Endoscopic and histological findings in the duodenum of adults with celiac disease before and after changing to a gluten-free diet: a 2-year prospective study.

BACKGROUND AND STUDY AIMS: Published follow-up data on small-intestinal recovery in patients with celiac disease are scarce and contradictory. This is especially the case for adult patients, who often show incomplete histological recovery after starting a gluten-free diet (GFD). We conducted a 2-year prospective study to evaluate the effectiveness of a GFD in improving the endoscopic and histological duodenal findings in adults with celiac disease. PATIENTS AND METHODS: We studied 42 consecutive adults with newly diagnosed celiac disease (13 men, 29 women; mean age 32.7 years, range 15 - 72 years). All the patients underwent esophagogastroduodenoscopy and small-bowel biopsy. We devised our own grading system for the endoscopic appearance of the duodenum, which ranged from "normal" appearance to "mild", "moderate", or "severe" alterations. Small-bowel biopsies were obtained from the second part of the duodenum (and from the duodenal bulb when it had a micronodular appearance). The histopathological appearances were described according to modified Marsh criteria. RESULTS: A normal endoscopic appearance in the duodenum was found in 5/42 patients (11.9 %) at entry and in 32/42 patients (76.2 %) after 2 years on a GFD. Subdividing the patients according to age, patients aged from 15 years to 60 years showed significant improvement within 12 months ( P < 0.0001 for patients aged from 15 years to 45 years; P < 0.003 for patients in the 46 years to 60 years group), whereas the improvement in endoscopic findings in patients older than 60 years was not statistically significant, even 24 months after starting the GFD. "Normal" histology was reported in none of the patients at entry, but in 25 patients (59.5 %) after 24 months on a GFD, but this parameter did not show a significant improvement until the patients had been on the GFD for 12 months ( P < 0.0001). Only the younger patients (5 - 30 years) showed significant improvement of histology within 12 months ( P < 0.034); older patients (>30 years) showed histological improvement but this was not statistically significant, even after 24 months on a GFD. CONCLUSIONS: This study shows for the first time that endoscopic recovery is faster than histological recovery in adults with celiac disease who go on a GFD. Moreover, older patients showed incomplete endoscopic and histological recovery even 24 months after starting a GFD. We therefore advise, as a minimum recommendation, that follow-up biopsies should be taken 1 - 2 years after starting a GFD in adults with celiac disease.

Symptomatic gastric leiomyoma mimicking giant gastric polyp: endoscopic diagnosis and removal.

Gastric leiomyoma is an uncommonly found benign submucosal neoplasm which may cause hemorrhage in rare cases. A 67-years-old patient was admitted to our attention due to two episodes of hematemesis and melena occurred in the previous two days. Esophagogastroduodenoscopy showed a giant semi-pedunculated gastric polyp (diameter of 4 centimeters) located at the distal body. A large ulcer with a clot was seen on the polyp. We treated endoscopically the giant polyp using the new two-steps-technique recently described by us for the treatment of the large pedunculated gastric and colorectal polyps, and the polypectomy was successfully performed without immediate or delayed complications. Histological evaluation of the transected polyp revealed morphology according to a gastric submucosal leiomyoma. Endoscopic control, performed one and four weeks and 12 months later, showed complete reepithelization of the gastric mucosa, without any sign of endoscopic, endosonographic and histological recurrence of the disease. This case report shows that our endoscopic approach may be successfully used also for giant semi-pedunculated gastric polyps.

Granular cell tumour of the oesophagus: a rare cause of dysphagia with differential diagnosis of oesophageal neoplastic lesions.

Granular cell tumour is a relatively uncommon, typically benign neoplasm of soft tissue. The macroscopic appearance of oesophageal granular cell tumour is a polypoid lesion, which is often asymptomatic and can be found incidentally, but, in some cases, is symptomatic and requires a correct differential diagnosis with malignant neoplasms of the oesophagus. We describe the case of a 28-year-old female who came to our attention due to a six-month history of heartburn and dysphagia. Oesophagogastroduodenoscopy showed the presence of a polypoid lesion 2 cm above the gastro-oesophageal junction. The overlying mucosa was normal and the lesion seemed to be an isolated submucosal nodule with a "submucosal pill" appearance. It was excised completely using a standard diathermic snare, and diagnosis of oesophageal granular cell tumour was made by histological and immunohistochemical staining. The patient's symptoms disappeared immediately after removal of the nodule by endoscopic polypectomy, and no macroscopic or microscopic recurrence of granular cell tumour was noted during follow-up. Likewise, the patient was symptom-free during follow-up. This case shows that endoscopy is very effective, not only in the diagnosis, but also in the treatment of oesophageal lesions which require careful differential diagnosis.