ORIGINAL CONTRIBUTIONS: PEDIATRICSA Prospective Study on the Usefulness of Duodenal Bulb Biopsies in Celiac Disease Diagnosis in Children: Urging CautionTaavela, Juha MD1,8; Popp, Alina MD1,2,8; Korponay-Szabo, Ilma Rita MD3; Ene, Adina MD4; Vornanen, Martine MD5; Saavalainen, Päivi PhD6; Lähdeaho, Marja-Leena MD1; Ruuska, Tarja MD1; Laurila, Kaija MSc1; Parvan, Alexandru MD7; Anca, Ioana MD2,✠; Kurppa, Kalle MD1; Mäki, Markku MD1Author Information 1Tampere Centre for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland 2University of Medicine and Pharmacy “Carol Davila” and Institute for Mother and Child Care, Bucharest, Romania 3Celiac Disease Center, Heim Palm Children’s Hospital, Budapest and Department of Pediatrics, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary 4Department of Pathology, Institute for Mother and Child Care, Bucharest, Romania 5Department of Pathology, University of Tampere and Tampere University Hospital, Tampere, Finland 6Research Programs Unit, Immunobiology, and Department of Medical Genetics, Haartman Institute, University of Helsinki, Helsinki, Finland 7University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania Correspondence: Markku Mäki, MD, Tampere Centre for Child Health Research, School of Medicine, Tampere University Hospital, University of Tampere, Building Finn Medi 3, FIN-33014, Tampere, Finland. E-mail: email@example.com 8These authors contributed equally to this work ✠Deceased Received 20 June 2015; accepted 02 November 2015 Gurarantor of the article: Markku Mäki, MD. Specific author contributions: Study concept and design: J.T., A.P., K.K., and M.M.; acquisition of patients and specimens: A.P., M.L.L., T.R., A.P., and K.K.; reading of the specimens: J.T., A.P., I.K.S., A.E., M.V., and K.L.; genetic analysis: P.S.; analysis of data: J.T. and A.P.; data interpretation and drafting of the manuscript: J.T., A.P., and M.M. All authors critically read, commented on, and approved the final version of the manuscript. Financial support: This study was financially supported by the Competitive State Research Financing of the Expert Responsibility Area of Tampere University Hospital, Grant No. 9S041, the Romanian National Authority for Scientific Research, CNDI-UEFISCDI, Project No. 111/2012, the Finnish Celiac Society, the Foundation for Pediatric Research, the Finnish Medical Foundation, and the Hungarian Research Fund (OTKA) grant K101788 and TÁMOP-4.2.2.A-11/1/KONV-2012-0023. Potential competing interests: None. American Journal of Gastroenterology: January 2016 - Volume 111 - Issue 1 - p 124-133 doi: 10.1038/ajg.2015.387 Buy Metrics Abstract Objectives: Several recent celiac disease guidelines recommend the acquisition of duodenal bulb biopsies for diagnostics. This is in conflict with previously reported evidence and routine practice from the 1960s onward. We reopened the issue in a prospective multicenter study and used morphometric variables in evaluating the usefulness of bulb biopsies in children. We further sought to establish whether deposits of IgA targeting bulb transglutaminase 2 (TG2) could be of diagnostic help. Methods: Diagnoses of celiac disease were based on clinic and distal duodenal histopathology statements. Centralized reading of villous height (VH) to crypt depth (CrD) ratios and IgA deposits was performed on anatomical duodenal bulb specimens. All children participating also underwent routine investigations for other diseases. Results: Twenty-two children had celiac disease, and another 22 served as non-celiac disease controls. The quality of the anatomical bulb specimens was unsatisfactory for reliable morphometric measurements in 20 out of 44 (45%) patients even after recuttings. All celiac disease patients had VH:CrD<2.0 (mean 0.2) but also 10 out of 13 (77%) non-celiac control patients had an injured bulb mucosal lining (mean 1.3) even up to false-positive “flat lesion”. Bulb IgA deposits were able to separate celiac disease from disease controls. Conclusions: Morphological injury is common in the anatomical bulb even without celiac disease, increasing the risk of false-positive diagnoses. Premature conclusions might have been drawn on current care guidelines as to celiac disease diagnosis based solely on anatomical bulb specimens. Bulb mucosal IgA targeting TG2 in poor quality biopsy specimens is a powerful clinical tool in finding celiac disease patients. © The American College of Gastroenterology 2016. All Rights Reserved.