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When to Perform Endoscopy or Radiological Tests in Patients with Unresponsive Celiac Disease

Clinical Review

When To Perform Endoscopy Or Radiological Tests In Patients With Unresponsive Celiac DiseaseKlaus Mönkemüller, MD, PhD

Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

In general, celiac disease patients with unresponsive or worsening GI symptoms are the ones at higher risk of complicated disease or complications such as EATL (lymphoma), adenocarcinoma, or ulcerative enteritis (1).

Figure 1 · Refractory celiac disease

Endoscopic Views In Refractory Celiac Disease

Figure 1. Refractory celiac disease (RCD).

In patients with persistent symptoms, one should perform capsule endoscopy, deep enteroscopy, or radiological imaging (small bowel follow-through/enteroclysis) or MR enterography (2).

Alerting findings on endoscopy

01Ulcerations

02Polypoid or tumor lesions

03Raised discoid (round) type lesions

Figure 2 · Small bowel adenocarcinoma

Endoscopic, Capsule, Surgical, And Histologic Images Of Small Bowel Adenocarcinoma

Figure 2. Small bowel adenocarcinoma: 5% of all GI tumors and the second most common after NET (neuroendocrine tumor, carcinoid). It also occurs in celiac disease. Poor prognosis: 30% 5-year survival. Fry LC, Gutierrez JP, Mönkemüller K. Gastrointest Tumors 2014;1:9-17.

Figure 3 · "Small" EATL

Terminal Ileum In A Patient With Celiac Disease And Small Eatl

Figure 3. "Small" EATL (enteropathy-associated T-cell lymphoma) in a patient with celiac disease: fever, night sweats, weight loss, anorexia, abdominal pain. Terminal ileum: Kerckring folds ++. Courtesy of Prof. Chris Mulder, Holland.

Signs on x-ray

01Reversed fold pattern (more Kerckring folds in the ileum than in the jejunum)

02Small bowel dilation

03Small bowel wall thickening

04Cavitating mesenteric lymphadenopathy

05Mesenteric hypervascularization

06Splenic atrophy

Figure 4 · Enteropathy-associated T-cell lymphoma (EATL)

Mr Images, Endoscopy, And Histology In Enteropathy-Associated T-Cell Lymphoma

Figure 4. A 69-year-old woman with longstanding CT stenosis near the ligament of Treitz and pre-stenotic dilatation. Courtesy of van Weyenberg, Holland.

Indeed, splenic atrophy is more common in RCD II (refractory celiac disease), but not in celiac disease and lymphoma (likely because the lymphoma brought the spleen size back to "normal") (3).

Because of both functional hyposplenism and spleen atrophy, patients with celiac disease are prone to infections with encapsulated organisms such as Klebsiella, Staphylococcus aureus, and Streptococcus pneumoniae (pneumococcus). Vaccination against Streptococcus pneumoniae is indicated.

References

  1. Al-Toma A, Branchi F, Zingone F, et al. European Society for the Study of Coeliac Disease (ESsCD) 2025 updated guidelines on the diagnosis and management of coeliac disease in adults. Part 2: Management, follow-up, and complex disease courses. United European Gastroenterol J. 2026;14(2):e70195.
  2. Al-Toma A, Zingone F, Branchi F, et al. European Society for the Study of Coeliac Disease 2025 updated guidelines on the diagnosis and management of coeliac disease in adults. Part 1: Diagnostic approach. United European Gastroenterol J. 2025;13(10):1855-1886.
  3. van Gils T, Nijeboer P, van Waesberghe JHT, et al. Splenic volume differentiates complicated and non-complicated celiac disease. United European Gastroenterol J. 2017;5(3):374-379.

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Conflict of Interest

The author declares no conflict of interest.

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