Bonamico

Brocchi

Caruso

David S Sanders

Gonzalez

Hopper

Lebwohl

Levinson-Castiel

Mangiavillano

Matthew Kurien

Mooney

Peter D Mooney

Rashid

Sanders

Sharma

Simon S Cross

Taavela

Vogelsang

Weir

Crossref

The American Journal of Gastroenterology

Bulb Biopsy in Adult Celiac Disease: Pros Outweigh the Cons?

Kurien, M.

Mooney, P.D.

Cross, S.S.

Sanders, D.S.

White Rose Research Online

This is a repository copy of Bulb Biopsy in Adult Celiac Disease: Pros Outweigh the Cons?.White Rose Research Online URL for this paper:http://eprints.whiterose.ac.uk/103823/Version: Accepted VersionArticle:Kurien, M., Mooney, P.D., Cross, S.S. orcid.org/0000-0003-2044-1754 et al. (1 more author) (2016) Bulb Biopsy in Adult Celiac Disease: Pros Outweigh the Cons? Am J Gastroenterol, 111 (8). pp. 1205-1206. ISSN 0002-9270 https://doi.org/10.1038/ajg.2016.173eprints@whiterose.ac.ukhttps://eprints.whiterose.ac.uk/Reuse Unless indicated otherwise, fulltext items are protected by copyright with all rights reserved. The copyright exception in section 29 of the Copyright, Designs and Patents Act 1988 allows the making of a single copy solely for the purpose of non-commercial research or private study within the limits of fair dealing. The publisher or other rights-holder may allow further reproduction and re-use of this version - refer to the White Rose Research Online record for this item. Where records identify the publisher as the copyright holder, users can verify any specific terms of use on the publisher’s website. Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. Letter to the Editor  Bulb biopsy in adult celiac disease: pros outweigh the cons?  Matthew Kurien, MD1 Peter D Mooney, MD1 Simon S Cross, FRCPath2 David S Sanders, FACG1  1Academic Unit of Gastroenterology, Departments of Infection and Immunity and Cardiovascular Science, University of Sheffield, Medical School, Beech Hill Road, Sheffield, South Yorkshire, S10 2RX  2 Academic Unit of Pathology, Department of Neuroscience, Faculty of Medicine, Dentistry & Health, the University of Sheffield, Sheffield, UK Corresponding author: Dr Matthew Kurien, P26, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF.   Tel: 01142261179   Email: matthew.kurien@sth.nhs.uk  Keywords: Celiac, Biopsy  Word Count: 267 (excluding title page, references and table)     Dear Editor,  We read the excellent study by the Taavela et al (1) suggesting caution when considering the diagnosis of pediatric celiac disease based on a duodenal bulb biopsy. We completely agree and share their concerns. However, we would like to pose a question: what are the ‘big issues’ in adult celiac disease? We would suggest that they are delays in diagnosis and under-diagnosis. Both US and UK studies have revealed that 5-13.6% of patients with newly diagnosed celiac disease have had a prior endoscopy where a chance to diagnose celiac disease was missed.(2, 3) By advocating a bulb biopsy the diagnostic rate is increased by approximately 10% (Table 1). Caution is required in the selection of patients who should have this performed - weight loss, anaemia, diarrhea, family history or positive serology, however for routine practice a duodenal bulb biopsy may not be necessary. The Finnish group has shown that all their cases of celiac disease had TG-2 IgA deposits within the bulb biopsy, which we believe further supports the merit of a bulb biopsy.(1) We have historically reported that 100% sensitivity for the detection of celiac disease can only be achieved in the presence of a bulb biopsy and more recently that even in ultra-short celiac disease (bulb only) there are systemic consequences.(4, 5) Surely the crucial next step is to enlist the help of our pathology colleagues by providing them with bulb biopsies in a separate pot to the second part of the duodenum samples? This may improve both interpretation and detection for a group of patients who have significant delays in their diagnosis.     Table 1: Studies evaluating the diagnostic yield of taking duodenal bulb biopsies    References 1. Taavela J, Popp A, Korponay-Szabo IR, et al. A Prospective Study on the Usefulness of Duodenal Bulb Biopsies in Celiac Disease Diagnosis in Children: Urging Caution. Am J Gastroenterol 2016;111:124-33. 2. Sanders DS, Hurlstone DP, Stokes RO, et al. Changing face of adult coeliac disease: experience of a single university hospital in South Yorkshire. Postgrad Med J 2002;78:31-3. 3. Lebwohl B, Bhagat G, Markoff S, et al. Prior endoscopy in patients with newly diagnosed celiac disease: a missed opportunity? Dig Dis Sci 2013;58:1293-8. 4. Hopper AD, Cross SS, Sanders DS. Patchy villous atrophy in adult patients with suspected gluten-sensitive enteropathy: is a multiple duodenal biopsy strategy appropriate? Endoscopy 2008;40:219-24. 5. Mooney PD, Kurien M, Evans KE, et al. Clinical and Immunologic Features of Ultra-Short Celiac Disease. Gastroenterology 2016.  Year Authors Country Adults / Pediatrics Number of patients Number of celiac disease (%) Number of USCD (%) 2001 Vogelsang H et al Austria Adults 51 21 (41.2%) 2 (9.5%) 2004  Bonamico M et al Italy Pediatrics 95 95 (100%) 4 (4.2%) 2005  Brocchi E et al Italy Adults 1 1 (100%) 1 (100%) 2008  Hopper AD et al UK Adults 56 56 (100%) 1 (1.8%) 2008  Bonamico M et al Italy Pediatrics 1013 665(65.6%) 16 (2.4%) 2009  Rashid M et al Canada Pediatrics 35 29 (81.6%) 3 (11.4%) 2010  Weir DC et al USA Pediatrics 198 198 (100%) 10 (5.1%) 2010  Mangiavillano B et al Italy Pediatrics 47 42 (89.4%) 5 (11.9%) 2010  Gonzalez S et al USA Adults 80 40 (50%) 5 (12.5%) 2011  Levinson-Castiel R et al Israel Pediatrics 87 87 (100%) 6 (7.0%) 2011  Evans KE et al UK Adults 376 126 (33.5%) 11 (9.0%) 2012  Kurien M et al UK Adults 77 28 (36.4%) 5 (17.9%) 2013  Sharma A Australia Pediatrics 101 101 (100%) 8 (7.9%) 2014  Caruso R et al  Italy Adults 42 25 (59.5%) 0 (0%) 2016 Stoven SA et al USA Adults 679 16 (2.4%) 1  (6.2%) 

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Bulb Biopsy in Adult Celiac Disease: Pros Outweigh the Cons?

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