Video Capsule Endoscopy in the Evaluation of Celiac Patients with Persistent or Recurrent Symptoms. Who and When?

Background: A proportion of patients with celiac disease are classified as having non-responsive celiac disease despite following a gluten free diet. This study seeks to clarify the appropriate use of video capsule endoscopy in non-responsive celiac disease patients. Methods: We retrospectively reviewed 32 patients with biopsy-proven celiac disease classified as having non-responsive celiac disease and referred for video capsule endoscopy at a single tertiary care center over 10 years. Results: 32 patients were categorized into those with ongoing gluten exposure at time of video capsule endoscopy (14), and those with strict gluten free diet compliance (18). Gluten free diet compliant patients were stratified by biopsy results: ongoing villous atrophy (3), no villous atrophy (6), or no biopsy data within 6 months (9). In patients with ongoing gluten exposure, video capsule endoscopy detected no concerning findings, and all patients ultimately improved with a gluten free diet. Among patients with recent negative biopsy, none had findings of celiac disease on their video capsule endoscopy and none developed complications related to celiac disease. However, in gluten free diet compliant patients with villous atrophy on biopsy, 2 of 3 were ultimately diagnosed with refractory celiac disease. Conclusions: Video capsule endoscopy may be useful in the evaluation of celiac disease in limited settings, namely after ongoing gluten exposure has been excluded and duodenal biopsy shows ongoing villous atrophy.