Prospective study of the role of duodenal bulb biopsies in the diagnosis of celiac disease

Background: Studies have demonstrated that villous atrophy in celiac disease is patchy and have suggested that duodenal bulb biopsies aid in diagnosis. Objective: To determine the role of the addition of duodenal bulb biopsies to distal duodenum (D2) biopsies in the diagnosis of celiac disease. Design: Prospective, case-control study. Setting: Tertiary referral hospital. Patients: Patients undergoing upper endoscopy with biopsy for diagnosis or follow-up of celiac disease and control patients. Interventions: Blinded review of duodenal biopsy samples. Main Outcome Measurements: Increasing the yield as well as accuracy of the histologic diagnosis of celiac disease with the addition of bulb biopsies. Results: Of 128 patients enrolled in the study, 67 had celiac disease. Of 1079 biopsy specimens, only 319 (30%) were adequate for complete histologic analysis, resulting in 40 celiac patients and 40 control patients for analysis. Of the 40 celiac patients, 35 (87.5%) had atrophy in either the bulb or D2, 30 (75%) exhibited atrophy at both sites with an identical grade of atrophy seen in 18 patients (45%). Fourteen patients (35%) had identical types of Marsh lesions in both biopsy sites. Twelve patients (30%) had atrophy detected in the bulb, D2, or both, but lacked intraepithelial lymphocytes and thus could not be assigned a Marsh grade. Five patients (13%) had a diagnosis of celiac disease based on findings in the bulb biopsy only. Limitations: Small sample size and study performed in an academic medical center. Conclusions: Our study confirms the patchy nature of villous atrophy as well as intraepithelial lymphocytosis in biopsy specimens from individuals with celiac disease. Adding duodenal bulb biopsies to our sampling regimen increased the diagnostic yield of celiac disease. (Gastrointest Endosc 2010;72:758-65.)