Bulb biopsies for the diagnosis of celiac disease in pediatric patients

Background: Celiac disease (CD) is a gluten-dependent enteropathy. The current standard for diagnosing CD involves obtaining 4 biopsy samples from the descending duodenum. It has been suggested that duodenal bulb biopsies may also be useful. Objective: To assess the utility of bulbar biopsies for the diagnosis of CD in pediatric patients. Design: Prospective study. Setting: Single center. Patients: Forty-seven consecutively enrolled pediatric patients with celiac serologies and a clinical suspicion of CD. Interventions: All patients underwent EGD, and 4 biopsy samples were obtained from the duodenal bulb and 4 from the descending duodenum of each child. Main Outcome Measurements: The pathologist blindly reported the Marsh histological grade for the diagnosis of CD of the bulb and descending duodenum. Results: The diagnosis of CD was histologically confirmed in 89.4% (42/47) of the cases of biopsy samples obtained from the descending duodenum and in all 47 obtained from the bulb. In 35 patients (74.5%), histology was the same in the bulb and duodenum; in 11 (23.4%) cases, the grade of atrophy was higher in the bulb than in the descending duodenum, and 5 (10.6%) had bulb histology positive for CD but negative duodenal findings. One child (2.1%) had a higher histological grade in the duodenum than in the bulb. The diagnostic gain with bulbar biopsies was 10.6%. Limitations: Small sample and absence of a comparison group (asymptomatic children with normal CD antibodies). Conclusions: We suggest examining 4 biopsy samples from the duodenal bulb and 4 from the descending duodenum to improve diagnostic accuracy of CD.