Reply to Leung

Unlike our study [1], Leong et al. had included a proportion of patients with untreated celiac disease in their study [2], they had taken an additional biopsy from the duodenal bulb, and had used a complex score to quantify the endomicroscopic changes in celiac disease.

We discussed in our paper that the inclusion of patients with untreated celiac disease by Leong et al. may have influenced their highly sensitive detection rate for crypt hyperplasia. For the determination of crypt hyperplasia, however, identification of hyperplastic crypts in the horizontal plane and the evaluation of the crypt length (and the villous height-crypt depth ratio) in the vertical plane should be considered. Confocal endomicroscopy (CEM) is hampered by an insufficient assessment of the crypt length and therefore, in our study, crypt hyperplasia did not reach a high value of sensitivity.

In our study, we did not take biopsies from the duodenal bulb for two reasons: all of our patients had a long history of celiac disease; the diagnosis was already confirmed. Although there is some evidence, particularly in children, that the diagnostic yield for celiac disease may be increased by taking biopsies from the duodenal bulb [3], there is no consensus so far among gastroenterologists for generally changing current clinical practice. Further studies in adult populations are necessary to provide a similar level of supportive evidence.

If CEM is ever to be commonly used as a new diagnostic imaging technology in celiac disease, the use of a simple celiac disease score in everyday clinical practice is mandatory. In contrast to the complex score established by Leong et al., we used an easily applicable score to determine Marsh grades I – III during ongoing endoscopy.

Competing interests: None

References

• 1 Günther U, Daum S, Heller F. et al . Diagnostic value of confocal endomicroscopy in celiac disease.  Endoscopy. 2010;  42 197-202
• 2 Leong R W, Nguyen N Q, Meredith C G. et al . In vivo confocal endomicroscopy in the diagnosis and evaluation of celiac disease.  Gastroenterology. 2008;  135 1870-1876
• 3 Prasad K K, Thapa B R, Nain C K, Singh K. Assessment of the diagnostic value of duodenal bulb histology in patients with celiac disease, using multiple biopsy sites.  J Clin Gastroenterol. 2009;  43 307-311