Esophagus to Small Intestine
Clin Gastroenterol Hepatol. 2022;20(4):941–9.e3
Effectiveness of capsule endoscopy and double-balloon enteroscopy in suspected complicated celiac disease
Background and aims: Complicated celiac disease (CCD) is a rare but severe condition with a poor prognosis. Guidelines recommend use of capsule endoscopy (CE) to explore the small bowel, followed by a double-balloon enteroscopy (DBE) in selected cases with suspected CCD. The present study aimed to evaluate the diagnostic yield of CE and DBE in identifying and monitoring CCD.
Methods: Consecutive suspected CCD patients were enrolled prospectively to undergo CE and/or DBE in the presence of: persistent symptoms despite a correct gluten-free diet (GFD), increased anti-transglutaminase antibodies titer, lack of adherence to the GFD, and CCD monitoring. The diagnostic yield of CE and DBE were calculated. The incidence of neoplastic complications and mortality were assessed.
Results: In total, 130 patients (97 women; age, 49 ± 16 years) underwent 151 CEs and 23 DBEs. The diagnostic yield of CE was 46%. Patients older than age 50 years (at CE examination or at CD diagnosis) with a CD duration shorter than 5 years were at higher risk of positive CE (relative risk = 1.6 and 1.7 in case of enrollment or CD diagnosis after 50 years of age, and 1.5 in case of short CD duration; p < 0.05) than their counterparts. Up to 40% of small-bowel lesions were unreachable by upper endoscopy. At the end of the diagnostic work-up, 25 patients with premalignant/malignant lesions were identified: 12 type 1 refractory CD (RCD-1), 7 type 2 RCD (RCD-2), and 6 enteropathy-associated T-cell lymphoma (EATL). Six patients died: 2 patients with RCD-2 and 4 patients with EATL.
Conclusions: In case of suspected complicated celiac disease (CCD), capsule endoscopy should be the first-line approach to detect complications and to identify patients deserving double-balloon enteroscopy. Older and symptomatic patients with suspected CCD deserve a careful evaluation of the small bowel, especially during the first years after diagnosis.