The Role of Endoscopy in Assessing Small Intestine Mucosal Recovery in Patient with Celiac Disease

Aim: to present a clinical case of celiac disease with intestinal and extraintestinal manifestations, as well as demonstrate the possibilities of endoscopic diagnosis in assessing the mucosal recovery of the small intestine on a gluten-free diet.

Key points. Celiac disease is a genetically determined disease of the small intestine with a wide range of intestinal and extraintestinal clinical manifestations associated with gluten intake. The main treatment strategy for this disease is strict adherence to a gluten-free diet. The therapeutic goal of a gluten-free diet is to achieve healing of the small intestinal mucosa, which occurs slowly and, according to research, is recorded in only a third of patients. Celiac disease was revealed during esophagogastroduodenoscopy in 30-year-old female patient with symptoms of dyspepsia, anemia and suspected localized scleroderma, morphologically confirmed total atrophy of Marsh 3C villi, and received serological verification of the diagnosis. Two and a half years later complete mucosal recovery was detected on strict gluten-free diet.

Conclusions. Achieving and controlling remission of celiac disease has important role in the treatment strategy of patients. The gluten-free diet has demonstrated successful results within the expected timeframe. Today, modern endoscopic technologies and use of prognostic classifications of the severity of atrophy have great diagnostic value in assessing the mucosal recovery of small intestine.

1. Bernardes C. Mucosal healing in celiac disease: A necessary or unrealistic goal? GE Port J Gastroenterol. 2020;27(5):299–301. DOI: 10.1159/000507965

2. Parfenov A.I., Bykova S.V., Sabelnikova E.A., Maev I.V., Baranov A.A., Bakulin I.G., et al. All-Russian consensus on the diagnosis and treatment of celiac disease in children and adults. Terapevticheskii arkhiv. 2017;89(3):94–107. (In Russ.).

3. Singh P., Arora A., Strand T.A., Leffler D.A., Catassi C., Green P.H., et al. Global prevalence of celiac disease: Systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2018;16(6):823–36. DOI: 10.1016/j.cgh.2017.06.037

4. Al-Toma A., Volta U., Auricchio R., Castillejo G., Sanders D.S., Cellier C., et al. European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten-related disorders. United European Gastroenterol J. 2019;7(5):583–613. DOI: 10.1177/2050640619844125

5. Rubio-Tapia A., Hill I.D., Semrad C., Kelly C.P., Greer K.B., Limketkai B.N., et al. American College of Gastroenterology guidelines update: Diagnosis and management of celiac disease. Am J Gastroenterol. 2023;118(1):59–76. DOI: 10.14309/ajg.0000000000002075

6. Wahab P.J., Meijer J.W.R., Mulder C.J.J. Histologic follow-up of people with celiac disease on a gluten-free diet: Slow and incomplete recovery. Am J Clin Pathol. 2002;118(3):459–63. DOI: 10.1309/EVXT-851X-WHLCRLX9

7. Bonatto M.W., Kotze L., Orlandoski M., Tsuchyia R., de Carvalho C.A., Lima D., et al. Endoscopic evaluation of celiac disease severity and its correlation with histopathological aspects of the duodenal mucosa. Endosc Int Open. 2016;4(7):E767–77. DOI: 10.1055/s-0042-108190

8. Gulati S., Emmanuel A., Ong M., Pavlidis P., Patel M., El-Menabawey T., et al. Near-focus narrow-band imaging classification of villous atrophy in suspected celiac disease: Development and international validation. Gastrointest Endosc. 2021;94(6):1071–81. DOI: 10.1016/j.gie.2021.06.031

9. Ribeiro C.S., Uenishi R.H., Domingues A.S., Nakano E.Y., Botelho R.B.A., Raposo A., et al. Gluten-free diet adherence tools for individuals with celiac disease: A systematic review and meta-analysis of tools compared to laboratory tests. Nutrients. 2024;16(15):2428. DOI: 10.3390/nu16152428

10. Lepe K., Riley C.A., Hashmi M.F., Salazar F.J. Necrobiosis lipoidica. 2024 Jun 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.

11. Ionescu C., Petca A., Dumitrașcu M.C., Petca R.C., Ionescu Miron A.I., Șandru F. The intersection of dermatological dilemmas and endocrinological complexities: Understanding necrobiosis lipoidica — a comprehensive review. Biomedicines. 2024;12(2):337. DOI: 10.3390/biomedicines12020337

12. Dhalwani N.N., West J., Sultan A.A., Ban L., Tata L.J. Women with celiac disease present with fertility problems no more often than women in the general population. Gastroenterology. 2014;147(6):1267–74. DOI: 10.1053/j.gastro.2014.08.025

13. Vargas F.M., Cardoso L.T., Didoné A., Lima J.P.M., Venzke J.G., de Oliveira V.R. Celiac disease: Risks of cross-contamination and strategies for gluten removal in food environments. Int J Environ Res Public Health. 2024;21(2):124. DOI: 10.3390/ijerph21020124

14. Nemteanu R., Danciu M., Clim A., Girleanu I., Ciortescu I., Gheorghe L., et al. Predictors of slow responsiveness and partial mucosal recovery in adult patients with celiac disease. Gastroenterol Hepatol Bed Bench. 2023;16(2):194–202. DOI: 10.22037/ghfbb.v16i2.2734

15. Szakács Z., Mátrai P., Hegyi P., Szabó I., Vincze Á., Balaskó M., et al. Younger age at diagnosis predisposes to mucosal recovery in celiac disease on a gluten-free diet: A meta-analysis. PLoS One. 2017;12(11):e0187526. DOI: 10.1371/journal.pone.0187526

16. Tye-Din J.A. Evolution in coeliac disease diagnosis and management. JGH Open. 2024;8(7):e13107. DOI: 10.1002/jgh3.13107

17. Stefanolo J.P., Tálamo M., Dodds S., de la Paz Temprano M., Costa A.F., Moreno M.L., et al. Real-world gluten exposure in patients with celiac disease on gluten-free diets, determined from gliadin immunogenic peptides in urine and fecal samples. Clin Gastroenterol Hepatol. 2021;19(3):484–91.e1. DOI: 10.1016/j.cgh.2020.03.038

18. Gładyś K., Dardzińska J., Guzek M., Adrych K., Małgorzewicz S. Celiac dietary adherence test and standardized dietician evaluation in assessment of adherence to a gluten-free diet in patients with celiac disease. Nutrients. 2020;12(8):2300. DOI: 10.3390/nu12082300

19. Silvester J.A., Kurada S., Szwajcer A., Kelly C.P., Leffer D.A., Duerksen D. Tests for serum transglutaminase and endomysial antibodies do not detect most patients with celiac disease and persistent villous atrophy on gluten-free diets: A meta-analysis. Gastroenterology. 2017:153(3):689–701.

20. Rubio-Tapia A., Rahim M.W., See J.A., Lahr B.D., Wu T.T., Murray J.A. Mucosal recovery and mortality in adults with celiac disease after treatment with a gluten-free diet. Am J Gastroenterol. 2010;105(6):1412–20. DOI: 10.1038/ajg.2010.10

21. Freeman H.J. Dietary compliance in celiac disease. World J Gastroenterol. 2017;23(15):2635–9. DOI: 10.3748/wjg. v23.i15.2635

22. Shiha M.G., Yusuf A., Sanders D.S. Role of endoscopy in the diagnosis of coeliac disease: A narrative review. Transl Gastroenterol Hepatol. 2024;9:51. DOI: 10.21037/tgh-23-122

23. Scheppach M.W., Rauber D., Stallhofer J., Muzalyova A., Otten V., Manzeneder C., et al. Detection of duodenal villous atrophy on endoscopic images using a deep learning algorithm. Gastrointest Endosc. 2023;97(5):911– 6. DOI: 10.1016/j.gie.2023.01.006

24. Lebwohl B., Sanders D.S., Green P.H.R. Coeliac disease. Lancet. 2018;391(10115):70–81. DOI: 10.1016/S0140-6736(17)31796-8

25. Galron E., Boyarsky R., Solt I., Ben David C., Gal E. Interactions between celiac disease and pregnancy: Literature review. Isr Med Assoc J. 2023;25(12):830–5.