Sequential capsule endoscopy (CE) followed by double-balloon enteroscopy (DBE) is effective for monitoring small bowel complications and neoplasms in patients with suspected complicated celiac disease (CCD), according to a study in Clinical Gastroenterology and Hepatology.

Investigators sought to assess the diagnostic yield (DY) of CE and DBE in patients with suspected CCD. They prospectively enrolled consecutive CD patients from a center in Italy between November 2014 and March 2018.

The participants were categorized into 4 groups according to persistent symptoms despite a correct gluten-free diet, increased antitransglutaminase antibodies titer, lack of adherence to the gluten-free diet, and CCD monitoring.


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The analysis included 130 consecutive patients with suspected CCD (33 men; mean age, 49±16 years at enrollment and 39±18 years at CD diagnosis). A total of 151 CE and 23 DBE were performed.

The DY of CE was 46% (69 of 151) and was significantly higher in the follow-up evaluation of patients with known CCD (P <.05). The DY was significantly higher in patients aged 50 years and older at enrollment or at CD diagnosis (P <.05), with an increased relative risk (RR) of detecting lesions at CE of 1.6 (95% CI, 1.1-2.2) in those enrolled after age 50 years and 1.7 (95% CI, 1.3-2.3) in those with a CD diagnosis after 50 years of age.

An increased DY was observed in the first 5 years after CD diagnosis (RR, 1.5; 95% CI, 1.1-2.1). The finding was confirmed in multivariate logistic regression analysis, which showed that a disease duration less than 5 years was related to an increased odds ratio of 2.4 (95% CI, 1.18-5.04).

In 27 of 69 cases (40%), the lesions could not be assessed with upper endoscopy, and CE allowed correct definition and extension.

The DY of DBE was 83% (19 of 23 cases), and the concordance of CE and DBE was substantial (ĸ coefficient=0.62), noted the researchers.

A comparison of the CE findings with histology obtained from esophagogastroduodenoscopy showed that CE sensitivity and specificity for atrophy were 63% (95% CI, 0.51-0.73) and 80% (95% CI, 0.68-0.89), respectively.

After a median follow-up of 13 months (IQR, 6-19 months) and complete diagnostic work-up, the CCD rate was 19% (25 of 130). The rate of refractory CD (RCD) diagnosis in the full cohort was 15% (19 of 130) — 12 RCD type 1 cases and 7 RCD type 2 cases. A total of 6 deaths occurred among the 25 CCD patients (4 women; median age, 60 years; IQR, 55-67 years), all of which were CD related.

“Our results show that a sequential CE-DBE approach is effective and should be considered as the first-line approach to assess at-risk patients and detect CD-related complications,” the researchers concluded.

Reference

Ferretti F, Branchi F, Orlando S, et al. Effectiveness of capsule endoscopy and double-balloon enteroscopy in suspected complicated celiac disease. Clin Gastroenterol Hepatol. 2022;20(4):941-949.e3. doi:10.1016/j.cgh.2020.11.010