Immunohistologic analysis of the duodenal bulb: a new method for celiac disease diagnosis in children

      Background and Aims

      Anti-tissue transglutaminase antibodies (anti-tTG) have simplified celiac disease (CD) diagnosis. However, in atypical forms of CD, intestinal biopsy sampling is still required. This prospective study investigates whether histologic analysis of the duodenal bulb combined with intestinal IgA anti-tTG deposit immunoassay makes CD diagnosis possible in at-risk children with low concentrations of serum anti-tTG.


      Histologic and intestinal IgA anti-tTG deposit immunoassays were used.


      Two hundred forty-five symptomatic children positive for serum anti-tTG (>7 U/mL) were enrolled and divided into 3 groups: extensive duodenal atrophy (n = 209), with IgA anti-tTG deposits throughout the duodenum and high serum anti-tTG concentrations (157 ± 178 U/mL); bulb duodenal atrophy (n = 22), with widespread IgA anti-tTG deposits in 9 and in the bulb alone in 13 and low serum anti-tTG concentrations (13.9 ± 8.7 U/mL); and normal duodenum (n = 14), with widespread IgA anti-tTG deposits in 8 and in the bulb alone in 6 and low serum anti-tTG concentrations (10.6 ± 6.2 U/mL). All patients in the first 2 groups were diagnosed with CD and 8 from the third group. All improved after 1 year of gluten-free diet. Bulb duodenal analysis led to a 12% (30/245) increase in CD diagnosis. No CD-related lesions were observed in the 30 control subjects.


      In children at risk for CD, bulb duodenum biopsy sampling is essential to identify villous atrophy and detect IgA anti-tTG deposits even in absence of intestinal lesions. These mucosal autoantibodies could well represent a new standard for diagnosing CD.


      AEA (anti-endomysium antibodies), anti-tTG (anti-tissue transglutaminase antibodies), CD (celiac disease), GFD (gluten-free diet), HLA (human leucocyte antigen), IEL (intraepithelial lymphocyte)
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      Linked Article

      • Intestinal IgA tTG deposits in the duodenal bulb in patients with celiac disease: light at the beginning of the tunnel!
        Gastrointestinal EndoscopyVol. 88Issue 6
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          We read with interest the article by De Leo et al1 and found it worth discussing. The authors show that immunohistologic analysis of the duodenal bulb helps in the diagnosis of celiac disease (CD) in children, even in the absence of intestinal changes, and that mucosal immunoglobulin A (IgA) anti-tissue transglutaminase (anti-tTG) deposits may represent a new standard for diagnosing celiac disease. IgA anti-tTG deposits were confined to the bulb only in a higher proportion of patients with normal duodenal histologic features (43%) in comparison with patients with bulb-only atrophy (13%) and extensive duodenal atrophy (2%).
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