Difficult diagnosis of celiac disease: diagnostic accuracy and utility of chromo-zoom endoscopy

doi:10.1016/j.gie.2012.09.036

Gastrointestinal Endoscopy

Volume 77, Issue 2, February 2013, Pages 233-240

https://doi.org/10.1016/j.gie.2012.09.036 Get rights and content

Background

Chromo-zoom endoscopy has been demonstrated to be valuable in assessing the degree of intestinal villous atrophy in patients with suspected celiac disease.

Objective

To evaluate the diagnostic accuracy of chromo-zoom endoscopy in patients with difficult diagnosis because of nonconcordant test results and/or the confounding of a gluten-free diet initiated before an appropriate diagnosis of celiac disease and to compare the findings to a recent reference standard, the in vitro gliadin challenge test.

Design

Prospective, case-control study.

Setting

Tertiary-care referral hospital.

Patients

Patients without celiac disease (negative control group, n = 9), patients with celiac disease (positive control group, n = 41), and patients with difficult diagnosis (n = 27).

Intervention

Chromo-endoscopy with indigo carmine and endoscopic zoom-magnification were performed. Duodenal fragments were collected for the in vitro gliadin challenge test. The area under the receiver operating characteristic curve (ROC) was used for statistical analyses on accuracy.

Main Outcome Measurements

Diagnostic accuracy of chromo-zoom endoscopy for detection of mucosal abnormalities in patients with difficult diagnosis.

Results

Chromo-zoom endoscopy had a high accuracy for celiac disease diagnosis in analyses on negative controls and positive controls (area under roc = 0.99). In the difficult diagnosis group, the accuracy of chromo-zoom endoscopy was lower (area under roc = 0.83), but it increased after exclusion of patients with celiac disease on gluten-free diet (area under roc = 0.88).

Limitations

There was a 4% failure rate in the ability to cultivate biopsies. Also, the study was done at an academic medical center.

Conclusion

Chromo-zoom endoscopy has high accuracy for cases of difficult diagnosis of celiac disease but only in untreated patients with celiac disease.

Section snippets

Aims

This study aimed to evaluate the diagnostic accuracy of zoom-endoscopy combining with indigo carmine dye spray in the direct evaluation of duodenal villi in patients with a difficult diagnosis and to compare the findings with a recent reference standard, which is the in vitro gliadin challenge test.

Study design

The accuracy of chromo-zoom endoscopy was evaluated in patients in whom CD had been excluded (negative controls), in patients with serology-proven and biopsy-proven CD (positive controls), and in cases in which the diagnosis of CD was difficult (Fig. 1).

Patients

Three groups of patients were recruited at the CD center, Gastroenterology Unit, at the University of Naples Federico II, and included in this study: a negative control group, a positive control group, and a difficult diagnosis group. The

Demographic characteristics

A total of 80 patients were enrolled in the study. Two were excluded for contamination of samples and another for inadequate (superficial) biopsy samples. Table 2 shows the sex, age, anthropometry, and clinical features of the participants.

Sex and age had a similar distribution among the difficult diagnosis, the negative control, and the positive control groups (Fisher exact test 0.27; P = .93 and analysis of variance P = .30, respectively). Serum a-tTG values averaged in the normal range in

Discussion

Our results confirm that the chromo-zoom endoscopy has a high accuracy in the identification of untreated patients with CD and negative controls. The novel finding of our study was that chromo-zoom endoscopy is highly accurate for diagnosing difficult cases of CD with high specificity and high sensitivity; however, this applies only to patients on a normal gluten-containing diet.

Currently, the criterion standard for the diagnosis of CD remains in the histologic demonstration of the

Acknowledgment

The authors are grateful to Dr Vincenzo Bruno for technical support, to Mrs Imma Di Palma and Mrs Speranza Iovino for their nursing assistance, and to Mrs Piantedosi for secretarial assistance.

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: If you would like to chat with an author of this article, you may contact Dr Iovino at [email protected].

: DISCLOSURE: The following authors disclosed a financial relationship: Drs Russo and Ciacci received support for this study from the Italian Research Program (PRIN 2006) and by Regione Campania, Assessorato Sanità. None of the funders had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. No other financial relationships relevant to this publication were disclosed.

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Original articleClinical endoscopyDifficult diagnosis of celiac disease: diagnostic accuracy and utility of chromo-zoom endoscopy

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Aims

Study design

Patients

Demographic characteristics

Discussion

Acknowledgment

Lancet

Gastroenterology

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastroenterology

Gastroenterology

Lancet

Gastroenterology

Gastrointest Endosc

Clin Gastroenterol Hepatol

Celiac disease

N Engl J Med

Original article
Clinical endoscopy
Difficult diagnosis of celiac disease: diagnostic accuracy and utility of chromo-zoom endoscopy