Pediatr Gastroenterol Nutr. 2023 Jul 1;77(1):79-85. doi: 10.1097/MPG.0000000000003799.Epub 2023 Apr 21.

Supriya Behl ¹, Muhammad Rehan Khan ², Yasmine Ismail ³, Courtney Swantek ⁴, Zong-Ming Eric Chen ⁵, Joseph A Murray ⁶, Imad Absah ³

Author information

¹From the Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.

²the Division of Pediatric Gastroenterology, Hepatology & Nutrition, University of Illinois College of Medicine at Peoria; Children's Hospital of Illinois, Peoria, IL.

³the Division of Pediatric Gastroenterology and Hepatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.

⁴the Department of Pediatrics/Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL.

⁵the Department of Lab Medicine and Pathology, Mayo Clinic, Rochester, MN.

⁶the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.

Abstract

Objectives: Mucosal injury in celiac disease (CD) patients can be patchy, and up to 12% of CD patients can have mucosal changes limited to the duodenal bulb. Hence, recent guidelines recommend obtaining bulb biopsies in addition to distal duodenum. This study aimed to describe a cohort of children with isolated bulb CD and assess the benefit of separating bulb biopsies.

Methods: A retrospective chart review between January 2011 and January 2022 at 2 medical centers was conducted. We included children with CD who underwent endoscopy with separated biopsies from the bulb and distal duodenum. A blinded pathologist performed Marsh-Oberhuber grading on selected cases.

Results: We identified 224 CD patients, of which 33 (15%) had histologically confirmed isolated bulb CD. Patients with isolated bulb CD were older at diagnosis (10 vs 8 years; P = 0.03). Median anti-tissue transglutaminase immunoglobulin A (TTG IgA) level was lower in isolate bulb CD (2.8 vs 16.7 times the upper limit of normal [ULN], P < 0.001). Almost 88% (29/33) of isolated bulb CD patients had an anti-TTG IgA value of less than 10 times the ULN. Time to anti-TTG IgA normalization (mean 14 months) was similar between the 2 groups. A pathologist review of diagnostic biopsies could not distinguish between the bulb and distal duodenum biopsies in approximately one-third of the reviewed samples.

Conclusions: Separating bulb from distal duodenum biopsies can be considered during CD diagnosis, particularly in children with anti-TTG IgA levels less than 10 times the ULN. Larger prospective cohorts are needed to decide whether isolated bulb CD is a unique cohort or an early stage of the conventional CD.