Digestive Diseases and Sciences

, Volume 56, Issue 2, pp 499–505 | Cite as

The Role of Capsule Endoscopy in Suspected Celiac Disease Patients with Positive Celiac Serology

  • Ilmars LidumsEmail author
  • Adrian G. Cummins
  • Edward Teo
Original Article



Endomysial antibody (EMA) and tissue transglutaminase (tTG) antibody testing is used to screen subjects with suspected celiac disease. However, the traditional gold standard for the diagnosis of celiac disease is histopathology of the small bowel. As villous atrophy may be patchy, duodenal biopsies could potentially miss the abnormalities. Capsule endoscopy can obtain images of the whole small intestine and may be useful in the early diagnosis of celiac disease.


To evaluate suspected celiac disease patients who have positive celiac serology and normal duodenal histology and to determine, with capsule endoscopy, whether these patients have any endoscopic markers of celiac disease.


Twenty-two subjects with positive celiac serology (EMA or tTG) were prospectively evaluated. Eight of the subjects had normal duodenal histology and 14 had duodenal histology consistent with celiac disease. All subjects underwent capsule endoscopy. Endoscopic markers of villous atrophy such as loss of mucosal folds, scalloping, mosaic pattern, and visible vessels were assessed.


Eight subjects with normal duodenal histology had normal capsule endoscopy findings. In the 14 subjects with duodenal histology that was consistent with celiac disease, 13 had celiac disease changes seen at capsule endoscopy. One subject with normal capsule endoscopy findings showed Marsh IIIc on duodenal histology. Using duodenal histology as the gold standard, capsule endoscopy had a sensitivity of 93%, specificity of 100%, PPV of 100%, and NPV of 89% in recognizing villous atrophy.


Capsule endoscopy is useful in the detection of villous abnormalities in untreated celiac disease. Patients with positive celiac serology (EMA or tTG) and normal duodenal histology are unlikely to have capsule endoscopy markers of villous atrophy.


Celiac disease Celiac serology Capsule endoscopy 



Endomysial IgA antibody


Tissue transglutaminase IgA antibody


Endomysial antibody


Tissue transglutaminase antibody


Standard error of the mean


Positive predictive value


Negative predictive value



Financial support: Given Imaging Ltd partially supported the study by supplying PillCam® SB capsules to perform the study and did not have any role in the design of the study, analysis, or writing of the article.


  1. 1.
    Cook HB, Burt MJ, Collett JA, Whitehead MR, Frampton CN. Chapman BA: Adult coeliac disease: prevalence and clinical significance. J Gastroenterol Hepatol. 2000;15:1032–1036.CrossRefPubMedGoogle Scholar
  2. 2.
    Hovell CJ, Collett JA, Vautier G, et al. High prevalence of coeliac disease in a population-based study from Western Australia: a case for screening? Med J Aust. 2001;175:247–250.PubMedGoogle Scholar
  3. 3.
    Not T, Horvath K, Hill ID, et al. Celiac disease risk in the USA: high prevalence of antiendomysium antibodies in healthy blood donors. Scand J Gastroenterol. 1998;33:494–498.CrossRefPubMedGoogle Scholar
  4. 4.
    Rewers M. Epidemiology of celiac disease: what are the prevalence, incidence, and progression of celiac disease? Gastroenterology. 2005;128:S47–S51.CrossRefPubMedGoogle Scholar
  5. 5.
    Holmes GK, Prior P, Lane MR, Pope D. Allan RN: Malignancy in coeliac disease—effect of a gluten-free diet. Gut. 1989;30:333–338.CrossRefPubMedGoogle Scholar
  6. 6.
    Anderson RP. Coeliac disease: current approach and future prospects. Intern Med J. 2008;38:790–799.CrossRefPubMedGoogle Scholar
  7. 7.
    Picarelli A, Maiuri L, Mazzilli MC, et al. Gluten-sensitive disease with mild enteropathy. Gastroenterology. 1996;111:608–616.CrossRefPubMedGoogle Scholar
  8. 8.
    Thijs WJ, van Baarlen J, Kleibeuker JH, Kolkman JJ. Duodenal versus jejunal biopsies in suspected celiac disease. Endoscopy. 2004;36:993–996.CrossRefPubMedGoogle Scholar
  9. 9.
    Brocchi E, Corazza GR, Caletti G, Treggiari EA, Barbara L, Gasbarrini G. Endoscopic demonstration of loss of duodenal folds in the diagnosis of celiac disease. New Engl J Med. 1988;319:741–744.CrossRefPubMedGoogle Scholar
  10. 10.
    Jabbari M, Wild G, Goresky CA, et al. Scalloped valvulae conniventes: an endoscopic marker of celiac sprue. Gastroenterology. 1988;95:1518–1522.PubMedGoogle Scholar
  11. 11.
    Magazzu G, Bottari M, Tuccari G, et al. Upper gastrointestinal endoscopy can be a reliable screening tool for celiac sprue in adults. J Clin Gastroenterol. 1994;19:255–257. (discussion 257–258).CrossRefPubMedGoogle Scholar
  12. 12.
    Maurino E, Capizzano H, Niveloni S, et al. Value of endoscopic markers in celiac disease. Dig Dis Sci. 1993;38:2028–2033.CrossRefPubMedGoogle Scholar
  13. 13.
    Bardella MT, Minoli G, Radaelli F, Quatrini M, Bianchi PA, Conte D. Reevaluation of duodenal endoscopic markers in the diagnosis of celiac disease. Gastrointest Endosc. 2000;51:714–716.CrossRefPubMedGoogle Scholar
  14. 14.
    Siegel L, Stevens PD, Lightdale CJ, et al. Combined magnification endoscopy with chromoendoscopy in the evaluation of patients with suspected malabsorption. Gastrointest Endosc. 1997;46:226–230.CrossRefPubMedGoogle Scholar
  15. 15.
    Leong RW, Nguyen NQ, Meredith CG, et al. In vivo confocal endomicroscopy in the diagnosis and evaluation of celiac disease. Gastroenterology. 2008;135:1870–1876.CrossRefPubMedGoogle Scholar
  16. 16.
    Badreldin R, Barrett P, Wooff DA, Mansfield J, Yiannakou Y. How good is zoom endoscopy for assessment of villous atrophy in coeliac disease? Endoscopy. 2005;37:994–998.CrossRefPubMedGoogle Scholar
  17. 17.
    Iddan G, Meron G, Glukhovsky A, Swain P. Wireless capsule endoscopy. Nature. 2000;405:417.CrossRefPubMedGoogle Scholar
  18. 18.
    Appleyard M, Fireman Z, Glukhovsky A, et al. A randomized trial comparing wireless capsule endoscopy with push enteroscopy for the detection of small-bowel lesions. Gastroenterology. 2000;119:1431–1438.CrossRefPubMedGoogle Scholar
  19. 19.
    Hopper AD, Sidhu R, Hurlstone DP, McAlindon ME, Sanders DS. Capsule endoscopy: an alternative to duodenal biopsy for the recognition of villous atrophy in coeliac disease? Dig Liver Dis. 2007;39:140–145.CrossRefPubMedGoogle Scholar
  20. 20.
    Petroniene R, Dubcenco E, Baker JP, et al. Given capsule endoscopy in celiac disease: evaluation of diagnostic accuracy and interobserver agreement. Am J Gastroenterol. 2005;100:685–694.CrossRefPubMedGoogle Scholar
  21. 21.
    Rondonotti E, Spada C, Cave D, et al. Video capsule enteroscopy in the diagnosis of celiac disease: a multicenter study. Am J Gastroenterol. 2007;102:1624–1631.CrossRefPubMedGoogle Scholar
  22. 22.
    Marsh MN. Gluten, major histocompatibility complex, and the small intestine. A molecular and immunobiologic approach to the spectrum of gluten sensitivity (‘celiac sprue’). Gastroenterology. 1992;102:330–354.PubMedGoogle Scholar
  23. 23.
    Oberhuber G, Granditsch G, Vogelsang H. The histopathology of coeliac disease: time for a standardized report scheme for pathologists. Eur J Gastroenterol Hepatol. 1999;11:1185.CrossRefPubMedGoogle Scholar
  24. 24.
    Dickey W, Hughes DF, McMillan SA. Patients with serum IgA endomysial antibodies and intact duodenal villi: clinical characteristics and management options. Scand J Gastroenterol. 2005;40:1240–1243.CrossRefPubMedGoogle Scholar
  25. 25.
    Salmi TT, Collin P, Jarvinen O, et al. Immunoglobulin A autoantibodies against transglutaminase 2 in the small intestinal mucosa predict forthcoming coeliac disease. Aliment Pharmacol Ther. 2006;24:541–552.CrossRefPubMedGoogle Scholar
  26. 26.
    Scott BB, Losowsky MS. Patchiness and duodenal-jejunal variation of the mucosal abnormality in coeliac disease and dermatitis herpetiformis. Gut. 1976;17:984–992.CrossRefPubMedGoogle Scholar
  27. 27.
    Rostom A, Murray JA, Kagnoff MF. American Gastroenterological Association (AGA) Institute technical review on the diagnosis and management of celiac disease. Gastroenterology. 2006;131:1981–2002.CrossRefPubMedGoogle Scholar
  28. 28.
    Pais WP, Duerksen DR, Pettigrew NM, Bernstein CN. How many duodenal biopsy specimens are required to make a diagnosis of celiac disease? Gastrointest Endosc. 2008;67:1082–1087.CrossRefPubMedGoogle Scholar
  29. 29.
    Ravelli A, Bolognini S, Gambarotti M, Villanacci V. Variability of histologic lesions in relation to biopsy site in gluten-sensitive enteropathy. Am J Gastroenterol. 2005;100:177–185.CrossRefPubMedGoogle Scholar
  30. 30.
    Goldstein JL, Eisen GM, Lewis B, et al. Video capsule endoscopy to prospectively assess small bowel injury with celecoxib, naproxen plus omeprazole, and placebo. Clin Gastroenterol Hepatol. 2005;3:133–141.CrossRefPubMedGoogle Scholar
  31. 31.
    Murray JA, Rubio-Tapia A, Van Dyke CT, et al. Mucosal atrophy in celiac disease: extent of involvement, correlation with clinical presentation, and response to treatment. Clin Gastroenterol Hepatol. 2008;6:186–193.CrossRefPubMedGoogle Scholar
  32. 32.
    Biagi F, Rondonotti E, Campanella J, et al. Video capsule endoscopy and histology for small-bowel mucosa evaluation: a comparison performed by blinded observers. Clin Gastroenterol Hepatol. 2006;4:998–1003.CrossRefPubMedGoogle Scholar
  33. 33.
    Chin MW, Mallon DF, Cullen DJ, Olynyk JK, Mollison LC, Pearce CB. Screening for coeliac disease using anti-tissue transglutaminase antibody assays, and prevalence of the disease in an Australian community. Med J Aust. 2009;190:429–432.PubMedGoogle Scholar
  34. 34.
    Collin P, Helin H, Maki M, Hallstrom O, Karvonen AL. Follow-up of patients positive in reticulin and gliadin antibody tests with normal small-bowel biopsy findings. Scand J Gastroenterol. 1993;28:595–598.CrossRefPubMedGoogle Scholar
  35. 35.
    Biagi F, Luinetti O, Campanella J, et al. Intraepithelial lymphocytes in the villous tip: do they indicate potential coeliac disease? J Clin Pathol. 2004;57:835–839.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of Gastroenterology and HepatologyThe Queen Elizabeth HospitalWoodville SouthAustralia

Personalised recommendations