Endoscopy in Celiac Disease

Indication for biopsy of the duodenum

Biopsy may be performed because of positive serologic tests. Alternatively a biopsy may be performed because of the recognition of abnormalities at endoscopy suggestive of celiac disease when endoscopy is performed for a reason such as esophageal reflux or dyspepsia [44]. In one series, unsuspected celiac disease discovered by biopsy during EGD for another indication accounted for 8% of new diagnoses in the 1990's [2]. However an argument can be made for the routine biopsy of the duodenum during endoscopy performed for any reason, irrespective of the appearance of the duodenum [45].

Endoscopic appearance in celiac disease
Characteristic changes in the appearance of the duodenum on endoscopy are suggestive of celiac disease.  The normal duodenal appearance should include at least three normal folds per endoscopic field.
Figure 1
The changes seen in celiac disease include:

1. Reduced or absent duodenal folds


Figure 2
Figure 3

Figure 4
2. Scalloping of folds

Figure 5
Figure 6
3. Mosaic pattern to the mucosa
Figure 7
 
4. Mucosal fissures or cracks

Figure 8		  
Figure 9
These mucosal features are highlighted by the use of chromo-endoscopy.

5. Visible vessels

These changes are highly predictive of duodenal pathology that may represent celiac disease in the right patient population. However other causes, apart from celiac disease may also produce these endoscopic findings [46]. These include HIV enteropathy, opportunistic infections, tropical sprue.  The appearance of the mucosa may however be normal in patients with celiac disease [47], especially in the setting of partial villous atrophy [48].
Villi can in fact be visualized using under-water or emersion techniques and/ or chromo-endoscopy as seen in the final figure.  
Figure 10