title: A Prospective Study on the Usefulness of Duodenal Bulb Biopsies in Celiac Disease Diagnosis in Children: Urging Caution.
abstract: OBJECTIVE
  Several recent celiac disease guidelines recommend the acquisition of duodenal bulb biopsies for diagnostics. This is in conflict with previously reported evidence and routine practice from the 1960s onward. We reopened the issue in a prospective multicenter study and used morphometric variables in evaluating the usefulness of bulb biopsies in children. We further sought to establish whether deposits of IgA targeting bulb transglutaminase 2 (TG2) could be of diagnostic help.
  
  
  METHODS
  Diagnoses of celiac disease were based on clinic and distal duodenal histopathology statements. Centralized reading of villous height (VH) to crypt depth (CrD) ratios and IgA deposits was performed on anatomical duodenal bulb specimens. All children participating also underwent routine investigations for other diseases.
  
  
  RESULTS
  Twenty-two children had celiac disease, and another 22 served as non-celiac disease controls. The quality of the anatomical bulb specimens was unsatisfactory for reliable morphometric measurements in 20 out of 44 (45%) patients even after recuttings. All celiac disease patients had VH:CrD<2.0 (mean 0.2) but also 10 out of 13 (77%) non-celiac control patients had an injured bulb mucosal lining (mean 1.3) even up to false-positive "flat lesion". Bulb IgA deposits were able to separate celiac disease from disease controls.
  
  
  CONCLUSIONS
  Morphological injury is common in the anatomical bulb even without celiac disease, increasing the risk of false-positive diagnoses. Premature conclusions might have been drawn on current care guidelines as to celiac disease diagnosis based solely on anatomical bulb specimens. Bulb mucosal IgA targeting TG2 in poor quality biopsy specimens is a powerful clinical tool in finding celiac disease patients.
authors.affiliation: Tampere Centre for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland.
authors.forename: Juha
authors.initials: J
authors.lastname: Taavela
authors.affiliation: Tampere Centre for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland.|University of Medicine and Pharmacy "Carol Davila" and Institute for Mother and Child Care, Bucharest, Romania.
authors.forename: Alina
authors.initials: A
authors.lastname: Popp
authors.affiliation: Celiac Disease Center, Heim Palm Children's Hospital, Budapest and Department of Pediatrics, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary.
authors.forename: Ilma Rita
authors.initials: IR
authors.lastname: Korponay-Szabo
authors.affiliation: Department of Pathology, Institute for Mother and Child Care, Bucharest, Romania.
authors.forename: Adina
authors.initials: A
authors.lastname: Ene
authors.affiliation: Department of Pathology, University of Tampere and Tampere University Hospital, Tampere, Finland.
authors.forename: Martine
authors.initials: M
authors.lastname: Vornanen
authors.affiliation: Research Programs Unit, Immunobiology, and Department of Medical Genetics, Haartman Institute, University of Helsinki, Helsinki, Finland.
authors.forename: Päivi
authors.initials: P
authors.lastname: Saavalainen
authors.affiliation: Tampere Centre for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland.
authors.forename: Marja-Leena
authors.initials: ML
authors.lastname: Lähdeaho
authors.affiliation: Tampere Centre for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland.
authors.forename: Tarja
authors.initials: T
authors.lastname: Ruuska
authors.affiliation: Tampere Centre for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland.
authors.forename: Kaija
authors.initials: K
authors.lastname: Laurila
authors.affiliation: University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania.
authors.forename: Alexandru
authors.initials: A
authors.lastname: Parvan
authors.affiliation: University of Medicine and Pharmacy "Carol Davila" and Institute for Mother and Child Care, Bucharest, Romania.
authors.forename: Ioana
authors.initials: I
authors.lastname: Anca
authors.affiliation: Tampere Centre for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland.
authors.forename: Kalle
authors.initials: K
authors.lastname: Kurppa
authors.affiliation: Tampere Centre for Child Health Research, School of Medicine, University of Tampere and Tampere University Hospital, Tampere, Finland.
authors.forename: Markku
authors.initials: M
authors.lastname: Mäki
mesh_terms: D000293:Adolescent; D001706:Biopsy; D002446:Celiac Disease / Q000473:pathology*; D002648:Child; D002675:Child, Preschool; D004386:Duodenum / Q000737:chemistry / Q000473:pathology*; D005260:Female; D019204:GTP-Binding Proteins / Q000276:immunology; D006801:Humans; D007070:Immunoglobulin A / Q000032:analysis; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D000091345:Protein Glutamine gamma Glutamyltransferase 2; D011503:Transglutaminases / Q000276:immunology
chemical_list: D007070:Immunoglobulin A; D000091345:Protein Glutamine gamma Glutamyltransferase 2; D011503:Transglutaminases; D019204:GTP-Binding Proteins