Introduction There has been increasing interest in the role that duodenal bulb biopsies may have in helping to establish the diagnosis of coeliac disease. This study aims to determine whether a targeted duodenal bulb biopsy in addition to distal duodenal biopsies is the optimal strategy when trying to identify villous atrophy, comparing histological findings from different quadrants of the duodenal bulb.
Methods Patients undergoing oesophogastroduodenoscopy (OGD) were prospectively recruited from a single tertiary referral hospital in the UK between July 2010 and October 2011. Indications for biopsy included positive coeliac serology, family history of coeliac disease, chronic diarrhoea, iron deficiency anaemia, abdominal pain and weight loss. All patients recruited to the study had immunoglobulin A (IgA) endomysial antibody (EMA) and tissue transglutaminase (tTG) antibody measurements prior to undergoing their EGD. At endoscopy, eight duodenal biopsies were taken: four from the second part of the duodenum and four quadrantically from the bulb (3,6,9 and 12 o'clock). Each biopsy was graded according to the modified Marsh Criteria, with the optimal biopsy site in the bulb being evaluated by the ability to detect the presence and severity of villous atrophy.
Results A total of 77 patients were recruited (27 male (35%), 50 female (65%), median age 45, range 19–79) between July 2010 and November 2011. Of these, 28 (36%) were found to have newly diagnosed coeliac disease and 49 were controls (64%). Bulbar villous atrophy was identified in 96% of the coeliac patients, with five patients having villous atrophy confined to the bulb alone (Abstract PWE-119 table 1). The most severe degree of villous atrophy was detected when distal duodenal biopsies were taken in addition to a duodenal bulb biopsy from either the 9 or 12 o'clock position (sensitivity 96.4%, 95% CI 79.7% to 100%). The difference between the 12 o'clock biopsy and the 3 o'clock biopsy in detecting the most severe villous atrophy was 92% (24/26) vs 65% (17/26) (p=0.04).
Conclusion This study demonstrates the patchy appearance of villous atrophy that occurs within the duodenum. A targeted duodenal bulb biopsy from either the 9 or 12 o'clock position in addition to distal duodenal biopsies, may improve diagnostic yields by detecting the most severe villous atrophy within the duodenum.
Competing interests None declared.