Endoscopic Signs in Celiac Disease

We read with interest the article by Tursi et al. [1], dealing with the relationships between the endoscopic signs of celiac disease, histological damage, age of the patients, and the clinical form of the disease. Their conclusions stated that the endoscopic appearance of the duodenum may be predictive of the grade of histological damage, and that in young patients with subclinical or silent celiac disease, there is a greater probability of finding milder endoscopic abnormalities associated with milder histological damage. We agree in part with these conclusions; other authors have suggested that the presence of endoscopic signs in celiac disease increases as villous atrophy becomes more evident [2] [3] and that in childhood, some endoscopic signs are more frequent than others [4] [5]. However, in our opinion simpler and more useful data can be drawn from the results obtained by the authors, taking into account the distribution of the normal endoscopic appearance of the duodenum among Marsh histological classes (Table 1 in [1]), age groups (Table 2 in [1]), and clinical forms of the disease (Table 3 in [1]).

As the authors' Table 1 shows, a normal endoscopic appearance in the duodenum was principally found in Marsh class II (13 of 38 patients, 34 %), less frequently in type IIIa (six of 46 patients, 13 %), and never in type IIIb or IIIc: thus, the sensitivity of all the endoscopic signs in the 144 adult patients with celiac disease was 66 % in Marsh class II, 87 % in type IIIa, and 100 % in types IIIb and IIIc, increasing as histological damage became more evident.

In the authors' Table 2, a normal endoscopic appearance of the duodenum was reported in six of 38 patients aged 15 - 30 (16 %), in eight of 38 patients aged 30 - 45 (21 %), in three of 35 patients aged 45 - 60 (9 %), and in two of 33 patients aged over 60 (6 %). The sensitivity of the endoscopic signs was thus 86 %, 79 %, 91 %, and 94 % for these groups, respectively, with an upward trend as the age of patients increased.

In Table 3, a normal endoscopic appearance of the duodenum was found in 10 of 28 patients (36 %) with the silent form of celiac disease, in eight of 64 patients (13 %) with the subclinical form, and in one of 52 patients (2 %) with the classical clinical form, showing an increasing sensitivity of the endoscopic signs (64 %, 87 % and 98 %, respectively) when passing from the silent, to the subclinical, and to the classical forms of celiac disease.

In our opinion, this could be an additional way of presenting the results of the study - highlighting the ability of all the endoscopic signs to suggest the diagnosis of celiac disease when passing from slight to severe histological damage, from younger to older patients, and from the silent to the subclinical or classical forms of celiac disease. In fact, it is of minor clinical relevance whether any single endoscopic sign is associated with milder or severe histological damage, with younger or older patients, or with different clinical forms. In our view, the true clinical impact of the endoscopic signs lies in the sensitivity for diagnosis of all duodenal abnormalities as a whole (the presence of one or more endoscopic signs in the first and/or in second part of the duodenum) [6]. In addition - on a minor point - it is not strictly correct to assess arbitrarily at the beginning of the study (as the authors did) which endoscopic sign may be associated with mild or severe duodenal damage; this should be a final conclusion, resulting from the relationship between the endoscopic features and the histology, since (as a general rule in pathology) microscopic damage usually occurs in advance of macroscopic findings.

Finally, we were not able to find, either in the reported reference [7] or in other related articles, the endoscopic sign defined by the authors as “granular mucosa” in the second part of the duodenum; perhaps they are referring to a micronodular aspect of the second part of the duodenum.

In conclusion, the worthwhile aspect of the study by Tursi et al. lies, in our opinion, in its demonstration that the sensitivity of endoscopic signs of celiac disease increases in parallel with histological damage, the age of the patients, and the clinical form of the disease - emphasizing once again the important (but not absolute) role of these signs in detecting unsuspected patients during routine endoscopy.

References

• 1 Tursi A, Brandimarte G, Giorgetti G M, Giglioblanco A. Endoscopic features of celiac disease in adults and their correlation with age, histological damage and clinical form of the disease.  Endoscopy. 2002;  34 787-792
• 2 Dickey W, Hughes D. Disappointing sensitivity of endoscopic markers for villous atrophy in a high-risk population: implication for celiac disease diagnosis during routine endoscopy.  Am J Gastroenterol. 2001;  96 2126-2128
• 3 Brocchi E, Tomassetti P, Biasco G. et al . Celiac disease: improving the diagnosis.  Am J Gastroenterol. 2002;  97 1269-1270
• 4 Corazza G R, Caletti G, Lazzari R. et al . Scalloped duodenal folds in childhood celiac disease.  Gastrointest Endosc. 1993;  39 543-545
• 5 Ravelli A M, Tobanelli P, Minelli L. et al . Endoscopic features of celiac disease in children.  Gastrointest Endosc. 2001;  54 736-742
• 6 Brocchi E, Tomassetti P, Misitano B. et al . Endoscopic markers in adult celiac disease.  Dig Liver Dis. 2002;  34 177-182
• 7 Dickey W, Hughes D. Prevalence of celiac disease and its endoscopic markers among patients having routine upper gastrointestinal endoscopy.  Am J Gastroenterol. 1999;  94 2182-2186