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Cross-sectional imaging in refractory celiac disease

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The purpose of this study is to identify unique imaging findings of refractory celiac disease (RCD) including Type I RCD, Type II RCD versus healed celiac disease (CD).


A retrospective study of patients with known CD and refractory symptoms with cross-sectional imaging was performed. We included patients who underwent T cell receptor rearrangement or T-cell immunophenotyping studies on small bowel (SB) biopsies to classify patients into: healed CD, Type I RCD, or Type II RCD. GI radiologists performed a blinded review of the imaging studies.


One-hundred eighteen patients (32 healed; 67 Type I RCD; 19 Type II RCD) were included (mean age 53 ± 6 years; 62% female). The presence of any fold pattern abnormality was more likely to be found in Type II and Type I RCD than healed CD (53% vs. 43% vs.16%; p = 0.009). Type II RCD patients were more likely than Type I RCD and healed CD to have imaging findings of ulcerative jejunitis (26% vs. 6% vs. 3%; p = 0.009), SB wall thickening (37% vs. 16% vs. 0%; p = 0.002) and SB dilation (26% vs. 7% vs. 6%; p = 0.04). Type II RCD demonstrated non-significant trends for decreased number of jejunal folds only, SB mass, mesenteric lymphadenopathy, localized peri-mural edema, and intramural duodenal edema.


Fold pattern abnormalities, ulcerative jejunitis, SB wall thickening, and SB dilation are more likely to be identified in cross-sectional imaging of RCD than healed CD. SB dilatation and ulcerative jejunitis are more likely to be found in Type II than Type I RCD.

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Celiac disease


Refractory celiac disease


Small bowel


Computed tomography enterography


Magnetic resonance enterography


Computed tomography abdomen/pelvis


Magnetic resonance imaging


Superior mesenteric vein


Enteropathy-associated T-cell lymphoma


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Authors’ contributions

BA-B: Study design, data abstraction, analysis, manuscript draft, and revision. JMB: Review of radiographic images, manuscript review, and editing. RNV: Review of radiographic images. STK: Data abstraction. DHB: Manuscript review and editing. SLH: Manuscript review and editing. SPS: Manuscript review and editing. JAM: Manuscript review and editing. AR-T: Manuscript review and editing. ER: Manuscript review and editing. JLF: Original concept, study design, manuscript review, and editing. JGF: Original concept, study design, review of radiographic images, manuscript review, and editing.

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Correspondence to Badr Al-Bawardy.

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No funding was received for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical aproval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

This study was approved by our institutional IRB prior to initiation. As this was a retrospective study, participating patients had consented to the retrospective use of images and other medical data for research purposes.

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Al-Bawardy, B., Barlow, J.M., Vasconcelos, R.N. et al. Cross-sectional imaging in refractory celiac disease. Abdom Radiol 42, 389–395 (2017). https://doi.org/10.1007/s00261-016-1032-0

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  • Celiac disease
  • Enteropathy
  • CT enterography
  • Ulcerative jejunitis