Effectiveness of capsule endoscopy and double-balloon enteroscopy in suspected complicated celiac disease

Background and aims: Complicated celiac disease (CCD) is a rare but severe condition with a poor prognosis. Guidelines recommend use of capsule endoscopy (CE) to explore the small bowel (SB), followed by a double-balloon enteroscopy (DBE) in selected cases with suspected CCD. Our study aims to evaluate the diagnostic yield of CE and DBE in identifying and monitoring CCD. Methods: Consecutive suspected CCD patients were prospectively enrolled to undergo CE and/or DBE in the presence of persistent symptoms despite gluten-free diet (GFD), increased anti-transglutaminase antibodies titer, lack of adherence to GFD and CCD follow-up. The diagnostic yields (DY) of CE and DBE were calculated. The incidence of neoplastic complications and mortality were assessed. Results: In total, 130 patients (97 females, age 49±16 years) underwent 151 CE and 23 DBE. The DY of CE was 46%. Patients age >50 years (at CE examination or at CD diagnosis) with a disease duration <5 years were at higher risk of positive CE (RR 1.6, 1.7 and 1.5 respectively, p<0.05) than their counterparts. Up to 40% of SB lesions were unreachable by upper endoscopy. At the end of the diagnostic work-up, 25 patients with pre-malignant/malignant lesions were identified: 12 type-1 refractory CD (RCD-1), 7 type-2 RCD (RCD-2), 6 enteropathy-associated T-cell lymphoma (EATL). Six patients (2 RCD-2 and 4 EATL) died. Conclusions: In case of suspected CCD, CE should be the first-line approach to detect complications and to identify patients deserving DBE. Older and symptomatic patients with suspected CCD deserve a careful evaluation of small bowel especially during the first years after CD diagnosis.