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Duodenal bulb for diagnosing adult celiac disease: much more than an optimal biopsy site
Letters to the Editor
Figure 1. Upper endoscopic view of a pedunculated polyp rising from the incisura with a scarf held by a ring: “scarf ring sign.”
monopolar snare polypectomy in both establishing a histologic diagnosis and offering treatment.5 The application of a detachable snare for the induction of polyp ischemia and necrosis may be an attractive option in selected cases with large polyps and high risk for polypectomy. In this case, pathologic analysis is mandatory, and regular follow-up and endoscopic examination are suggested after the procedure.6 Guilherme Macedo, MD, PhD, FACG, FASGE, AGAF Susana Lopes, MD Andreia Albuquerque, MD Gastroenterology Department Centro Hospitalar São João Porto, Portugal
REFERENCES 1. Hughes RW Jr. Gastric polyps and polypectomy: rationale, technique, and complications. Gastrointest Endosc 1984;30:101-2. 2. Hobbs WH, Cohen SE. Gastroduodenal invagination due to a submucous lipoma of the stomach. Am J Surg 1946;71:505-18. 3. Yazumi S, Nakase H, Matsushima Y, et al. The “scarf-ring sign” of ball valve syndrome. Gastrointest Endosc 2002;55:560. 4. Sone Y, Honda T, Nakano S. Hyperplastic polyp causing ball-valve effect. Gastrointest Endosc 2000;51:193. 5. Parikh M, Kelley B, Rendon G, et al. Intermittent gastric outlet obstruction caused by a prolapsing antral gastric polyp. World J Gastrointest Oncol 2010;2:242-6. 6. Sun CK, Yang KC, Liao CS. Endoscopic management of gastric polyp with outlet obstruction without polypectomy. Case Rep Gastroenterol 2011; 5:267-71. http://dx.doi.org/10.1016/j.gie.2012.06.018
Duodenal bulb for diagnosing adult celiac disease: much more than an optimal biopsy site To the Editor: We read with interest the article by Kurien et al1 about the importance of duodenal bulb biopsies in adult patients www.giejournal.org
with celiac disease (CD). The study demonstrates that a targeted duodenal bulb biopsy in addition to distal duodenal biopsies may improve diagnostic yields. It also appears evident that bulb biopsies need to be included in the guidelines for CD diagnosis. Nevertheless, we consider striking the authors’ claim that in the literature there are no works evaluating the specificity of this intervention because of the lack of control individuals. In a recent study we evaluated the morphology of bulb mucosa in 43 adult patients with CD at diagnosis compared with 43 GI control individuals to assess its usefulness for diagnosis.2 In all our patients with CD, lesions were present in the bulb mucosa, and in one female patient, the lesions were present only at the bulb. This latter finding suggests an increase of 2.3% of the diagnostic potential of endoscopy for the diagnosis of CD. It is worth noting that in 16.3% the bulb area showed higher-grade lesions than the distal duodenum, inasmuch as it was the first part involved by damage. Moreover, the normal aspect of this mucosa in the control individuals implies the high negative predictive value of this finding. The authors show that biopsy specimens taken from the 9 o’clock or 12-o’clock position identified villous atrophy (Marsh grades 3a-3c) in 100% of cases, with only a 92% detection rate of villous atrophy in biopsy specimens taken from either the 3 o’clock or the 6 o’clock position. Combining this evidence on a larger series with the results of our study, we suggest that at least two biopsy specimens be always taken from duodenal bulb from the 9 o’clock and 12 o’clock positions. In this way, endoscopic examination could reach very high values of sensitivity and specificity for the diagnosis of CD also in adults. Raffaella Nenna, MD Stefano Pontone, MD Maurizio Mennini, MD Laura Petrarca, MD Department of Surgical Sciences “Sapienza” University Volume 76, No. 5 : 2012 GASTROINTESTINAL ENDOSCOPY 1081
Letters to the Editor
Gerarda Mastrogiorgio, MD Margherita Bonamico, MD Department of Pediatrics “Sapienza” University Rome, Italy
onstrate the merits of taking a duodenal bulb biopsy, and we concur with them that this should be reflected in diagnostic guidelines for celiac disease. Matthew Kurien, MBChB, MRCP Andrew D. Hopper, MD, MBChB, MRCP David S. Sanders, MD, MBChB, FRCP, FACG Gastroenterology & Liver Unit Royal Hallamshire Hospital Sheffield, United Kingdom
REFERENCES 1. Kurien M, Evans KE, Hopper AD, et al. Duodenal bulb biopsies for diagnosing adult celiac disease: is there an optimal biopsy site? Gastrointest Endosc 2012;75:1190-6. 2. Nenna R, Pontone S, Pontone P, et al. Duodenal bulb in celiac adults: the “whether biopsying” dilemma. J Clin Gastroenterol 2012;46:302-7. http://dx.doi.org/10.1016/j.gie.2012.06.019
http://dx.doi.org/10.1016/j.gie.2012.07.028
Neosquamous epithelium after ablation of Barrett’s epithelium: cause for concern?
Response:
To the Editor:
Internationally, there is increased recognition of undetected adult celiac disease, with duodenal bulb biopsies being an evolving area, potentially helping in establishing a diagnosis (Table 1). We appreciate the comments made by Nenna et al1 and are sorry that we did not comment on their study. Although we agree that controls are incorporated into their study, the specificity of this strategy continues to remain the problem for all of us. Accurately assessing specificity involves undertaking the same biopsy strategy on antibody-negative patients, with an unassociated human leukocyte antigen type attending for gastroscopy. Given the low prevalence of histologic findings within the bulb in both our control group and in the authors’ study, accurately determining the prevalence of histologic lesions within the duodenal bulb within the normal population would require a large, prospective study to be undertaken. Only then may we accurately determine whether or not our strategy results in a high false-positive detection rate of villous atrophy unrelated to celiac disease. We agree with the authors that taking two bulbar biopsies has 100% sensitivity; however, our findings were derived from a small sample size, and we believe that findings need to be replicated in other cohorts. Nevertheless, it is reassuring that the authors’ findings, like ours, dem-
Endoscopic mucosal ablation is recommended for Barrett’s epithelium (intestinal metaplasia) with high-grade dysplasia (HGD) or carcinoma in situ. Radiofrequency ablation (RFA), cryotherapy, and photodynamic therapy are some of the modalities used for ablation.1-4 Although ablative therapy can eliminate intestinal metaplasia, there is always a concern of intestinal metaplasia buried under the neosquamous epithelium.5 Moreover, the stability of the neosquamous epithelium is unknown. Early studies have shown no genetic or molecular aberrations in the neosquamous epithelium.6-7 However, recently we published a case report on a patient who had short-segment Barrett’s with carcinoma in situ who initially achieved a complete response with ablative therapy (cryotherapy and then several sessions of RFA).8 He subsequently went on to develop HGD in the neosquamous epithelium at the site of ablation. He had no history of head and neck cancer and had been a remote smoker. Four biopsies every 2-cm from rest of the esophagus showed normal squamous epithelium.8 This letter is a follow-up on the case. We ablated the squamous cell HGD with additional sessions of RFA. After a brief period of returning to normal squamous cell epithelium (6 months), this patient developed a 2 to 3–mm nodule at the ablation site. Biopsy showed a moderately to
Table 1. Adult studies of duodenal bulb biopsies in celiac disease
Year
Country
Sample size
Controls
Villous atrophy present only in the duodenal bulb
2001
Austria
21
21
2/21 (9.5%)
2007
United Kingdom
56
None
1/56 (1.8%)
2010
United States
40
40
5/40 (12.5%)
2011
United Kingdom
461
250
11/126 (8.7%)
2012
Italy
86
43
1/43 (2.3%)
1082 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 5 : 2012
www.giejournal.org
Figure 1. Upper endoscopic view of a pedunculated polyp rising from the incisura with a scarf held by a ring: “scarf ring sign.”
monopolar snare polypectomy in both establishing a histologic diagnosis and offering treatment.5 The application of a detachable snare for the induction of polyp ischemia and necrosis may be an attractive option in selected cases with large polyps and high risk for polypectomy. In this case, pathologic analysis is mandatory, and regular follow-up and endoscopic examination are suggested after the procedure.6 Guilherme Macedo, MD, PhD, FACG, FASGE, AGAF Susana Lopes, MD Andreia Albuquerque, MD Gastroenterology Department Centro Hospitalar São João Porto, Portugal
REFERENCES 1. Hughes RW Jr. Gastric polyps and polypectomy: rationale, technique, and complications. Gastrointest Endosc 1984;30:101-2. 2. Hobbs WH, Cohen SE. Gastroduodenal invagination due to a submucous lipoma of the stomach. Am J Surg 1946;71:505-18. 3. Yazumi S, Nakase H, Matsushima Y, et al. The “scarf-ring sign” of ball valve syndrome. Gastrointest Endosc 2002;55:560. 4. Sone Y, Honda T, Nakano S. Hyperplastic polyp causing ball-valve effect. Gastrointest Endosc 2000;51:193. 5. Parikh M, Kelley B, Rendon G, et al. Intermittent gastric outlet obstruction caused by a prolapsing antral gastric polyp. World J Gastrointest Oncol 2010;2:242-6. 6. Sun CK, Yang KC, Liao CS. Endoscopic management of gastric polyp with outlet obstruction without polypectomy. Case Rep Gastroenterol 2011; 5:267-71. http://dx.doi.org/10.1016/j.gie.2012.06.018
Duodenal bulb for diagnosing adult celiac disease: much more than an optimal biopsy site To the Editor: We read with interest the article by Kurien et al1 about the importance of duodenal bulb biopsies in adult patients www.giejournal.org
with celiac disease (CD). The study demonstrates that a targeted duodenal bulb biopsy in addition to distal duodenal biopsies may improve diagnostic yields. It also appears evident that bulb biopsies need to be included in the guidelines for CD diagnosis. Nevertheless, we consider striking the authors’ claim that in the literature there are no works evaluating the specificity of this intervention because of the lack of control individuals. In a recent study we evaluated the morphology of bulb mucosa in 43 adult patients with CD at diagnosis compared with 43 GI control individuals to assess its usefulness for diagnosis.2 In all our patients with CD, lesions were present in the bulb mucosa, and in one female patient, the lesions were present only at the bulb. This latter finding suggests an increase of 2.3% of the diagnostic potential of endoscopy for the diagnosis of CD. It is worth noting that in 16.3% the bulb area showed higher-grade lesions than the distal duodenum, inasmuch as it was the first part involved by damage. Moreover, the normal aspect of this mucosa in the control individuals implies the high negative predictive value of this finding. The authors show that biopsy specimens taken from the 9 o’clock or 12-o’clock position identified villous atrophy (Marsh grades 3a-3c) in 100% of cases, with only a 92% detection rate of villous atrophy in biopsy specimens taken from either the 3 o’clock or the 6 o’clock position. Combining this evidence on a larger series with the results of our study, we suggest that at least two biopsy specimens be always taken from duodenal bulb from the 9 o’clock and 12 o’clock positions. In this way, endoscopic examination could reach very high values of sensitivity and specificity for the diagnosis of CD also in adults. Raffaella Nenna, MD Stefano Pontone, MD Maurizio Mennini, MD Laura Petrarca, MD Department of Surgical Sciences “Sapienza” University Volume 76, No. 5 : 2012 GASTROINTESTINAL ENDOSCOPY 1081
Letters to the Editor
Gerarda Mastrogiorgio, MD Margherita Bonamico, MD Department of Pediatrics “Sapienza” University Rome, Italy
onstrate the merits of taking a duodenal bulb biopsy, and we concur with them that this should be reflected in diagnostic guidelines for celiac disease. Matthew Kurien, MBChB, MRCP Andrew D. Hopper, MD, MBChB, MRCP David S. Sanders, MD, MBChB, FRCP, FACG Gastroenterology & Liver Unit Royal Hallamshire Hospital Sheffield, United Kingdom
REFERENCES 1. Kurien M, Evans KE, Hopper AD, et al. Duodenal bulb biopsies for diagnosing adult celiac disease: is there an optimal biopsy site? Gastrointest Endosc 2012;75:1190-6. 2. Nenna R, Pontone S, Pontone P, et al. Duodenal bulb in celiac adults: the “whether biopsying” dilemma. J Clin Gastroenterol 2012;46:302-7. http://dx.doi.org/10.1016/j.gie.2012.06.019
http://dx.doi.org/10.1016/j.gie.2012.07.028
Neosquamous epithelium after ablation of Barrett’s epithelium: cause for concern?
Response:
To the Editor:
Internationally, there is increased recognition of undetected adult celiac disease, with duodenal bulb biopsies being an evolving area, potentially helping in establishing a diagnosis (Table 1). We appreciate the comments made by Nenna et al1 and are sorry that we did not comment on their study. Although we agree that controls are incorporated into their study, the specificity of this strategy continues to remain the problem for all of us. Accurately assessing specificity involves undertaking the same biopsy strategy on antibody-negative patients, with an unassociated human leukocyte antigen type attending for gastroscopy. Given the low prevalence of histologic findings within the bulb in both our control group and in the authors’ study, accurately determining the prevalence of histologic lesions within the duodenal bulb within the normal population would require a large, prospective study to be undertaken. Only then may we accurately determine whether or not our strategy results in a high false-positive detection rate of villous atrophy unrelated to celiac disease. We agree with the authors that taking two bulbar biopsies has 100% sensitivity; however, our findings were derived from a small sample size, and we believe that findings need to be replicated in other cohorts. Nevertheless, it is reassuring that the authors’ findings, like ours, dem-
Endoscopic mucosal ablation is recommended for Barrett’s epithelium (intestinal metaplasia) with high-grade dysplasia (HGD) or carcinoma in situ. Radiofrequency ablation (RFA), cryotherapy, and photodynamic therapy are some of the modalities used for ablation.1-4 Although ablative therapy can eliminate intestinal metaplasia, there is always a concern of intestinal metaplasia buried under the neosquamous epithelium.5 Moreover, the stability of the neosquamous epithelium is unknown. Early studies have shown no genetic or molecular aberrations in the neosquamous epithelium.6-7 However, recently we published a case report on a patient who had short-segment Barrett’s with carcinoma in situ who initially achieved a complete response with ablative therapy (cryotherapy and then several sessions of RFA).8 He subsequently went on to develop HGD in the neosquamous epithelium at the site of ablation. He had no history of head and neck cancer and had been a remote smoker. Four biopsies every 2-cm from rest of the esophagus showed normal squamous epithelium.8 This letter is a follow-up on the case. We ablated the squamous cell HGD with additional sessions of RFA. After a brief period of returning to normal squamous cell epithelium (6 months), this patient developed a 2 to 3–mm nodule at the ablation site. Biopsy showed a moderately to
Table 1. Adult studies of duodenal bulb biopsies in celiac disease
Year
Country
Sample size
Controls
Villous atrophy present only in the duodenal bulb
2001
Austria
21
21
2/21 (9.5%)
2007
United Kingdom
56
None
1/56 (1.8%)
2010
United States
40
40
5/40 (12.5%)
2011
United Kingdom
461
250
11/126 (8.7%)
2012
Italy
86
43
1/43 (2.3%)
1082 GASTROINTESTINAL ENDOSCOPY Volume 76, No. 5 : 2012
www.giejournal.org