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Gastrointest Endosc 2003 Mar;57(3):348-51

Lack of endoscopic visualization of intestinal villi with the "immersion
technique" in overt atrophic celiac disease.

Gasbarrini A, Ojetti V, Cuoco L, Cammarota G, Migneco A, Armuzzi A, Pola P,
Gasbarrini G.

Current affiliations: Internal Medicine and Gastroenterology, Gemelli
Teaching Hospital, Catholic University of Rome, Italy.

BACKGROUND: The endoscopic appearance of the duodenal folds can predict the
presence of celiac disease. However, endoscopic alterations can be minimal
and the disease can have a "patchy" distribution histopathologically. The
observation that intestinal villi can be better visualized when the
duodenum is filled with water led to the development of an
endoscopic "immersion technique" to assess celiac disease.

METHODS: Endoscopy with duodenal biopsies was performed in 20 patients with
malabsorption syndrome (positive for antiendomysial antibodies) and in 30
patients with reflux-like symptoms (negative for antiendomysial
antibodies). Duodenal hypotonia was induced pharmacologically, water was
introduced, and the mucosa was observed for the presence of villi.
Photographs were obtained for subsequent analysis. The endoscopic
appearance was classified from 1 (folds certainly present) to 4 ("scalloped
valvulae"); villous structures were classified from 1 (definitely present)
to 3 (definitely absent).

RESULTS: Celiac disease was confirmed histopathologically in all patients
with positive antiendomysial antibodies. The endoscopic appearance of the
duodenum with air insufflation alone had a positive predictive value for
the diagnosis of celiac disease of 84% and a specificity of 87%.
Visualization of villi with the "immersion technique" had a higher positive
predictive value (99%) and specificity (99%).

CONCLUSIONS: A lack of visualization of intestinal villi in the descending
duodenum with the "immersion technique" may increase the diagnostic
accuracy of endoscopy for celiac disease. This technique could also be
useful for targeting duodenal biopsies.

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