Original article—alimentary tract
Mucosal Atrophy in Celiac Disease: Extent of Involvement, Correlation With Clinical Presentation, and Response to Treatment

https://doi.org/10.1016/j.cgh.2007.10.012Get rights and content

Background & Aims: Wireless capsule endoscopy provides an opportunity to study the macroscopic features in celiac disease by providing a magnified view of the intestinal mucosa. In this study, we evaluated the following: (1) the distribution of atrophy in untreated celiac disease, (2) the correlation between extent of changes and clinical manifestations, (3) the accuracy and interobserver agreement of wireless capsule endoscopy assessment, and (4) the effect of gluten withdrawal. Methods: Thirty-eight consecutive patients with untreated biopsy-proven celiac disease underwent wireless capsule endoscopy. Each subject was invited to undergo repeat testing after at least 6 months of gluten withdrawal. The video images of each patient were reviewed independently by 2 investigators. Results: Thirty-five (92%) subjects had visible atrophy detected by capsule endoscopy. Twenty-two (59%) subjects showed an extensive enteropathy, 12 (32%) had enteropathy limited to the duodenum, and only 1 had a jejunal enteropathy. No association was shown between the extent of the lesion and clinical manifestations. Capsule endoscopy had a better overall sensitivity for the detection of atrophy as compared with upper endoscopy (92% vs 55%, P = .0005), with a specificity of 100%. The overall interobserver agreement for the 2 reviewers was relatively high (% total agreement, 86.5%). After gluten withdrawal, the extent and the pattern of atrophy improved both qualitatively and quantitatively. Conclusions: Celiac disease affects a highly variable portion of the small intestine starting at the duodenum. The extent of visible enteropathy does not explain differences in clinical presentation. Most subjects with visually detected villous atrophy showed a clinically significant improvement after gluten withdrawal.

Section snippets

Experimental Design

The study was a single-center prospective study of patients with newly diagnosed CD. Within 2 weeks of the diagnosis but before the onset of a GFD, patients giving informed consent underwent WCE. The video images of each patient were reviewed independently by 2 investigators (C.J.G. and J.A.M.) for the presence and distribution of mucosal abnormalities associated with CD. Each subject was invited to undergo repeat testing at least 6 months after starting a GFD.

Inclusion criteria

We included consecutive adult

Characteristics of Patients With Celiac Disease and Negative Control Group

Forty patients initially were enrolled into the study during the period from March 2003 to August 2004 at Mayo Clinic Rochester. Three patients ultimately were excluded because of the following: (1) incorrect initial diagnosis in 2 patients (both had negative celiac serology and absence of the HLA-DQ2 or -DQ8 haplotypes), and (2) the capsule did not exit the stomach in 1 patient (this patient was included as if she had normal WCE findings in the sensitivity analysis to avoid overestimation of

Discussion

This study showed that CD affects the proximal small intestine and extends distally for a variable distance in a more or less continuous fashion and also heals in the reverse direction after gluten withdrawal. The study confirmed that most patients have a continuous pattern of atrophy, almost always observable in the duodenum. Just 1 patient did not have observable atrophy changes on the duodenal images with atrophy being seen only in the jejunum. Although these data support the concept that CD

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Supported in part by Given Imaging Ltd, who did not have any role in the design, execution, analysis, or preparation of the manuscript. Also supported by National Institutes of Health grants DK-57892 and DK-070031 (J.A.M.).

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