Capsule endoscopy in nonresponsive celiac disease

Abstract

Background: Nonresponsive celiac disease (CD) is defined by persistent or recurrent symptoms, common after treatment with a gluten-free diet (GFD).

Objective: To evaluate the utility of capsule endoscopy (CE) in nonresponsive CD.

Design: Case-control study.

Setting: Tertiary-care center.

Patients: Forty-two consecutive patients with nonresponsive CD and 84 age- and sex-matched CD-free controls who underwent CE were included. In addition, capsules taken after treatment with a GFD were retrospectively evaluated in 30 patients with uncomplicated CD.

Intervention: CE.

Main outcome measurements: Diagnostic accuracy of CE for the detection of mucosal abnormalities in nonresponsive CD.

Results: Macroscopic features of villous atrophy were detected in 13 of 42 patients (31%) with nonresponsive CD compared with none among 84 CD-free controls and 14 of 30 patients (47%) with uncomplicated CD. Among nonresponsive CD cases, the overall sensitivity and specificity of CE for the detection of any degree of villous atrophy as graded by histology were 56% and 85%, respectively. Single or multiple erosions/ulcerations of the gut were observed in 19% of nonresponsive CD patients, 18% of CD-free controls, and 31% of patients with uncomplicated CD (P = .35). The presence of erosions/ulcerations was associated with increased aspirin/nonsteroidal anti-inflammatory drug use in nonresponsive CD (P =.05). Two severe complications (ulcerative jejunitis and adenocarcinoma) were detected by CE in nonresponsive CD.

Limitations: Single-center, retrospective study.

Conclusions: Mucosal abnormalities were observed by CE in patients with both nonresponsive CD and uncomplicated CD. CE can detect severe complications in patients with nonresponsive CD.

Figure 1

Examples of macroscopic features of atrophy detected by CE in nonresponsive CD: normal villi (A), scalloping of the mucosa on circular folds (B), fissuring of the mucosa (C), mosaic pattern (D).

Figure 2

Examples of a single erosion (A), multiple erosions (B), and ulceration of the jejunum (C).

Figure 3

Ulcerative jejunitis detected by capsule endoscopy in a patient with nonresponsive celiac disease. A T-cell clone was confirmed by demonstration of T-cell receptor–γ clonal rearrangement by polymerase chain reaction characteristic of refractory celiac disease type II. No overt lymphoma was evident.