CT and MR Enterography in the Evaluation of Celiac Disease.

Celiac disease is a common inflammatory disease of the small bowel that induces mucosal intestinal lesions. The disease is mediated by an immune response and triggered by the ingestion of gluten in genetically predisposed individuals. Gluten contains gliadin, a component found mostly in wheat, barley, and rye. This process leads to gastrointestinal malabsorption with symptoms such as diarrhea, constipation, abdominal pain, and distention. It has a prevalence of 1%-2% in the general adult population, who present with symptoms at any age, but is more frequently found in adult women in the 3rd or 4th decade of life. Recognition of the disease has increased, but it remains a challenge to diagnose. CT and MR enterography are noninvasive studies used for evaluation of small bowel neoplasms and inflammatory small bowel pathologic conditions such as celiac disease. The authors review the spectrum of intestinal and extraintestinal findings of celiac disease at CT and MR enterography, as well as its complications, and the importance of recognizing certain imaging features that help in the diagnosis of celiac disease. More common and specific findings of celiac disease such as inversion of the jejunoileal fold pattern and mesenteric lymphadenopathy are reviewed. More uncommon entities that are more frequently associated with refractory or untreated celiac disease, such as ulcerative jejunoileitis, cavitary mesenteric lymph node syndrome, and malignancies including small bowel adenocarcinoma and lymphoma, are described. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. The slide presentation from the RSNA Annual Meeting is available for this article.

Celiac disease diagnosis from endoscopic images based on multi-scale adaptive hybrid architecture model.

Objective. Celiac disease (CD) has emerged as a significant global public health concern, exhibiting an estimated worldwide prevalence of approximately 1%. However, existing research pertaining to domestic occurrences of CD is confined mainly to case reports and limited case analyses. Furthermore, there is a substantial population of undiagnosed patients in the Xinjiang region. This study endeavors to create a novel, high-performance, lightweight deep learning model utilizing endoscopic images from CD patients in Xinjiang as a dataset, with the intention of enhancing the accuracy of CD diagnosis.Approach. In this study, we propose a novel CNN-Transformer hybrid architecture for deep learning, tailored to the diagnosis of CD using endoscopic images. Within this architecture, a multi-scale spatial adaptive selective kernel convolution feature attention module demonstrates remarkable efficacy in diagnosing CD. Within this module, we dynamically capture salient features within the local channel feature map that correspond to distinct manifestations of endoscopic image lesions in the CD-affected areas such as the duodenal bulb, duodenal descending segment, and terminal ileum. This process serves to extract and fortify the spatial information specific to different lesions. This strategic approach facilitates not only the extraction of diverse lesion characteristics but also the attentive consideration of their spatial distribution. Additionally, we integrate the global representation of the feature map obtained from the Transformer with the locally extracted information via convolutional layers. This integration achieves a harmonious synergy that optimizes the diagnostic prowess of the model.Main results. Overall, the accuracy, specificity, F1-Score, and precision in the experimental results were 98.38%, 99.04%, 98.66% and 99.38%, respectively.Significance. This study introduces a deep learning network equipped with both global feature response and local feature extraction capabilities. This innovative architecture holds significant promise for the accurate diagnosis of CD by leveraging endoscopic images captured from diverse anatomical sites.

Myocardial function using two dimension speckle-tracking echocardiography in children with celiac disease.

The prevalence of cardiac complications linked to celiac disease (CD) is on expanding. This study aimed to evaluate the cardiac function in children with CD using two dimensional speckle tracking echocardiography (2D-STE) to detect early myocardial dysfunction, if any. This cross-sectional study included 40 children with CD as the patient group and 40 healthy age- and sex-matched children served as the control group. High sensitive troponin T (Hs-troponin T), anti-tissue transglutaminase immunoglobulin A (tTG-IgA), hemoglobin, ferritin, albumin, and vitamin D levels were measured in all participants. Conventional, tissue Doppler imaging (TDI), and 2D-STE were performed for all included children. Conventional echocardiographic parameters showed no significant difference between the two groups. Left ventricular global longitudinal strain (LV GLS) obtained by 2D-STE was substantially lower in children with CD than the control group; however, myocardial performance index (MPI) obtained by TDI was significantly higher in children with CD. Hs-troponin T levels were comparable in both groups. LV GLS was positively correlated with hemoglobin, ferritin, and albumin level, but it was inversely correlated with the duration of the disease and anti tTG-IgA.    Conclusion: 2D-STE can detect subclinical early cardiac dysfunction in children with CD and this cardiac injury correlated to the duration and severity of the disease and some nutritional deficiency in these children. What is Known: • The prevalence of cardiac complications linked to celiac disease (CD) is on expanding. • Only one study evaluated cardiac function in children with CD using two dimensional speckle tracking echocardiography (2D-STE). What is New: • Our study found that 2D-STE can detect early subclinical cardiac dysfunction in children with CD. Cardiac injury in theses children correlated to the duration and severity of the disease, hemglobin, ferritin, and albumin levels.

Cross-sectional imaging: current status and future potential in adult celiac disease.

Celiac disease (CD), triggered by exposure to gluten in genetically susceptible individuals, is an immune-mediated small bowel disease affecting about 1% of the population worldwide. But the prevalence of CD varies with age, sex, and location. A strict gluten-free diet remains the primary treatment for CD, currently. Most of patients with CD respond well to gluten-free diet with good prognosis, while some patients fail to get symptomatic relief or histological remission (e.g., nonresponsive or refractory CD). Because of heterogeneous clinical appearance, the diagnosis of CD is difficult. Moreover, malignant complications and poor outcomes accompanied with refractory CD present great challenges in disease management. Over the past three decades, cross-sectional imaging techniques (computed tomography [CT] and magnetic resonance imaging [MRI]) play an important role in small bowel inflammatory and neoplastic diseases. Compared with endoscopic techniques, cross-sectional imaging permits clearly presentation of both intraluminal and extraluminal abnormalities. It provides vascular and functional information, thus improving the possibility as diagnostic and follow-up tool. The value of cross-sectional imaging for patients with suspected or confirmed CD has been gradually demonstrated. Studies revealed that certain features suggested by cross-sectional imaging could help to establish the early diagnosis of CD. Besides, the potential contributions of cross-sectional imaging may lie in the evaluation of disease activity and severity, which helps guiding management strategies. The purpose of this review is to provide current overviews and future directions of cross-sectional imaging in adult CD, thus facilitating the understanding and application in clinical practice. CLINICAL RELEVANCE STATEMENT: In this review, we systematically summarized the existing knowledge of cross-sectional imaging in adult CD and analyzed their possible roles in clinical practice, including disease diagnosis, complication identification, treatment evaluation, and prognostic prediction. KEY POINTS: • Regarding a condition described as "celiac iceberg", celiac disease remains underdiagnosed and undertreated. • Cross-sectional imaging is helpful in clinical management of celiac disease, including disease diagnosis, complication identification, treatment evaluation, and prognostic prediction. • Cross-sectional imaging should be considered as the valuable examination in patients suspected from celiac disease.

Small Bowel Imaging in Celiac Disease: Is there a role for Small Bowel Ultrasound?

PURPOSE OF REVIEW: The incidence of celiac disease (CD) has increased over the last decades in part due to better disease awareness. Small bowel ultrasound (sb US) enables dynamic assessment of the bowel; although this topic has been addressed, the use of sb US in the diagnosis and in the follow-up of CD patients is limited to a few specialized tertiary referral centers. Herein, we aimed at summarizing the available literature on this topic to better define the potential clinical implications of sb US in CD, also through a comparison with other available diagnostic techniques. RECENT FINDINGS: According to available data, sb US can be of help in confirming or excluding CD in patients with clinical suspicion; specifically, the finding of increased gall bladder volume, free abdominal fluid and enlargement of mesenteric lymph nodes reliably and accurately predicts the diagnosis of CD, whereas the absence of bowel dilatation and increased peristalsis may exclude the diagnosis. However, the place of intestinal US in the diagnostic algorithm of CD is likely to vary depending on the probability of the disease in a given population. There are only a few studies on the role of sb US in complicated CD, even if recent reports suggest a possible clinical role. There is a lack of data on follow-up of CD patients, particularly with the aim of detecting a poor diet adherence. According to current data sb US parameters have been shown to be of value in confirming and excluding the diagnosis of CD. Prospective studies with large sample size are warranted to determine whether to include sb US in the available guidelines for CD diagnosis and monitoring.

Advancing dentistry: fractal assessment of bone health in pediatric patients with celiac disease using dental images.

OBJECTIVES: To assess the effects of a gluten-free diet on bone structure in children with celiac disease using fractal analysis on panoramic radiographs. METHOD AND MATERIALS: A total of 49 patients with celiac disease aged 6 to 13 years, separated into two groups as previously and newly diagnosed, and a control group of 32 healthy individuals were evaluated. In previously and newly diagnosed patients with celiac disease, body mass index Z-scores were calculated, calcium, alkaline phosphatase, vitamin D3, and parathormone levels were measured, and bone mineral density Z-scores were obtained from dual energy x-ray absorptiometry. In all patients, the fractal dimensions of the right and left temporomandibular condyles were evaluated with the fractal analysis method on panoramic radiographs. RESULTS: The mean values of serum biomarker levels and the body mass index and bone mineral density Z-scores for both celiac groups were within the normal reference range. No statistically significant difference was determined between right and left condyle fractal dimensions values in the three groups examined. In terms of both right and left condyle fractal dimensions values, there was a statistically significant difference between groups. The highest fractal dimensions values were determined in the previously diagnosed group. CONCLUSIONS: Differences in fractal dimensions values were observed among patients with celiac disease following the gluten-free diet. Utilizing fractal analysis on panoramic radiographs can prove valuable for dental practitioners in evaluating bone mineral density due to its cost-effectiveness, easy accessibility, and reduced radiation exposure for patients, enabling them to provide comprehensive oral health care and potential early interventions for patients with celiac disease.

Quantification of Celiac Disease Severity Using Video Capsule Endoscopy: A Comparison of Human Experts and Machine Learning Algorithms.

BACKGROUND: Video capsule endoscopy (VCE) is an attractive method for diagnosing and objectively monitoring disease activity in celiac disease (CeD). Its use, facilitated by artificial intelligence- based tools, may allow computer-assisted interpretation of VCE studies, transforming a subjective test into a quantitative and reproducible measurement tool. OBJECTIVE: To evaluate and compare objective CeD severity assessment as determined with VCE by expert human readers and a machine learning algorithm (MLA). METHODS: Patients ≥ 18 years with histologically proven CeD underwent VCE. Examination frames were scored by three readers from one center and the MLA, using a 4-point ordinal scale for assessing the severity of CeD enteropathy. After scoring, curves representing CeD severity across the entire small intestine (SI) and individual tertiles (proximal, mid, and distal) were fitted for each reader and the MLA. All comparisons used Krippendorff's alpha; values > 0.8 represent excellent to 'almost perfect' inter-reader agreement. RESULTS: VCEs from 63 patients were scored. Readers demonstrated strong inter-reader agreement on celiac villous damage (alpha=0.924), and mean value reader curves showed similarly excellent agreement with MLA curves (alpha=0.935). Average reader and MLA curves were comparable for mean and maximum values for the first SI tertile (alphas=0.932 and 0.867, respectively) and the mean value over the entire SI (alpha=0.945). CONCLUSION: A novel MLA demonstrated excellent agreement on whole SI imaging with three expert gastroenterologists. An ordinal scale permitted high inter-reader agreement, accurately and reliably replicated by the MLA. Interpreting VCEs using MLAs may allow automated diagnosis and disease burden assessment in CeD.

[Asymptomatic celiac disease: the importance of neuroimaging]. / Enfermedad celíaca asintomática: importancia de la neuroimagen.

TITLE: Enfermedad celíaca asintomática: importancia de la neuroimagen.

Validation of the X-ray microtomography in the assessment of duodenal morphometry and surface area in celiac disease.

Background: Duodenal histology remains the diagnostic reference standard in celiac disease. However, traditional methods have suboptimal sensitivity and reproducibility for early mucosal changes and research purposes. We validated a recently introduced micro-CT imaging method for an accurate digital evaluation of duodenal histomorphometry and mucosal surface areas. Methods: Endoscopic biopsies from 58 individuals were utilized for the micro-CT imaging, selecting histological changes ranging from normal to severely damaged mucosa. The imaging protocol was optimized for practicability and resolution. The Bland-Altman method was applied to test intra- and interobserver variations in the blinded measurements. Results: The 3D micro-CT reconstructions enabled easy and precise digital cutting with optimal orientation and computer-assisted measurement of the surface area. Intraobserver analysis of morphological measurements showed a mean difference of 0.011 with limits of agreement (LA) from -0.397 to 0.375 and a standard deviation (SD) of 0.197. The corresponding figures for interobserver analysis were 0.080, from -0.719 to 0.537 and 0.320, respectively. The intraclass correlation coefficients (ICC) for the intraobserver and interobserver variations were 0.981 and 0.954, respectively. Intraobserver surface area analysis yielded a mean difference of 0.010, LA from -0.764 to 0.785 and an SD of 0.395, and an interobserver analysis mean difference of 0.028, LA from -0.642 to 0.698 and SD of 0.342. The respective ICCs for the intra- and interobserver variations were 0.963 and 0.972. Conclusions: Micro-CT showed excellent accuracy and reproducibility in the evaluation of mucosal morphometry and surface areas. The improved sensitivity for histological changes is a powerful tool for the diagnosis of celiac disease and for clinical and pharmacological studies.

Analysis of Thyroid Gland Problems with Shear Wave Elastography in Children with Celiac Disease.

BACKGROUND: The rate of autoimmune thyroiditis in children with celiac disease (CD) is high relative to the normal population. Since the majority of these patients are also euthyroid, thyroid imaging methods are gaining significance in diagnosis and follow-up. This study examines the effectiveness of thyroid ultrasonography (US) and thyroid shear wave elastography (SWE) in diagnosing thyroid disease in children with CD. MATERIALS AND METHODS: This cross-sectional controlled study analyzed thyroid US, SWE, serum thyroid function tests, and thyroid autoimmune antibodies of 106 CD patients and 103 control patients without CD. An Aplio 500 ultrasound device with a linear array transducer and elastography software was used for thyroid US and SWE measurement of all patients. RESULTS: Right lobe thyroid volume, left lobe thyroid volume, total thyroid volume, thyroid mean elasticity (m/s), right lobe elasticity (kPa), left lobe elasticity (kPa), and mean thyroid elasticity (kPa) levels of the CD group were higher than those of the control group (p < 0.001). The relationships between thyroid US and thyroid mean elasticity (m/s), thyroid mean elasticity (kPa), anti-thyroid peroxidase antibody, and thyroid-stimulating hormone were positive and moderate, respectively (r = 0.612, 0.612, 0.636, and 0.565, respectively; p < 0.001). CONCLUSION: In this study, SWE findings were compatible with laboratory findings, as they constituted a sensitive and useful method in the diagnosis and follow-up of autoimmune thyroid disease in children with CD.

Does contrast-enhanced computed tomography raise awareness in the diagnosis of the invisible side of celiac disease in adults?

PURPOSE: This study aimed to evaluate the diagnosis and determine major and minor criteria of celiac disease (CD) with the malabsorption patterns (MABP) in the small intestine and colon on computed tomography (CT) and additional CT findings. METHODS: This retrospective study was conducted with 116 patients diagnosed with CD, 14 CD patients recovering with treatment, and 35 control patients with non-CD. All patients had CT examinations and histopathological diagnoses. The sensitivity, specificity, PPV, NPV, and accuracy values of each CT finding defined in the literature were statistically evaluated. According to the patient and control groups, the numerical values of the findings and the sensitivity and specificity values were measured according to this cut-off value. The distribution of CT findings according to pathological Marsh data was evaluated in CD patients. RESULTS: Sensitivity and specificity were found to be higher in small bowel MABP findings, mesenteric hypervascularity, and increased SMV/aorta diameter. There was a numerically significant difference in MDCT findings between the control and pathological Marsh groups. In the ROC analysis performed in terms of the total numerical values of each MDCT finding observed between the groups, it was found that there were more than 7 MDCT findings, 100% sensitivity, and 92% specificity. The presence of four major and three minor criteria or three major and four minor criteria were considered significant. CONCLUSIONS: Being aware of CT findings below the iceberg that may suggest CD in abdominal CT examinations performed in patients with atypical clinical and malabsorption findings or other nonspecific findings may prevent diagnostic delay and unnecessary procedures.

Optical coherence tomography angiography findings of retinal vascular structures in children with celiac disease.

PURPOSE: To investigate the vasculature of the retina and choroid in children with celiac disease using optical coherence tomography angiography (OCTA). METHODS: A total of 60 children with celiac disease and 71 healthy controls were included in this study. All participants underwent comprehensive ophthalmologic examination and OCTA imaging. The vascular structures and the vascular density (VD) in the superficial and deep retinal vascular zones, the foveal avascular zone (FAZ) and foveal density were automatically determined using the software 3 × 3 OCTA and AngioAnalytics. Choroid thickness was calculated manually by retinal specialists. RESULTS: No statistically significant difference in VD was found between subjects and controls. The FAZ was larger in the celiac group than in controls (0.306 ± 0.12 mm2 vs 0.287 ± 0.11 mm2), but the difference was not statistically significant (P = 0.383). Subfoveal choroid thickness was thinner in the celiac group (309.9 ± 76.97 µm) than in the control group (328 ± 68.51 µm), but the difference was not statistically significant (P = 0.157) CONCLUSIONS: No statistically significant differences in VD, mean FAZ or mean subfoveal choroidal thickness were found in children with CD compared to controls.

Cerebellar Symptoms in Gluten Sensitivity: a Systematic Review of the Effect of a Gluten-Free Diet on Brain Imaging.

Cerebellar manifestations have been described in patients with gluten sensitivity (GS)-related disorders. A better understanding of the neurological manifestations of GS requires the use of neuroimaging techniques. We performed a systematic review on neuroimaging findings in GS patients with cerebellar symptoms. We also included a specific search on neuroimaging findings in GS patients with cerebellar manifestations on a gluten-free diet (GFD). PubMed, Embase, and Bireme were systematically searched to identify studies assessing neuroimaging features of adults with cerebellar manifestations and GS with or without enteropathy on a GFD. Ten studies with a total of 222 adult-GS patients were included. Magnetic resonance imaging was used in 100% of the studies. Cerebellar atrophy was evaluated in 7 studies and observed in 63% of the patients. White matter abnormalities were described in 2 studies. Single-photon emission computed tomography was used in 2 studies, and decreased cerebellar perfusion was detected in 92% of the included patients. No study employed nuclear medicine after the start of GFD. Magnetic resonance spectroscopy (MRS) was performed in 2 studies before and after GFD. An increase in the Naa/Cr ratio in cerebellar vermis was seen in 98% of the cases on a strict GFD. Cerebellar atrophy was found to be a prevalent condition in GS patients. MRS demonstrated to be useful in the follow-up of GS patients with cerebellar manifestations on a GFD. Prospective studies using nuclear medicine imaging are needed to study brain changes in GS patients on a GFD.

Evaluation of the Relationship Between Carotid Intima Media Thickness and Dietary Compliance in Pediatric Celiac Patients: A Single-Center Pilot Study.

OBJECTIVES: This study aimed to show the relationship between gluten-free diet (GFD) compliance in Celiac Disease (CD) and early atherosclerotic findings in pediatric patients and to test the effectiveness of carotid-intima-media-thickness (cIMT) to possibly predict long-term compliance to the GFD. METHODS: Patients from 6 to 18 years of age with a diagnosis of CD confirmed by endoscopic duodenal biopsy who were followed at our hospital's pediatric gastroenterology outpatient clinic between November 2020 and May 2021 were evaluated in this single-center, prospective study. The study patients were divided into two groups according to GFD compliance. Serologic and biochemical tests were conducted routinely during the follow-up period. cIMT was measured using ultrasound for both groups. RESULTS: A total of 80 patients (GFD-non-compliant: n = 35, GFD-compliant: n = 45) were evaluated. No significant differences were observed between the groups in terms of demographic data and pathology results. The mean cIMT value was 0.44 ± 0.028 mm for the GFD-compliant group and 0.54 ± 0.036 mm for the GFD-non-compliant group, with a statistically significant between-group difference (P < .001). The receiver operating characteristic curve analysis showed an area under the curve of 0.992 (95% confidence interval [CI]: 0.978-1, P < .001) for discrimination of the groups. In addition, a cutoff value of 0.486 mm for cIMT showed 96% (95% CI: 0.83-0.99) sensitivity and 94% (95% CI: 0.79-0.99) specificity for distinguishing GFD-compliant patients from non-GFD-compliant patients. CONCLUSION: In this study, the relationship between long-term GFD compliance and cIMT was demonstrated in CD. Currently used by some authors for the assessment of preclinical atherosclerosis, cIMT can also be used as a long-term indicator of dietary compliance as well as cardiovascular risk.

Resolution-based distillation for efficient histology image classification.

Developing deep learning models to analyze histology images has been computationally challenging, as the massive size of the images causes excessive strain on all parts of the computing pipeline. This paper proposes a novel deep learning-based methodology for improving the computational efficiency of histology image classification. The proposed approach is robust when used with images that have reduced input resolution, and it can be trained effectively with limited labeled data. Moreover, our approach operates at either the tissue- or slide-level, removing the need for laborious patch-level labeling. Our method uses knowledge distillation to transfer knowledge from a teacher model pre-trained at high resolution to a student model trained on the same images at a considerably lower resolution. Also, to address the lack of large-scale labeled histology image datasets, we perform the knowledge distillation in a self-supervised fashion. We evaluate our approach on three distinct histology image datasets associated with celiac disease, lung adenocarcinoma, and renal cell carcinoma. Our results on these datasets demonstrate that a combination of knowledge distillation and self-supervision allows the student model to approach and, in some cases, surpass the teacher model's classification accuracy while being much more computationally efficient. Additionally, we observe an increase in student classification performance as the size of the unlabeled dataset increases, indicating that there is potential for this method to scale further with additional unlabeled data. Our model outperforms the high-resolution teacher model for celiac disease in accuracy, F1-score, precision, and recall while requiring 4 times fewer computations. For lung adenocarcinoma, our results at 1.25× magnification are within 1.5% of the results for the teacher model at 10× magnification, with a reduction in computational cost by a factor of 64. Our model on renal cell carcinoma at 1.25× magnification performs within 1% of the teacher model at 5× magnification while requiring 16 times fewer computations. Furthermore, our celiac disease outcomes benefit from additional performance scaling with the use of more unlabeled data. In the case of 0.625× magnification, using unlabeled data improves accuracy by 4% over the tissue-level baseline. Therefore, our approach can improve the feasibility of deep learning solutions for digital pathology on standard computational hardware and infrastructures.

Evaluation of celiac disease with uniphasic and multiphasic dynamic MDCT imaging.

PURPOSE: An analysis of dynamic contrast MRI has been shown to provide valuable information about disease activity in Crohn's disease and Celiac disease (CD). However, there are no reports of dynamic multi-detector computer tomography use in patients with CD. The aim of this study is to determine and compare the perfusion dynamics of the patients treated with control subjects and the perfusion dynamics in patients with untreated CD, using dynamic contrast in MDCT and compare studying contrast dynamics in Marsh types as well. METHODS: In this retrospective study, uniphasic and multiphasic MDCT, untreated, treated, incompatible CD patients and healthy control group duodenum wall thickness and HU values were compared in terms of patient groups and modified Marsh types. RESULT: In dynamic CT, the highest contrast curve was observed in the untreated group and Marsh type 1. While the contrast curve of the untreated and non-compliant patients increased rapidly and showed wash out, the type 4 contrast curve was observed, whereas the treated and control group slowly increased type 5 contrast curve. In the contrast-enhanced CT in the venous phase, in the ROC analysis between Marsh 1-2 and Marsh 3a-c, the sensitivity was 97% and the specificity was 87% when the cut off was taken as 4.45 mm for wall thickness (p: 0.005). CONCLUSION: Contrast-enhanced single-phase and dynamic MDCT imaging in CD patients may be useful in evaluating the inflammatory and pathological process in the small intestine.

Near-focus narrow-band imaging classification of villous atrophy in suspected celiac disease: development and international validation.

BACKGROUND AND AIMS: There are no agreed-on endoscopic signs for the diagnosis of villous atrophy (VA) in celiac disease (CD), necessitating biopsy sampling for diagnosis. Here we evaluated the role of near-focus narrow-band imaging (NF-NBI) for the assessment of villous architecture in suspected CD with the development and further validation of a novel NF-NBI classification. METHODS: Patients with a clinical indication for duodenal biopsy sampling were prospectively recruited. Six paired NF white-light endoscopy (NF-WLE) and NF-NBI images with matched duodenal biopsy sampling including the bulb were obtained from each patient. Histopathology grading used the Marsh-Oberhuber classification. A modified Delphi process was performed on 498 images and video recordings by 3 endoscopists to define NF-NBI classifiers, resulting in a 3-descriptor classification: villous shape, vascularity, and crypt phenotype. Thirteen blinded endoscopists (5 expert, 8 nonexpert) then undertook a short training module on the proposed classification and evaluated paired NF-WLE-NF-NBI images. RESULTS: One hundred consecutive patients were enrolled (97 completed the study; 66 women; mean age, 51.2 ± 17.3 years). Thirteen endoscopists evaluated 50 paired NF-WLE and NF-NBI images each (24 biopsy-proven VAs). Interobserver agreement among all validators for the diagnosis of villous morphology using the NF-NBI classification was substantial (κ = .71) and moderate (κ = .46) with NF-WLE. Substantial agreement was observed between all 3 NF-NBI classification descriptors and histology (weighted κ = 0.72-.75) compared with NF-WLE to histology (κ = .34). A higher degree of confidence using NF-NBI was observed when assessing the duodenal bulb. CONCLUSIONS: We developed and validated a novel NF-NBI classification to reliably diagnose VA in suspected CD. There was utility for expert and nonexpert endoscopists alike, using readily available equipment and requiring minimal training. (Clinical trial registration number: NCT04349904.).

Evaluation of eye involvement in paediatric celiac disease patients.

BACKGROUND: The non-classic presentation of paediatric celiac disease (CeD) becomes increasingly common in daily practice, which requires an awareness of eye findings. The purpose of this study was to evaluate eye involvement and effect of gluten-free diet on ocular involvement in paediatric CeD patients by measuring the thicknesses of choroid and ganglion cell complex (GCC) composed of retinal nerve fibre layer, ganglion cell layer and inner plexiform layer using enhanced depth imaging optical coherence tomography. METHODS: Forty-three CeD patients aged between four and 16 years (mean age: 9.9 ± 4.1, 12 boys and 31 girls) and 48 healthy children (mean age: 11.3 ± 4.1,17 boys and 31 girls) were compared. Following comprehensive eye examinations, thicknesses of choroid at three points and GCC layers (retinal nerve fibre layer at five points, ganglion cell layer and inner plexiform layer) were obtained using enhanced depth imaging optical coherence tomography. Measurement of thicknesses of choroid and GCC layers by a trained optical coherence tomography technician and an ophthalmologist who were not aware about group of children in paediatric CeD patients with 1 year gluten-free diet was carried out. RESULTS: All layers of subfoveal, nasal and temporal choroid were significantly thinner in CeD than in the control group (P < .001, all, respectively). No significant difference was observed between the CeD and control groups in terms of GCC thicknesses (P > .05, all, respectively). CONCLUSION: Paediatric CeD caused thinning of subfoveal, nasal and temporal areas of choroid, and this change is apparent even after 1 year gluten-free diet. This eye involvement should be more closely screened at diagnosis, and long-term clinical results of thin choroid should be determined. Thicknesses of GCC layers were not different in CeD group and may reveal the effect of diet or not involvement.

A serial SPECT-CT study in a celiac disease patient with cerebellar ataxia and psychiatric symptoms.

Celiac disease (CD) is an immune-mediated systemic disorder triggered by gluten and related prolamins in genetically predisposed individuals. Here, we described a case of a 31-year-old Caucasian woman who exhibited cerebellar and psychiatric dysfunctions. The patient underwent single-photon emission computed tomography (SPECT-CT) before and after a gluten-free diet (GFD). There was an improvement in cerebellar perfusion accompanied by a remission of cerebellar manifestations. The maintenance of the psychiatric manifestations was related to the persistence of the hypoperfusion in the frontal lobes. The patient's psychiatric symptoms did not change after 4 months under a GFD in the hospital. To our knowledge, this is the first case that shows the relationship between improvement in cerebellar perfusion and remission of cerebellar clinical manifestations in a CD patient under a GFD.