenum during routine upper GI endoscopy allows accurate selection of patients for biopsy but may not detect patchy VA or milder enteropathy. Celiac disease should be considered as a cause of dyspeptic and reflux symptoms, as well as of iron-deficiency anemia.     

Role of magnification endoscopy in the diagnosis and evaluation of suspected celiac disease: correlation with histology.

BACKGROUND: Magnification endoscopy (ME), with 115-fold magnification, allows visualization of duodenal villi. We assessed the efficacy of ME for evaluation of villous atrophy. METHODS: ME and duodenal biopsy were done in 16 patients with suspected celiac disease and 16 control subjects undergoing endoscopy for reflux symptoms. The pathologist was unaware of the ME findings. RESULTS: Sensitivity, specificity and positive and negative predictive values for villous atrophy (partial or total) were 100%, 91%, 83% and 100%, respectively. Corresponding values for normal villous structure were 91%, 100%, 100% and 83%, respectively. There was significant concordance between the ME and histology findings. CONCLUSION: ME is a reliable technique to diagnose villous atrophy.     

Early duodenal adenocarcinoma arising in gastric metaplasia treated by endoscopic resection

Early duodenal carcinoma is a rare entity. Most duodenal carcinomas are diagnosed at a more advanced stage. This report describes the case of a 59-year-old lady with an early duodenal adenocarcinoma diagnosed at check-up gastroduodenoscopy in an outpatient clinic who was referred to us for further investigation and management. The initial upper endoscopy at our department revealed a type IIa+c lesion in the proximal duodenum (10 - 12 mm diameter, flat elevated lesion with central depression). Using chromoendoscopy and magnification endoscopy the lesion could be well demarcated and neoplastic changes in the architecture of the intestinal villi could be detected. After submucosal epinephrine-saline injection, the lesion was removed by endoscopic resection without complications. Histopathological examination revealed the rare entity of an early duodenal carcinoma arising from incomplete-type gastric metaplasia in the duodenum. In summary, the presented paper describes a case of successful endoscopic treatment of an early duodenal carcinoma arising from incomplete gastric metaplasia.     

Endoscopic markers in adult coeliac disease

BACKGROUND: Various endoscopic markers have been described in coeliac disease, particularly in the second part of the duodenum, with minor attention generally being paid to the duodenal bulb. AIMS: To evaluate, prospectively, the presence of all endoscopic markers in the bulb and the second part of the duodenum on a large series of patients submitted to endoscopy for duodenal biopsy. PATIENTS AND METHODS. A total of 367 consecutive patients, submitted to endoscopy with duodenal biopsy for various indications, were considered. Biopsies were graded as normal, with partial villous atrophy (mild, moderate, severe) or with subtotal villous atrophy. Endoscopic markers and corresponding locations evaluated were: micronodular pattern [bulb and descending duodenum], mosaic appearance (bulb and descending duodenum), scalloped folds (descending duodenum), reduced or absent folds (descending duodenum). RESULTS: In 78 patients, a diagnosis of untreated coeliac disease was made. Endoscopic markers were seen in 73/78 patients, with only a single sign present (bulb or descending duodenum) in 12 patients. In the remaining 289 patients, normal histology and normal endoscopic findings were observed, except in two patients with reduced folds. Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy regarding all endoscopic markers were 93.6%, 99.3%, 97.3%, 98.3% and 98.1%, respectively CONCLUSIONS: This study confirms the usefulness of endoscopic markers in detecting coeliac disease, underlining the importance of evaluating also abnormalities in the bulb and endoscopic single signs; although endoscopy may not detect all cases of coeliac disease, the recognition of endoscopic markers allows the selection for biopsy of unsuspected patients submitted to endoscopy for non-specific symptoms.     

Erosions in the second part of the duodenum in patients with villous atrophy

BACKGROUND: There are various, well-documented, duodenal endoscopic markers caused by the villous atrophy of celiac disease. Another abnormality seen in association with villous atrophy, erosions in the second part of the duodenum, is described. To our knowledge, this finding has not been heretofore described in patients with celiac disease. METHODS: Five patients with celiac disease and erosions were encountered over a period of 2 years. OBSERVATIONS: The erosions were multiple, superficial, and present in the second part of the duodenum but not the duodenal bulb. All 5 patients had findings typical of celiac disease (iron deficiency, osteopenia/osteoporosis), and 4 had at least one other endoscopic marker: scalloped duodenal folds (3), fold loss (2), or mosaic pattern mucosa (2). These patients represented 7% of new cases of celiac disease during the same time period. This pattern of erosion was not observed in over 1200 other patients undergoing upper endoscopy during the study period. CONCLUSIONS: In a European population, the finding of erosions confined to the second part of the duodenum is specific for villous atrophy, although sensitivity is low. Erosions in the second part of the duodenum should be added to the list of endoscopic markers of celiac disease.     

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.     

Continuous Infusion of Cholecystokinin Leads to Down-Regulation of the Cholecystokinin-A Receptor in the Rat Pancreas

Background: Coeliac disease may present with dyspepsia or reflux. There are characteristic duodenal appearances associated with villous atrophy (mosaic pattern mucosa and loss, reduction in number or scalloping of duodenal folds) which may prompt small-bowel biopsy during routine upper gastrointestinal endoscopy. These appearances were sought in patients referred by their general practitioners for open-access endoscopy (OAE), to determine the prevalence and significance of coeliac disease as a cause of symptoms. Methods: Five hundred consecutive patients undergoing OAE by one consultant gastroenterologist were studied. Forceps biopsy specimens from the distal duodenum were taken if appearances were suggestive. If villous atrophy was confirmed, the response of symptoms to dietary gluten exclusion was assessed. Results: Ten patients had suggestive endoscopic appearances, of whom eight had villous atrophy, giving a prevalence of coeliac disease of 1.6% (1:63). All eight had mosaic pattern mucosa, with three also having reduction of duodenal folds, and four having scalloped folds. All had serum endomysial antibodies (EmA). Apart from diarrhoea, described by one patient, there were no symptoms of `typical' coeliac disease at diagnosis: three patients were overweight. After dietary gluten exclusion all reported symptomatic improvement, with disappearance of EmA in five patients to date. Conclusions: There is a high prevalence of coeliac disease among patients undergoing OAE, which is relevant to their clinical symptoms and which can be identified by careful endoscopic inspection of the duodenum.     

Intestinal metaplasia of the gastric cardia: A prospective study with enhanced magnification endoscopy

OBJECTIVE: There are no endoscopic features that distinguish intestinal metaplasia of the cardia (CIM) from the normal cardia. Biopsy specimens are therefore randomly obtained from normal-appearing mucosa with significant potential sampling errors. Enhanced magnification endoscopy involves the combined use of magnification endoscopy with acetic acid instillation. This study assessed the value of enhanced magnification endoscopy in detecting CIM. METHODS: Patients undergoing elective upper endoscopy were invited to participate in the study. Patients were included if the squamocolumnar junction and the esophagogastric junction were judged to be at the same level. Enhanced magnification endoscopy was performed with 3% acetic acid instillation. Standard endoscopy was followed by magnification endoscopy and repeated after acetic acid spraying. Surface patterns were characterized before and after acetic acid spraying. The observed surface patterns were compared with histological results obtained from a single targeted biopsy specimen of each pattern. RESULTS: The overall prevalence of CIM was 34.8% (86/247 patients). After excluding 52 patients because of endoscopic evidence of Barrett's esophagus, 195 patients were eligible for participation in the study. In the study group, CIM was detected in 86 patients (44.1%) in targeted biopsy samples. No dysplasia was identified. Enhanced magnification endoscopy detected four different patterns of the mucosal surface: I) round pits, II) reticular, III) villous, and IV) ridged. The yields of detection of intestinal metaplasia according to endoscopic patterns were I) 0%, II) 5.3% (odds ratio = 0.05), III) 57.7% (odds ratio = 7.5, p = 0.0001), and IV) 95.8% (odds ratio = 42.8, p = 0.0001). CONCLUSIONS: CIM is more common than previously reported. Enhanced magnification endoscopy identifies two characteristic endoscopic patterns, villous (pattern III) and ridged (pattern IV), with outstanding clarity and resolution that correlate with histological identification of CIM with a single targeted biopsy sample. Enhanced magnification endoscopy will permit longitudinal studies of an entity that can be identified endoscopically.     

Disappointing sensitivity of endoscopic markers for villous atrophy in a high-risk population: implications for celiac disease diagnosis during routine endoscopy

OBJECTIVE: Endoscopic markers of duodenal villous atrophy (VA) can facilitate diagnosis of celiac disease during routine upper GI endoscopy. We studied their sensitivity for VA in a large series of patients undergoing GI endoscopy specifically for duodenal biopsy. Poor sensitivity in this setting would have significant and adverse implications for their performance during routine endoscopy. METHODS: All patients with VA on duodenal biopsy performed for positive serum endomysial antibody (EmA) and/or clinical features suggestive of celiac disease were included. The second part of duodenum was inspected carefully for endoscopic markers using videogastroscopes. RESULTS: Of 129 patients studied, 99 (77%) had at least one endoscopic markers. The most commonly seen marker were a mosaic pattern mucosa (68 patients, 53%) and scalloping of duodenal folds (74 patients, 57%). The prevalence of markers was significantly lower for partial VA (15 of 26 patients, 58%) than for subtotal or total VA (84 of 103 patients, 82%) (p < 0.02). CONCLUSIONS: Endoscopic markers have disappointing sensitivity even in a population at high risk of celiac disease, particularly for partial VA. Their performance may be even poorer in an unselected dyspeptic population. Although they may help improve diagnosis rates among patients with nonspecific dyspeptic symptoms, many patients, particularly those with milder enteropathy, will be missed. As celiac disease is an important cause of dyspepsia, consideration should be given to serological screening to further improve diagnosis rates, as few centers will have the resources to routinely biopsy all patients.     

Classification of villous atrophy with enhanced magnification endoscopy in patients with celiac disease and tropical sprue

BACKGROUND: Intestinal lesions in celiac disease (CD) and tropical sprue (TS) can be patchy. Improved endoscopic identification of affected areas may increase the diagnostic yield of biopsy specimens. Enhanced magnification endoscopy [EME] combines magnification endoscopy with 3% acetic acid instillation. OBJECTIVE: This study describes endoscopic findings associated with villous atrophy during EME. DESIGN: Patients underwent EME with a magnifying endoscope with acetic-acid application. Surface mucosal patterns were characterized before and after acetic-acid spraying. Observed surface patterns were compared with histologic results obtained from a single targeted biopsy specimen. SETTING: Policlinica Metropolitana in Caracas, Venezuela. PATIENTS: Patients with diagnosed but untreated CD or TS. RESULTS: Fifty-two biopsy specimens were obtained from 27 patients (17 men, 10 women; mean age 50.5 years; range, 24-76 years; 12 with CD and 15 with TS). EME of the duodenum revealed 4 different mucosal patterns: I, normal; II, stubbed; III, ridged; and IV, foveolar. Three of the 4 patterns were strongly associated with the presence of villous atrophy (pattern I, 1/18 [5.5%]; II, 16/17 [94%]; III, 12/12 [100%]; and IV, 5/5 [100%]). EME was more sensitive than standard endoscopy for detecting villous atrophy, 100% versus 58% in CD and 93% versus 20% in TS. Furthermore, EME identified patchy areas of partial villous atrophy in 16 patients (5 CD and 11 TS) in whom standard endoscopy was normal. CONCLUSIONS: EME identifies 3 characteristic endoscopic patterns that correlate with the presence of villous atrophy. EME could help identify patchy areas of partial mucosal atrophy, potentially reducing the need for blind biopsies.     

Role of the "immersion technique" in diagnosing celiac disease with villous atrophy limited to the duodenal bulb

GOALS: To investigate if the so-called immersion technique during upper endoscopy may be helpful to predict patterns of villous atrophy restricted to the duodenal bulb. BACKGROUND: Patients with celiac disease may have a patchy distribution of duodenal villous atrophy. In some cases, mucosa of duodenal bulb may be the only intestinal area involved. The immersion technique is a novel procedure that allows visualizing duodenal villi directly during endoscopy. STUDY: With this prospective study, the immersion duodenoscopy was performed in 67 celiac subjects to investigate their duodenal villous pattern. Villi were evaluated both in the first and in the second duodenal segment and judged as present or absent (flat mucosa). Results were compared with histology as reference. RESULTS: Among celiac subjects, 49 were newly diagnosed and 18 previously diagnosed celiac patients. Four (8%) newly diagnosed and 7 (39%) previously diagnosed celiac subjects had an extension of the villous atrophy (flat mucosa) limited to the duodenal bulb. The sensitivity, specificity, and positive and negative predictive values of the immersion-based duodenal investigation in predicting areas of duodenal villous atrophy was always 100%. CONCLUSIONS: Immersion technique may be useful for directing duodenal biopsies in celiac subjects with a patchy distribution of villous atrophy. This procedure can avoid blinded sampling of the duodenal mucosa and enhance the diagnostic yield.     

Enhanced magnification endoscopy: a new technique to identify specialized intestinal metaplasia in Barrett's esophagus

BACKGROUND: Specialized intestinal metaplasia (SIM) in Barrett's esophagus (BE) is not identifiable by standard endoscopy. Acetic acid instillation enhances the ability to detect columnar epithelium at the squamocolumnar union. Enhanced magnification endoscopy involves the combined use of magnification endoscopy with acetic acid. This study assessed the value of enhanced magnification endoscopy in detecting SIM in patients with BE. METHODS: Patients undergoing endoscopic surveillance because of short segment BE without dysplasia underwent enhanced magnification endoscopy with 1.5% acetic acid instillation. Standard endoscopy was followed by magnification endoscopy and repeated after acetic acid spraying. Surface patterns were characterized prior to and after acetic acid spraying. The observed surface patterns were compared with histology results. RESULTS: Forty-nine patients, 9 women and 39 men, with a mean age of 50.5 years were studied. One was excluded because of unclear definition of the surface pattern. Enhanced magnification endoscopy detected 4 different mucosal surface patterns: I, round pits; II, reticular; III, villous; and IV, ridged. A total of 129 areas were examined. Standard endoscopy identified an endoscopic pattern in 1.5% of the areas, standard endoscopy and acetic acid in 8.5%, magnification endoscopy alone in 38%, and enhanced magnification endoscopy in all 129 endoscopic areas. The yields for detecting SIM according to endoscopic patterns were as follows: pattern I, 0%; II, 11% (odds ratio 0.5, p = 0.54); III, 87% (odds ratio 36, p = 0.001); and IV, 100% (odds ratio 14, p = 0.015). CONCLUSIONS: Enhanced magnification endoscopy is an accurate method of predicting SIM in BE. The simplicity of the technique and its ability to identify characteristic endoscopic patterns with outstanding clarity and resolution that correlate with histologic identification of specialized intestinal metaplasia make enhanced magnification endoscopy an excellent method for the evaluation of patients with BE.     

Capsule endoscopy: An alternative to duodenal biopsy for the recognition of villous atrophy in coeliac disease?

BACKGROUND: Villous atrophy present on a duodenal biopsy remains the 'gold standard' diagnostic test for coeliac disease. However, endoscopic biopsy may cause morbidity and discomfort. Our aim was to evaluate wireless capsule endoscopy as an alternative test for the recognition of villous atrophy. METHOD: Twenty-one patients with a positive endomysial antibody referred for endoscopy and duodenal biopsy were also offered a wireless capsule endoscopy to evaluate their small bowel. Concurrently, other patients (n=23) referred for a wireless capsule endoscopy acted as controls. Wireless capsule endoscopy reports were assessed for the presence of villous atrophy by one blinded investigator. RESULTS: Twenty endomysial antibody positive patients subsequently had villous atrophy on duodenal biopsy. The controls all had normal duodenal biopsies (with a negative endomysial antibody) and no evidence of villous atrophy noted on their wireless capsule endoscopy. Of the 20 endomysial antibody positive patients with confirmed villous atrophy on biopsy, 17 had villous atrophy also detected by wireless capsule endoscopy. The sensitivity, specificity, positive and negative predictive values for wireless capsule endoscopy recognising villous atrophy were 85%, 100%, 100%, 88.9%, respectively. CONCLUSION: Wireless capsule endoscopy may be an option to recognise villous atrophy in patients with a positive endomysial antibody who are unwilling, or unable to have a gastroscopy. However, a negative test should be followed by a biopsy if coeliac disease is to be excluded.     

Endoscopic features of celiac disease in children.

BACKGROUND: Endoscopic abnormalities have been described in adult patients with celiac disease that may suggest the diagnosis, especially when the presentation is atypical. METHODS: The duodenum of 140 children undergoing EGD for various different indications was evaluated macroscopically and histologically. RESULTS: Histology revealed total villous atrophy in 80 patients, 79 of whom had celiac disease. Among these, 100% had a mucosal mosaic pattern in the duodenum (sensitivity 98.7%, specificity 96.7%, positive predictive value 97.5%, negative predictive value 98.3%), 70% had scalloped duodenal folds (sensitivity 68.7%, specificity 98.3%, positive predictive value 98.2%, negative predictive value 70.2%), 15% had visible vasculature, and 6% had reduction of duodenal folds. Sensitivity and specificity of endoscopic findings were not modified by chromoendoscopy. Except for the mosaic pattern, the frequency of endoscopic abnormalities increased with age; reduction of duodenal folds was never seen in children with celiac disease who were less than 5 years of age. CONCLUSIONS: The frequency and diagnostic value of endoscopic abnormalities are different in children with celiac disease compared with adults with this disease. Because indications for endoscopy, such as abdominal pain, dyspepsia, and unexplained anemia, can be manifestations of celiac disease, and villous atrophy may have a patchy distribution, awareness of these endoscopic abnormalities is important in the diagnosis of celiac disease in children.     

Endoscopic markers for celiac disease

Celiac disease is common and can present with nonspecific upper gastrointestinal symptoms. Patients may therefore undergo esophagogastroduodenoscopy as their initial investigation. Markers of villous atrophy, which can be seen in the duodenum during endoscopy, are well described. They have limited sensitivity for patients with mild enteropathy and duodenal biopsies should be performed if there is strong suspicion of celiac disease irrespective of endoscopic appearance. Endoscopic markers do, however, allow the selection of patients with nonspecific symptoms for duodenal biopsy, and these markers should, therefore, be looked for routinely during esophagogastroduodenoscopy.     

Prevalence of cryptosporidiosis in patients undergoing endoscopy: evidence for an asymptomatic carrier state

PURPOSE: We sought to determine the presence of the parasite cryptosporidium in the duodenal aspirates of patients undergoing routine upper gastrointestinal endoscopy. PATIENTS AND METHODS: The study consisted of 169 patients undergoing upper endoscopy or endoscopic retrograde cholangiopancreatography. Immunocompromised patients were not included in the study population. Samples were aspirated from the second portion of the duodenum. Biopsy specimens were also obtained. Three randomly passed stool samples were obtained from 75% of the patients who were found to have cryptosporidium in the duodenum. RESULTS: Overall, cryptosporidium oocysts were identified in 12.7% of patients. There was no significant difference in the prevalence of the parasite in any subgroup of procedure or symptom complex. Half of those (46.7%) with positive aspirates had demonstrable cryptosporidium in stool samples, although none of the patients had diarrhea. No patient had detectable cryptosporidium in biopsy samples of the duodenum. CONCLUSION: The findings suggest a surprisingly high asymptomatic carrier rate for cryptosporidium.