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The problem of biopsies in the diagnosis of celiac disease
Letters to the Editor
REFERENCES 1. Savides TJ. EUS-guided ERCP for patients with intermediate probability for choledocholithiasis: is it time for all of us to start doing this? Gastrointest Endosc 2008;67:669-72. 2. Lee YT, Chan FK, Leung WK, et al. Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study. Gastrointest Endosc 2008;67: 660-8. 3. Liu CL, Fan ST, Lo CM, et al. Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study. Clin Gastroenterol Hepatol 2005;3:1238-44. 4. Polkowski M, Regula J, Tilszer A, et al. Endoscopic ultrasound versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a randomized trial comparing two management strategies. Endoscopy 2007;39:296-303. 5. Cohen S, Bacon BR, Berlin JA, et al. National Institutes of Health State-of-the-Science Conference Statement: ERCP for diagnosis and therapy, January 14-16, 2002. Gastrointest Endosc 2002;56:803-9. 6. Vergel YB, Chilcott J, Kaltenthaler E, et al. Economic evaluation of MR cholangiopancreatography compared to diagnostic ERCP for the investigation of biliary tree obstruction. Int J Surg 2006;4:12-9. 7. Howard K, Lord SJ, Speer A, et al. Value of magnetic resonance cholangiopancreatography in the diagnosis of biliary abnormalities in postcholecystectomy patients: a probabilistic cost-effectiveness analysis of diagnostic strategies. Int J Technol Assess Health Care 2006;22: 109-18.
with a history of depression was related to eventual depression and post-traumatic stress syndrome. Purposely suppressing memories of the event may interfere with the patient’s natural ability to take corrective action. The better solution is to ensure that pain is never experienced in the first place. Studies that show low rates of adverse events when using a memory amnesiac may not represent the real rate of adverse effects. Follow-up studies are needed to measure the subtle psychosomatic effects of stress induction in the most difficult population within the first few weeks after the procedure. Jay R. Schrand, BSSE Enid, Oklahoma, USA REFERENCES 1. McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc 2008;67:910-23. 2. Kleim B, Ehlers A. Reduced autobiographical memory specificity predicts depression and posttraumatic stress disorder after recent trauma. J Consult Clin Psychol 2008;76:231-42. doi:10.1016/j.gie.2008.07.028
doi:10.1016/j.gie.2008.07.048
The problem of biopsies in the diagnosis of celiac disease Memory amnesiac use in endoscopy
To the Editor:
To the Editor: A review by McQuaid and Laine1 on moderate sedation for routine endoscopic procedures indicates that moderate sedation offers ‘‘a high level of physician and patient satisfaction and a low risk of serious adverse events.’’ However, 2 of the studies found an increased risk for dissatisfaction and memory of the procedure. They note that the importance of memory in the patient sedation experience requires further investigation. To reduce the risks inherent in heavy sedation, the pain medication is titrated to reduce the painful experience while allowing the practitioner to manipulate the body for easier maneuverability. This titration is based on observation of the patient’s responsiveness. However, because the sedation medication effects vocalization differently than the pain, the patient may indeed experience pain but be unable to express a meaningful response to the provider. The routine use of an amnesiac to reduce anxiety may seem like the perfect solution. However, studies of trauma suggest that stress has an adverse effect on the neurological and hormone subsystems long after the event, even if the details of the event are not remembered. A recent study2 found that the inability to recall specific events by those
My letter regards the article by Pais et al1 and the accompanying editorial by Dr Peter Green,2 both concerning the problem of biopsies in celiac disease (CD). As a pathologist, I would like to pinpoint some of these aspects. First, I would like to address the number of biopsies. I absolutely agree with the experience of Pais et al1 that 4 to 6 biopsy specimens are necessary for a correct diagnosis of CD; generally 2 in the descending duodenum and 2 in the duodenal bulb, as are the recommendations of international guidelines. The articles3,4 discussing the possibility of making the diagnosis of CD based only on bulb biopsies are, in my opinion, only speculative, in part mistaken, and not routinely useful. Second, I would like to address the orientation of the biopsies. Over the past 14 years, we have used the method of St Mark’s Hospital, which is based on acetate filters, but recently we have proposed a simplification of this model based on filters already cut. I agree that not all the biopsy specimens are correctly oriented, but with a strict collaboration between endoscopists and pathology technicians, correct orientation can be achieved in 60% to 70% of cases. This approach undoubtedly has advantages from both the morphological as well as the economical points of view. Third, I would like to address the diagnosis. Recently, we5 proposed a simplification of the current histological
www.giejournal.org
Volume 69, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 983
Letters to the Editor
classification of CD with the aims of making the work of pathologists more uniform and facilitating the interrelationship between pathologists and clinicians. In my opinion, the most significant pitfalls are the diagnosis of the initial lesions of CD (Marsh 1 and 2) and the real problem of uniformity for the pathologists, because in the presence of atrophy, the diagnosis in 90% of cases is certain. For this reason, and in order to provide the correct histological evaluation of the initial lesions of CD, I think, as Brown et al6 do, that it is necessary to accept the opinion that the criterion standard for diagnosing CD is no longer represented by the histological interpretation of the duodenal biopsy but, in reality, by the clinician alone, who is the only one who can make a definitive diagnosis on the basis of histological, serological, and clinical elements. The argument is more complex, and it is desirable that increased debate be undertaken in the future.
Figure 1. NBI view of the second part of the duodenum, showing normal villi.
Vincenzo Villanacci, MD 2 Department of Pathology Spedali Civili Brescia, Italy REFERENCES 1. Pais WP, Duerken DR, Pettigrew NM, et al. How many duodenal biopsy specimens are required to make a diagnosis of celiac disease? Gastrointest Endosc 2008;67:1082-7. 2. Green PHR. Celiac disease: how many biopsies for diagnosis? Gastrointest Endosc 2008;67:1088-90. 3. Vogelsang H, Hanel S, Steiner B, et al. Diagnostic duodenal bulb biopsy in celiac disease. Endoscopy 2001;33:336-40. 4. Bonamico M, Mariani P, Thanasi E, et al. Patchy villous atrophy of the duodenum in childhood celiac disease. J Pediatr Gastroenterol Nutr 2004;38:204-7. 5. Corazza GR, Villanacci V, Zambelli C, et al. Comparison of the interobserver reproducibility with different histologic criteria used in celiac disease. Clin Gastroenterol Hepatol 2007;5:838-43. 6. Brown I, Mino-Kenudson M, Deshpande V, et al. Intraepithelial lymphocytosis in architecturally preserved proximal small intestinal mucosa: an increasing diagnostic problem with a wide differential diagnosis. Arch Pathol Lab Med 2006;130:1020-5. doi:10.1016/j.gie.2008.07.004
Figure 2. NBI view showing patchy atrophy with flattened villi.
We read with interest the article by Pais et al1 and the accompanying editorial by Dr Green2 addressing the necessity of multiple biopsies to make a diagnosis of celiac disease (CD). To avoid insufficient sampling, the authors recommend 4 to 6 random biopsy specimens in patients with suspected CD. The patchy nature of the disease has been defined in numerous studies and demonstrated by magnification endos-
copy with chromoendoscopy.3 It is therefore equally important to obtain targeted biopsy specimens to increase the diagnostic yield. We have previously reported the role of magnification endoscopy with targeted biopsies in the diagnosis of CD.4 We have now combined high-resolution narrow-band imaging (NBI) with magnification to obtain targeted biopsy specimens. This is simpler than chromoendoscopy; it is available at the switch of a button and thereby reduces the procedure time. Patchy villous atrophy in the duodenum can be identified easily with NBI as areas of stunted or flattened villi. A view of the normal villi as demonstrated by NBI is shown in Figure 1. The patchy area with loss of villi is clearly observed in Figure 2. It is apparent that appropriate targeted biopsies would increase diagnostic yield.
984 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 4 : 2009
www.giejournal.org
High-resolution narrow-band imaging can identify patchy atrophy in celiac disease: targeted biopsy can increase diagnostic yield To the Editor:
REFERENCES 1. Savides TJ. EUS-guided ERCP for patients with intermediate probability for choledocholithiasis: is it time for all of us to start doing this? Gastrointest Endosc 2008;67:669-72. 2. Lee YT, Chan FK, Leung WK, et al. Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study. Gastrointest Endosc 2008;67: 660-8. 3. Liu CL, Fan ST, Lo CM, et al. Comparison of early endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the management of acute biliary pancreatitis: a prospective randomized study. Clin Gastroenterol Hepatol 2005;3:1238-44. 4. Polkowski M, Regula J, Tilszer A, et al. Endoscopic ultrasound versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a randomized trial comparing two management strategies. Endoscopy 2007;39:296-303. 5. Cohen S, Bacon BR, Berlin JA, et al. National Institutes of Health State-of-the-Science Conference Statement: ERCP for diagnosis and therapy, January 14-16, 2002. Gastrointest Endosc 2002;56:803-9. 6. Vergel YB, Chilcott J, Kaltenthaler E, et al. Economic evaluation of MR cholangiopancreatography compared to diagnostic ERCP for the investigation of biliary tree obstruction. Int J Surg 2006;4:12-9. 7. Howard K, Lord SJ, Speer A, et al. Value of magnetic resonance cholangiopancreatography in the diagnosis of biliary abnormalities in postcholecystectomy patients: a probabilistic cost-effectiveness analysis of diagnostic strategies. Int J Technol Assess Health Care 2006;22: 109-18.
with a history of depression was related to eventual depression and post-traumatic stress syndrome. Purposely suppressing memories of the event may interfere with the patient’s natural ability to take corrective action. The better solution is to ensure that pain is never experienced in the first place. Studies that show low rates of adverse events when using a memory amnesiac may not represent the real rate of adverse effects. Follow-up studies are needed to measure the subtle psychosomatic effects of stress induction in the most difficult population within the first few weeks after the procedure. Jay R. Schrand, BSSE Enid, Oklahoma, USA REFERENCES 1. McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc 2008;67:910-23. 2. Kleim B, Ehlers A. Reduced autobiographical memory specificity predicts depression and posttraumatic stress disorder after recent trauma. J Consult Clin Psychol 2008;76:231-42. doi:10.1016/j.gie.2008.07.028
doi:10.1016/j.gie.2008.07.048
The problem of biopsies in the diagnosis of celiac disease Memory amnesiac use in endoscopy
To the Editor:
To the Editor: A review by McQuaid and Laine1 on moderate sedation for routine endoscopic procedures indicates that moderate sedation offers ‘‘a high level of physician and patient satisfaction and a low risk of serious adverse events.’’ However, 2 of the studies found an increased risk for dissatisfaction and memory of the procedure. They note that the importance of memory in the patient sedation experience requires further investigation. To reduce the risks inherent in heavy sedation, the pain medication is titrated to reduce the painful experience while allowing the practitioner to manipulate the body for easier maneuverability. This titration is based on observation of the patient’s responsiveness. However, because the sedation medication effects vocalization differently than the pain, the patient may indeed experience pain but be unable to express a meaningful response to the provider. The routine use of an amnesiac to reduce anxiety may seem like the perfect solution. However, studies of trauma suggest that stress has an adverse effect on the neurological and hormone subsystems long after the event, even if the details of the event are not remembered. A recent study2 found that the inability to recall specific events by those
My letter regards the article by Pais et al1 and the accompanying editorial by Dr Peter Green,2 both concerning the problem of biopsies in celiac disease (CD). As a pathologist, I would like to pinpoint some of these aspects. First, I would like to address the number of biopsies. I absolutely agree with the experience of Pais et al1 that 4 to 6 biopsy specimens are necessary for a correct diagnosis of CD; generally 2 in the descending duodenum and 2 in the duodenal bulb, as are the recommendations of international guidelines. The articles3,4 discussing the possibility of making the diagnosis of CD based only on bulb biopsies are, in my opinion, only speculative, in part mistaken, and not routinely useful. Second, I would like to address the orientation of the biopsies. Over the past 14 years, we have used the method of St Mark’s Hospital, which is based on acetate filters, but recently we have proposed a simplification of this model based on filters already cut. I agree that not all the biopsy specimens are correctly oriented, but with a strict collaboration between endoscopists and pathology technicians, correct orientation can be achieved in 60% to 70% of cases. This approach undoubtedly has advantages from both the morphological as well as the economical points of view. Third, I would like to address the diagnosis. Recently, we5 proposed a simplification of the current histological
www.giejournal.org
Volume 69, No. 4 : 2009 GASTROINTESTINAL ENDOSCOPY 983
Letters to the Editor
classification of CD with the aims of making the work of pathologists more uniform and facilitating the interrelationship between pathologists and clinicians. In my opinion, the most significant pitfalls are the diagnosis of the initial lesions of CD (Marsh 1 and 2) and the real problem of uniformity for the pathologists, because in the presence of atrophy, the diagnosis in 90% of cases is certain. For this reason, and in order to provide the correct histological evaluation of the initial lesions of CD, I think, as Brown et al6 do, that it is necessary to accept the opinion that the criterion standard for diagnosing CD is no longer represented by the histological interpretation of the duodenal biopsy but, in reality, by the clinician alone, who is the only one who can make a definitive diagnosis on the basis of histological, serological, and clinical elements. The argument is more complex, and it is desirable that increased debate be undertaken in the future.
Figure 1. NBI view of the second part of the duodenum, showing normal villi.
Vincenzo Villanacci, MD 2 Department of Pathology Spedali Civili Brescia, Italy REFERENCES 1. Pais WP, Duerken DR, Pettigrew NM, et al. How many duodenal biopsy specimens are required to make a diagnosis of celiac disease? Gastrointest Endosc 2008;67:1082-7. 2. Green PHR. Celiac disease: how many biopsies for diagnosis? Gastrointest Endosc 2008;67:1088-90. 3. Vogelsang H, Hanel S, Steiner B, et al. Diagnostic duodenal bulb biopsy in celiac disease. Endoscopy 2001;33:336-40. 4. Bonamico M, Mariani P, Thanasi E, et al. Patchy villous atrophy of the duodenum in childhood celiac disease. J Pediatr Gastroenterol Nutr 2004;38:204-7. 5. Corazza GR, Villanacci V, Zambelli C, et al. Comparison of the interobserver reproducibility with different histologic criteria used in celiac disease. Clin Gastroenterol Hepatol 2007;5:838-43. 6. Brown I, Mino-Kenudson M, Deshpande V, et al. Intraepithelial lymphocytosis in architecturally preserved proximal small intestinal mucosa: an increasing diagnostic problem with a wide differential diagnosis. Arch Pathol Lab Med 2006;130:1020-5. doi:10.1016/j.gie.2008.07.004
Figure 2. NBI view showing patchy atrophy with flattened villi.
We read with interest the article by Pais et al1 and the accompanying editorial by Dr Green2 addressing the necessity of multiple biopsies to make a diagnosis of celiac disease (CD). To avoid insufficient sampling, the authors recommend 4 to 6 random biopsy specimens in patients with suspected CD. The patchy nature of the disease has been defined in numerous studies and demonstrated by magnification endos-
copy with chromoendoscopy.3 It is therefore equally important to obtain targeted biopsy specimens to increase the diagnostic yield. We have previously reported the role of magnification endoscopy with targeted biopsies in the diagnosis of CD.4 We have now combined high-resolution narrow-band imaging (NBI) with magnification to obtain targeted biopsy specimens. This is simpler than chromoendoscopy; it is available at the switch of a button and thereby reduces the procedure time. Patchy villous atrophy in the duodenum can be identified easily with NBI as areas of stunted or flattened villi. A view of the normal villi as demonstrated by NBI is shown in Figure 1. The patchy area with loss of villi is clearly observed in Figure 2. It is apparent that appropriate targeted biopsies would increase diagnostic yield.
984 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 4 : 2009
www.giejournal.org
High-resolution narrow-band imaging can identify patchy atrophy in celiac disease: targeted biopsy can increase diagnostic yield To the Editor: