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The Role of Duodenal Bulb Biopsy in the Diagnosis of Celiac Disease in Children

Levinson-Castiel, Rachel MD*; Hartman, Corina MD*; Morgenstern, Sara MD; Avitzur, Yaron MD*,‡; Hirsch, Akiva MD*; Rosenbach, Yoram MD*,‡; Shapiro, Rivka MD*,‡; Zevit, Noam MD*,‡; Fleischaker, Hava RN*; Niv, Yaron MD‡,§; Shamir, Raanan MD*,‡

Journal of Clinical Gastroenterology: January 2011 - Volume 45 - Issue 1 - p 26–29
doi: 10.1097/MCG.0b013e3181e04d26
ALIMENTARY TRACT: Original Articles

Background and Study Aims It is suggested that for celiac disease (CD) diagnosis, biopsies should also be taken from the duodenal bulb. Whether bulb biopsies suggestive of CD can be found on upper gastrointestinal endoscopy (EGD) done for reasons other than CD diagnosis is not clear. The aim of our study was to evaluate the contribution of routine bulb biopsies to the diagnosis of CD, when taken regardless of prior suspicion of CD.

Methods The study included 96 children who underwent EGD for suspected CD and a control group of 69 children who underwent EGD for reasons other than CD. The mucosal changes were evaluated using the Marsh-Oberhuber classification.

Results Among the 87 children diagnosed with CD, we identified 6 patients (7%) with typical histologic findings only in the bulb (Marsh 3), but also 1 patient (1.1%) with findings only in the distal duodenum (Marsh 2). In 20 patients (23%) the histological changes were more severe in the bulb. One patient had more prominent findings in the second part of the duodenum. None of the control patients had histological changes compatible with CD in the bulb or the second part of the duodenum.

Conclusions Our findings suggest that when CD is suspected, biopsies should be taken from both locations (bulb and second part) as mucosal changes may emerge only at one site. Nevertheless, the presence of characteristic histology on duodenal bulb biopsies might be sufficient for the diagnosis of CD.

*Institute for Gastroenterology, Nutrition and Liver Diseases, Schneider's Children Medical Center, Petach Tikvah

Pathology Department, Rabin Medical Center, Petach Tikvah

§Gastroenterology Department, Rabin Medical center, Petach Tikvah

Sackler Faculty of Medicine, Tel-Aviv University, Israel

Reprints: Rachel Levinson-Castiel, MD, Institute of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel (e-mail:

All authors declare no conflict of interest and no funding source.

Received November 15, 2009

Accepted March 25, 2010

© 2011 Lippincott Williams & Wilkins, Inc.