Introduction The prevalence of coeliac disease (CD) is around 1% in the UK. The ‘gold standard’ diagnosis of CD requires a distal duodenal (D2) biopsy when the patient is on a gluten containing diet and in most cases positive serology (eg tissue transglutaminase antibodies, tTG ab). CD is confirmed when histological criteria as set out in the Marsh classification [increased intraepithelial lymphocytosis, crypt hyperplasia, villous atrophy (VA)] are met. The diagnosis of CD may be delayed as it can present with a wide range of signs and symptoms including iron deficiency anaemia, weight loss, osteoporosis, neuropathy and vague abdominal symptoms. Many patients with vague abdominal symptoms undergo upper GI endoscopy (OGD), however, in the majority D2 biopsies to look for CD are not obtained. Endoscopic examination may reveal classical features of VA such as ‘scalloping’ of the duodenal mucosa but may also be normal. The aim of the study was to evaluate the range of duodenal endoscopic findings in patients with proven CD and VA on D2 biopsy.
Method A single centre, retrospective analysis of patients with histologically proven CD (Marsh 3 classification) on D2 biopsies in a London district general hospital was performed. Data was obtained from the hospital’s histology database, endoscopy reporting software and electronic patient record system. Information on the patients’ demographics, symptoms, index endoscopy findings, histology and coeliac serology prior to a gluten free diet was scrutinised.
Results 65 patients had a confirmed diagnosis of CD with VA. 6 patients were excluded from our analysis as endoscopy reports were unavailable. Of the remaining 59, there were 36 females and 29 males. Indications for endoscopy based on patients presenting symptoms were as follows: 18/59 for iron deficiency anaemia, 12/59 (abdominal pain/bloating), 11/59 (diarrhoea), 10/59 (asymptomatic but positive tTG ab), 6/59 (weight loss) and 2/59 for fatigue. tTG ab was positive in 50/59 patients, negative in 7 and not tested in 2. The Table 1below shows the endoscopy findings in these 59 patients with CD.
Conclusion Over half of our CD patient cohort had normal endoscopic findings on diagnosis despite confirmed VA on D2 biopsies. 17% of patients were asymptomatic at diagnosis and 12% of patients were tTG ab negative. Given the wide ranging clinical presentation of CD and its overall prevalence, D2 biopsies should not be limited to patients presenting with classical symptoms as we may be missing the opportunity to diagnose this easily treatable condition. We recommend that all patients presenting to OGD for vague abdominal symptoms have duodenal biopsies to exclude CD.
Disclosure of interest None Declared.
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