Video Capsule Endoscopy in Celiac Disease

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Introduction

Celiac disease is a common multisystem autoimmune disorder affecting approximately 1% of the population, which is triggered by the ingestion of gluten (a protein component of wheat, rye, and barley) in genetically susceptible individuals.1 Screening for celiac disease is available via serologic testing, with excellent reported sensitivity and specificity.2 Antibodies available for celiac disease screening include anti-tissue transglutaminase (TTG) immunoglobulin A (IgA) antibody, anti-endomysial (EMA) IgA antibody, and the more recently developed anti–deamidated gliadin peptide IgA/IgG antibodies. The gold standard for the diagnosis of celiac disease still remains small intestinal biopsy performed during upper endoscopy. Features of celiac disease appreciated on conventional upper endoscopy include a mosaic mucosal pattern, scalloping, villous atrophy, and flattening of folds.3, 4 In patients with partial villous atrophy, however, the small intestine may seem endoscopically normal and biopsies should be obtained regardless of the appearance if celiac disease is suspected. Histologic features suggestive of celiac disease include increased intraepithelial lymphocytes, crypt hyperplasia, and villous atrophy.5, 6 Marsh5 developed an initial grading system to classify the histologic changes associated with celiac disease and this was later refined by Oberhuber.5, 6 These histologic features are not unique to celiac disease and can be found in other conditions, such as tropical sprue and autoimmune enteropathy.1

Small bowel biopsy during upper endoscopy has several limitations. Upper endoscopy is an invasive procedure and sedation is routinely administered. Patients often require an escort home and miss work. During routine upper endoscopy, a very small portion of the small bowel is examined. Celiac disease may be patchy, and biopsies may fail to sample areas demonstrating disease. Some physicians may not obtain the suggested 4 to 6 biopsies during upper endoscopy when evaluating patients for suspected celiac disease.7 Interpretation of histology may also be problematic because pathologists in some settings, particularly in commercial laboratories or community hospitals, may fail to recognize the features of celiac disease.8 Histologic samples may also be poorly oriented, and the interpretation may be hindered.

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Video capsule endoscopy: technology and administration

Video capsule endoscopy (VCE) provides an alternative means to conventional upper endoscopy to visualize the small intestine. VCE was first introduced in 2001, and there are several systems currently available worldwide: PillCam SB2, Given Imaging, Yoqneam, Israel; Endo Capsule, Olympus America Inc, Center Valley, Pennsylvania; OMOM, Jinshan Science and Technology, Chongqing, China; and MiroCam, IntroMedic, Seoul, South Korea.9, 10 Currently, the PillCam SB2 and Endo Capsule endoscopes are

Indications for VCE in celiac disease

According to an international consensus conference, VCE can be considered as an imaging modality in cases of known or suspected celiac disease in select situations (Box 1).14 VCE can be performed when a person is unable or unwilling to have a conventional upper endoscopy. Examples include patients with cardiopulmonary instability or history of bleeding disorders. VCE may also be performed in cases of positive serology (TTG or EMA) and normal duodenal histology to visualize more distal portions

Role of VCE in celiac disease

The use of VCE in celiac disease is an area of active research. It is an appealing imaging modality for patients with celiac disease because it is a relatively noninvasive and safe procedure. Because capsule endoscopes are unable to obtain biopsies, and small bowel histology remains the gold standard for the diagnosis of celiac disease, VCE serves a complementary role to conventional endoscopy. Features of celiac disease visualized during VCE are similar to those seen during conventional upper

Limitations

VCE has several important limitations (Box 2). The capsule endoscopes obtain images deep in the small bowel but are presently unable to obtain biopsies or perform therapy. Using available technology, it may be possible to develop lighter video capsules equipped with small motors that can perform biopsies.30

VCE studies of the small intestine may be incomplete, fail to visualize an area of interest, or the reader may miss the area of abnormality. In approximately 15% to 20% of capsule endoscopy

Future direction: quantification of VCE images in celiac disease

Because VCE is limited by its subjective and labor-intensive nature, performing an analysis with the assistance of a computerized method would be helpful. There is no computer system to definitively diagnose celiac disease or villous atrophy, but recent research has focused on computer analysis of VCE imaging to detect areas of abnormality.

As the capsule endoscope tumbles during small intestinal passage, the camera angle, with respect to the mucosal surface, varies greatly and continuously.

Summary

The role of capsule endoscopy in the management of celiac disease is still evolving. VCE is useful in the diagnosis of celiac disease in special circumstances in which the gold standard of small bowel biopsy is not available because of medical or individual reasons. It is also being used to survey the small bowel for complications, such as malignancies, particularly in patients with refractory celiac disease type II. Capsule endoscopy examines the small bowel and can be helpful to detect distal

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