What is Upper Endoscopy and Why Is Small Intestine Biopsy Recommended for Celiac Disease?

When undergoing an assessment for potential celiac disease or gluten sensitive enteropathy doctors commonly recommend an upper endoscopy and small intestine biopsy. What that may mean or why it is recommended may not be clear to population who are facing the decision to undergo the policy themselves or to branch their child to the exam.

Endoscopy in celiac: What is it and how is it done?

Microscope

The medical name for upper endoscopy is esophagogastroduodenoscopy or Egd for short. The endoscope is a thin flexible tube about the diameter of a fat pencil that has a video chip in the end and channels for flushing of water, suctioning of secretions and duct of instruments. It has dials that allow the tube to be turned up/down and right and left at the tip permitting it to be passed straight through the mouth, down the esophagus or feeding tube, into the stomach and then into the first part of the small intestine the duodenum, hence the name Egd.

Endoscopy in celiac: Do you feel it or remember it?

People undergoing the exam in the U.S. Typically are sedated with a medication. Medications similar to valium with good amnesia and relaxing effect called midazolam or versed combined with a narcotic like meperidine (demerol) or fentanyl are generally used. More recently a very short acting intravenous sedative, propofol (diprovan), may be administered for deep sedation or an intravenous form of normal anesthesia. Occasionally, commonly in very young children or population with severe lung problems, normal anesthesia is required. The exam is commonly not felt or remembered because of the medications.

Endoscopy in celiac: What is examined in celiac and how well can the lining be seen?

Celiac disease affects the upper quantum of the small intestine, in the two sections known as the duodenum and jejunum. The exam of the small intestine is commonly wee to the first section termed the duodenum though occasionally the second section known as the jejunum may be reached especially when a longer endoscope is used. The resolution of video images are very high with the newest endoscopes and also may have a magnification and color inequity mode to detect very subtle signs of damage of the small intestine.

Endoscopy in celiac: What are the typical findings?

The characteristic appearance of the face of the small intestine in celiac disease contain superficial ulcerations that are generally linear, flattening of the folds, notching or scalloping of the folds and a mosaic like pattern. However, the face may appear normal and only under wee exam of samples will the lining show signs of gluten caused injury.

Endoscopy in celiac: What are biopsies?

Samples of small intestine are obtained with biopsy pliers that consist of tiny jaws with cups that permit pinching off samples of the intestinal lining. This is painless and very safe. The samples are sent to a prognosis lab in a preservative solution, processed, mounted on a microscope slide, and stained for exam under the microscope by a pathologist. Small intestine injury from gluten may be patchy, therefore, any samples are recommended. A minimum of 4 pieces and preferably 8-12 samples should be obtained to avoid missing wee signs of celiac disease.

Endoscopy in celiac: What does the pathologist look for on the slides?

The pathologist examines the slide for evidence of damage or injury characteristic of gluten sensitivity. Occasionally special stains are required to see signs of irritation known as inflammation characterized by an increased estimate of a type of immune active white blood cells called lymphocytes. In early celiac and gluten sensitivity without celiac disease the biopsy may be normal and the prognosis cannot be established by the biopsy.

Endoscopy in celiac: Summary.

The policy of endoscopy is safe, painless, and very helpful for establishing the prognosis of celiac disease while excluding other upper intestinal disorders. The main drawback of endoscopy is that nearly every person must have sedation to tolerate the exam and it can be expensive if not fully covered by insurance. Sometimes, celiac disease is diagnosed by endoscopic biopsy in population who either have normal blood tests or as an incidental finding in those undergoing endoscopy for other reasons. Fear or blurring about endoscopy should not forestall anything who is suspected of having celiac or gluten sensitivity from undergoing endoscopy. Supplementary data about celiac disease and other digestive diseases are ready at http://www.thefooddoc.com, the premier website under amelioration by "the food doc", Dr. Scot Lewey, a practicing stomach and intestinal devotee (gastroenterologist).

Copyright 2006, The Food Doc, Llc All rights Reserved. Http://www.thefooddoc.com

What is Upper Endoscopy and Why Is Small Intestine Biopsy Recommended for Celiac Disease?

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Celiac Disease Biopsy Explained: Part I Villous Atrophy

The determination of celiac disease is confirmed by a characteristic abnormal appearance of the small intestine under the microscope. Flattening of the general finger like projections called villi accompanied by signs of inflammation is taken to indicate damage or injury from the storage protein gluten in wheat and similar proteins in barley and rye. The small intestine biopsy has became the gold thorough for establishing the determination of Celiac disease or gluten sensitive enteropathy. Before 1960 gluten resignation followed by revision and subsequent worsening upon rechallenge was the diagnostic criteria.

Early in the 1960's straight through the 1970's the small intestine was biopsied by having population swallow a small metal capsule that was attached to a suction tube. This was used to suction up tissue into the capsule before guillotining off some tissue once the capsule was confirmed to be in the small intestine by x-ray. Now the tissue is obtained by upper endoscopy, the tube of a lighted video scope straight through the mouth under sedation to the small intestine, where biopsies are obtained with cupped forceps.

Microscope

Celiac disease biopsy: What does the pathologist look for under the microscope?

The small intestine ordinarily has finger like projections called villi that give it a large covering area or sense area for absorption. The villi follow in a shag rug or terry cloth towel type appearance. Lining the covering covering of each villous are intestinal cells or enterocytes that secrete mucus and Ant. Eject fluids, nutrients, minerals like iron, and vitamins like B12. On the covering of the enterocytes are digestive enzymes like lactase that Ant. Eject lactose or milk sugar. At the base of the villi are crypts or circular like collections of intestinal cells.

Celiac disease biopsy: What is villous atrophy?

Normally, villi are 3-5 times longer than the crypts are tall. However, intestinal injury can follow in blunting, shortening (partial villous atrophy) or perfect loss of the villi and flattening (villous atrophy) of the intestinal surface. The shag rug will have bare spots or the terry cloth towel becomes like a tee shirt. The follow is lack of absorption of nutrients and water resulting in weight loss, malnutrition, and diarrhea.

Celiac disease biopsy: What if the biopsy does not show atrophy or partial atrophy?

If the villi are at least 3 times as long as the crypts are tall then no flattening or blunting of the villi is gift and celiac disease becomes more difficult for the pathologist to diagnose without the history or blood test results. However, an increased whole of Iel's (intra-epitheliel lymphocytes) in the setting of a obvious exact blood test for celiac, symptoms and especially if supported by proximity of Dq2 and/or Dq8 gene pattern, is highly suggestive of celiac disease. The strangeness comes when the blood tests for the exact tests are negative or not elevated but only the "non-specific" blood tests (anti-gliadin or Aga and anti-reticulin antibodies) are elevated. Also, some population with milder forms of celiac have no blood tests abnormal but have first-rate biopsy findings of celiac and are termed seronegative (blood test negative) celiacs.

Celiac disease biopsy: Can the biopsy be general in celiac disease?

By definition, the biopsy has been carefully the gold thorough for diagnosing celiac. However, recent studies have shown that the biopsy can be general in some population with celiac. How can this be? The pathologist reading the biopsy may illustrate the biopsy as general based on his or her bias about celiac disease, a failure to appreciate the point of the proximity of Iel's, or misuse of the older thorough of >40 Iel's per 100. However, more importantly is the recent recognition that general appearing biopsies may not be normal. Electron microscopy has revealed ultra-structural abnormalities in apparent general biopsies of population confirmed to have celiac disease. Extra stains, that consist of immune labeling of lymphocytes, have also confirmed increased numbers of obvious types of exact lymphocytes in the villi of intestinal biopsies of population confirmed to have celiac. The lowest line is that a general biopsy does not definitively exclude celiac disease or gluten sensitivity.

Celiac diasease biopsy: What are other possible causes of biopsy changes that mimic celiac disease?

Cow's milk protein sensitive enteropathy (Cmse), viral or bacterial infections, medications (especially aspirin like arthritis medications e.g. Ibuprofen etc), autoimmune enteropathy, Helicobacter pylori infection (the stomach ulcer bacteria), Aids, base variable immunodeficiency, and lymphoma of the intestine are all possible causes of small intestine changes that may mimic celiac. However, if you have first-rate celiac type symptoms, a obvious celiac exact antibody (anti-endomysial antibody or tissue transglutaminase antibody) and a obvious response to a gluten free diet then celiac is the likely cause. The likelihood is supplementary increased if you carry one or both of the two major genes linked with celiac disease, Dq2 and/or Dq8. Normalization of celiac exact blood tests and the biopsy after a gluten free diet confirms the determination of celiac disease.

Celiac Disease Biopsy Explained: Part I Villous Atrophy

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Diagnosing Celiac Disease and Gluten Sensitivity

Celiac disease, also known as gluten sensitive enteropathy is very base but oftentimes missed. It is an autoimmune disease of intestinal damage due to gluten in population who are genetically predisposed. Superior Celiac disease is diagnosed by abnormal blood tests and an abnormal
appearing intestine on biopsy and symptoms that conclude with a gluten free diet.

Several blood tests exist for Celiac disease. They have varying degrees of accuracy. Some are more sensitive, meaning they will be definite in milder forms of the disease but are not specific, meaning a definite test may not indicate Celiac disease. Others are felt to be very specific, meaning that when they are positive, it is approximately definite you have the disease.

Microscope

The most exact tests are tests for Celiac disease endomysial antibodies (Ema) and
tissue transglutaminase antibody (tTg) tests. These two tests are IgA based tests and can be negative if you are deficient in the immunoglobin IgA, which occurs in 10-20% of population with Celiac. When whether Ema or tTg are definite Celiac disease is very likely and usually the intestine biopsy is positive. Up-to-date studies indicate that the tTg may only be definite in 40% of true Celiacs when mild degrees of intestine damage are present on biopsy. Seronegative Celiac, meaning the blood tests are negative but the biopsy is positive, may occur in up to 20% of Celiacs.

Antibodies for gliadin (Aga), the toxic fraction of gluten are carefully very sensitive but not exact for Celiac disease. Newer assays for Aga antibodies for gluten that has undergone a chemical change
called deamidation appear to be more exact for Celiac disease (Gliadin Ii,
Inova) than the older gliadin tests. They also may be as or more accurate than Ema and tTg
antibody tests but are not yet widely available.

The most distressing question for population with lesser forms of gluten intolerance who have blood tests and/or biopsies that are general or borderline yet sass to a gluten free diet is whether not being taken seriously or knowing for sure if they are sensitive to gluten. For these individuals stool
antibody testing for antigliadin and tTg have been helpful. Such stool testing has been performed in explore labs and published in a few studies but are only recently ready straight through the industrial lab, Enterolab. Founded by a old Baylor explore gastroenterologist, Dr Ken Fine, the tests are ready to population online without a doctors order but are not commonly covered by insurance. Dr. Fine, who patented the test, has yet to publish the results of his findings in a peer reviewed journal so his tests are not widely accepted. However, his unpublished data and the clinical caress of some of us who have used his test have
indicated the tests are very sensitive for signs of gluten sensitivity. He reports that they are 100% sensitive for Celiac disease and highly sensitive
for gluten sensitivity of lesser degrees. In the proximity of symptoms, that reverse on a gluten-free diet,
abnormal stool antibody levels can be found in most population before blood tests or biopsies come to be
abnormal.

Small intestine biopsies during upper gastrointestinal endoscopy
are carefully the "gold standard" for the prognosis of Celiac disease.
However, Up-to-date studies have demonstrated that some population with gluten sensitivity, especially relatives of Celiacs
with exiguous or no symptoms, have changes from gluten injury to the intestine that can not be seen with general microscope examination. They can only be seen with extra stains not routinely done or with a explore electron microscope. The extra stains are known as immunohistochemistry stains. They stain specialized white
blood cells called lymphocytes in the intestinal lining tips or villi. When these lymphocytes are increased it is known as intraepithelial lymphocytosis or increased Iels and it is the earliest sign
of gluten induced injury or irritation. Electron microscopy also reveals very early ultrastructural changes in some individuals when blood tests and suitable biopsy examination are normal. When population who have these changes are
offered the option of a gluten-free diet they usually responded favorably. In contrast, those who continue to eat gluten often later developed Superior Celiac disease.

What these studies propose is that a "normal small intestine biopsy" may exclude
Celiac disease as defined by accurate criteria but it is not a gold suitable for detecting gluten sensitivity. This fact is appreciated by many individuals who have sass to a gluten-free diet they start
based on their symptoms, house history, suggestive blood test or stool antibody
test(s).

Another source of obscuring is in the genetics of Celiac and gluten sensitivity.
Testing for exact blood type patterns on white blood cells known as Hla
Dq2 and Dq8 is increasingly being employed to conclude if a someone carries whether of the two gene
pattern present in 95-98% of Celiacs and predisposing them to the development of Celiac disease. Some use the absence of these two patterns
as a way of excluding the possibility of Celiac disease and the need for testing or
gluten-free diet. However, there are rare reports of documented Celiac disease in population who are Dq2 and
Dq8 negative. Moreover, Up-to-date studies indicate other Dq
patterns may be associated with gluten sensitivity though unlikely to
predispose to Superior Celiac disease.

Testing for all the Dq patterns is advocated by Dr. Fine, based on his
experience with stool antibody test results. He reports that other Dq types are
associated with elevated levels of gliadin and tTg in the stool and symptoms that sass to a gluten-free diet.
According to his unpublished data, all the Dq types except Dq4 are associated with
a risk of intolerance to gluten. Therefore, testing for all the Dq types allows a someone to
determine if they carry one of the two high risk gene types for Celiac disease or
any of the other "minor Dq" genes Fine has found associated with gluten sensitivity.

Enterolab's stool testing for gliadin antibodies and tissue
transglutaminase antibodies, though not widely accepted, have gained favor in the lay
public's notion as an option for determining sensitivity to gluten whether despite negative blood tests and/or biopsies or in place of the more invasive tests. Most doctors still propose the suitable blood tests and small
bowel biopsy for confirmation of Celiac. Though the reports in the lay society
are overwhelmingly definite they have not been subjected to peer retell in
the healing society pending Dr. Fine publishing his data or other researchers reproducing his results.

However, doctors open to
the broader question of gluten
sensitivity are reporting these tests helpful in many patients suspected of gluten
intolerance. Especially when someone has symptoms consistent with gluten sensitivity but has negative or inconclusive blood tests and/or biopsies these tests may be very helpful though some are not definite
how to construe the tests. The national Celiac organizations are uncertain about how to
comment on their application without published explore though a Up-to-date article
in the British healing Journal did show stool tests highly exact for Celiac. Dr.
Fine has publicly commented that his unpublished data demonstrates those with
abnormal stool tests indicating gluten sensitivity
overwhelmingly sass favorably to a gluten free diet with revision of
symptoms and general quality of life.

Another question is that there are not universally agreed upon definitions for gluten sensitivity or intolerance. This becomes especially difficult for those who do not meet accurate criteria for Celiac disease yet may have abnormal tests and/or symptoms that sass to a gluten-free diet. Those individuals come to be confused when they try to find data but do not have a formal prognosis of Celiac disease. Consensus in the healing society on definitions and more explore in this area is greatly needed.

The few doctors who appreciate the spectrum of gluten
intolerance or sensitivity are outnumbered by the healing majority that continue to
insist on accurate criteria for prognosis for Celiac disease before recommending a
gluten-free diet. Doctors whether unfamiliar with the limitations of the tests as documented by Celiac explore or who insist on the
strict criteria for Celiac being the only indication for recommending a gluten free
diet unfortunately may confuse or frustrate gluten sensitive individuals. Some of these population then seek answers on the internet or from alternative practitioners. Many have their prognosis missed, challenged, dismissed, or are misinformed. As a consequent they fail to benefit from the health
benefits of a gluten-free diet because they are advised that it is not required based on general blood tests and/or general biopsies. In the meantime, Celiac disease and gluten sensitivity continue to be undiagnosed or misdiagnosed. For more data visit http://www.thefooddoc.com.

Diagnosing Celiac Disease and Gluten Sensitivity

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