What is Upper Endoscopy and Why Is Small Intestine Biopsy Recommended for Celiac Disease?

When undergoing an evaluation for possible celiac disease or gluten sensitive enteropathy doctors usually recommend an upper endoscopy and small intestine biopsy. What that may mean or why it is recommended may not be clear to people who are facing the decision to undergo the procedure themselves or to subject their child to the exam.

Endoscopy in celiac: What is it and how is it done?

The medical name for upper endoscopy is esophagogastroduodenoscopy or EGD for short. The endoscope is a thin flexible tube about the diameter of a fat pencil that has a video chip in the end and channels for flushing of water, suctioning of secretions and passage of instruments. It has dials that allow the tube to be turned up/down and right and left at the tip permitting it to be passed through the mouth, down the esophagus or feeding tube, into the stomach and then into the first part of the small intestine the duodenum, hence the name EGD.

Endoscopy in celiac: Do you feel it or remember it?

People undergoing the exam in the U.S. typically are sedated with a medication. Medications similar to valium with good amnesia and relaxing effect called midazolam or versed combined with a narcotic like meperidine (demerol) or fentanyl are generally used. More recently a very short acting intravenous sedative, propofol (diprovan), may be administered for deep sedation or an intravenous form of general anesthesia. Occasionally, usually in very young children or people with severe lung problems, general anesthesia is required. The exam is usually not felt or remembered because of the medications.

Endoscopy in celiac: What is examined in celiac and how well can the lining be seen?

Celiac disease affects the upper portion of the small intestine, in the two sections known as the duodenum and jejunum. The examination of the small intestine is usually limited to the first section termed the duodenum though occasionally the second section known as the jejunum may be reached especially when a longer endoscope is used. The resolution of video images are very high with the latest endoscopes and also may have a magnification and color contrast mode to detect very subtle signs of damage of the small intestine.

Endoscopy in celiac: What are the typical findings?

The characteristic appearance of the surface of the small intestine in celiac disease include superficial ulcerations that are commonly linear, flattening of the folds, notching or scalloping of the folds and a mosaic like pattern. However, the surface may appear normal and only under microscopic examination of samples will the lining show signs of gluten caused injury.

Endoscopy in celiac: What are biopsies?

Samples of small intestine are obtained with biopsy forceps that consist of tiny jaws with cups that permit pinching off samples of the intestinal lining. This is painless and very safe. The samples are sent to a pathology lab in a preservative solution, processed, mounted on a microscope slide, and stained for examination under the microscope by a pathologist. Small intestine injury from gluten may be patchy, therefore, several samples are recommended. A minimum of 4 pieces and preferably 8-12 samples should be obtained to avoid missing microscopic signs of celiac disease.

Endoscopy in celiac: What does the pathologist look for on the slides?

The pathologist examines the slide for evidence of damage or injury characteristic of gluten sensitivity. Occasionally special stains are required to see signs of irritation known as inflammation characterized by an increased number of a type of immune active white blood cells called lymphocytes. In early celiac and gluten sensitivity without celiac disease the biopsy may be normal and the diagnosis cannot be established by the biopsy.

Endoscopy in celiac: Summary.

The procedure of endoscopy is safe, painless, and very helpful for establishing the diagnosis of celiac disease while excluding other upper intestinal disorders. The main drawback of endoscopy is that nearly everyone must have sedation to tolerate the exam and it can be expensive if not fully covered by insurance. Sometimes, celiac disease is diagnosed by endoscopic biopsy in people who either have normal blood tests or as an incidental finding in those undergoing endoscopy for other reasons. Fear or confusion about endoscopy should not prevent anyone who is suspected of having celiac or gluten sensitivity from undergoing endoscopy. Further information about celiac disease and other digestive diseases are available at http://www.thefooddoc.com, the premier website under development by “the food doc”, Dr. Scot Lewey, a practicing stomach and intestinal specialist (gastroenterologist).

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