A gastroscopy report may contain phrases such as “the duodenal villi are blunted”, “scalloping”, “flattening of the villi” or “an appearance suggesting villous atrophy”.
This appearance can suggest coeliac disease, but coeliac disease cannot be diagnosed from the endoscopic picture alone.
For a definitive assessment, blood tests and — in most adult patients — duodenal biopsies matter.
What are villi?
Villi are the microscopic, finger-like projections on the inner surface of the small bowel. By widening the bowel’s surface they help with the absorption of iron, folate, vitamins, fats, proteins and other nutrients.
In coeliac disease the immune response to gluten can damage these structures.
- Normal villi Are long and regular.
- Damaged villi Are shortened, flattened or, in advanced cases, lost. This change is called villous atrophy.
Which endoscopic findings suggest coeliac disease?
Blunting or loss of the villi, a reduction in the mucosal folds, scalloping of the folds, a mosaic appearance and a nodular appearance of the lining in the duodenum can all suggest coeliac disease.
But a normal-looking endoscopy does not entirely rule coeliac disease out. So where there is suspicion, biopsy matters.
Is every case of blunted villi coeliac disease?
No.
Coeliac disease is one of the most important causes of villous atrophy; but it is not the only one.
Some infections (Giardia, for example), enteropathies related to certain medicines, conditions of the immune system and some rarer bowel diseases can produce a similar appearance.
So one should not conclude “I have coeliac disease” from an endoscopy report alone.
How is coeliac disease diagnosed?
While the patient is still eating gluten, coeliac serology is usually assessed first:
- Anti-tTG IgA
- Total IgA
Where needed, EMA-IgA and, in people with IgA deficiency, appropriate IgG-based tests may be used.
In adults where coeliac disease is suspected, taking several biopsies from different parts of the duodenum during gastroscopy matters for the diagnosis.
Why are biopsies taken from more than one place?
The changes in coeliac disease may not be equal throughout the duodenum. Some areas can look normal while villous atrophy is present elsewhere.
This is why taking multiple biopsies, appropriately from the duodenal bulb and the distal duodenum, increases the diagnostic yield.
What is looked for on biopsy?
The pathologist assesses whether the villi are shortened, whether there is lengthening of the crypts (crypt hyperplasia) and whether intraepithelial lymphocytes are increased.
The Marsh classification may be used to grade these changes.
Villous atrophy is an important finding but is not on its own specific to coeliac disease.
Should a gluten-free diet be started before the tests?
No.
Do not cut out gluten before the diagnosis is complete
Starting a gluten-free diet before the investigation for coeliac disease is complete can lead to falsely negative blood tests and duodenal biopsies. So someone in whom coeliac disease is suspected should not cut out gluten before the diagnostic tests are complete, unless their doctor advises otherwise.
If coeliac disease is confirmed, do the villi recover?
Yes, recovery is expected in most patients.
In coeliac disease, the bowel lining can heal over time on an appropriate and strict gluten-free diet. Symptoms and blood tests usually improve earlier, while complete recovery of the villi can take longer in adults.
Remember
- Blunted villi / scalloping Can suggest coeliac disease.
- The endoscopic appearance Does not on its own make a diagnosis of coeliac disease.
- Serology + duodenal biopsies Form the basis of the diagnosis in adults.
- A normal-looking endoscopy Does not entirely rule coeliac disease out.
- Before the diagnosis is complete Do not start a gluten-free diet on your own.
This is not enough to make a diagnosis
When blunted villi or scalloping is seen at endoscopy, the endoscopic findings, the coeliac blood tests and the pathology result of the duodenal biopsies all have to be weighed together.
Sources
- Prof. Ali Tüzün İnce, MD