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        I have read the comments about the necessity of biopsy in celiac
disease and a patient's letter who was diagnosed by biopsy and his/her
symtoms did not improve. Let me write down my opinion shortly.
        -The biopsy is absolutely necessary in the diagnosis in CD,especially
in adult. I do not want to list all the reasons. One of them, that there is
a condition so called hypoplastic villus atrophy (CD is a
hyperplastic diseas with increased mitosis number), which is not CD, but
should be followed carefully, because of the possibility of malignancy.
        -A second reason: when we are performing a biopsy we analyze the
activity of lot of digestive enzyme. Tipically the enzymes localized
in the luminal part of intestinal cells can have low activities. It
means that at the beginning we should start not only a gluten-free
diet, but should consider the malabsorption of lactose, sucrose etc. If
somebody does not improve in gluten-free diet immediately one reason can
be a so-called secondary dissacharidase deficiency. The recovery time
of  the damaged intestine mucosa is generally much slower in adult than
in children.
        -Third: I have written down in the Celiac BBS that the biopsy is
nor a dangerous procedure and necessary for the diagnosis.
        -I understand the frustation of lot of people in this country
having celiac disease. However, I feel a bit "upset" that this negative
feeling are directed to gastroenterologist, who really have expertise in
the diagnosis of this disease (e.g. I have 18 years experience with
children), by questioning the necessity of intestinal biopsy and a proper
diagnosis.

Karoly Horvath, M.D.
University of Maryland