J. Pediatr. (Rio J.) vol.93 número4

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www.jped.com.br

ORIGINAL

ARTICLE

Magnetic

resonance

enterography

in

pediatric

celiac

disease

夽

Gonca

Koc

a,∗

_,

_Selim

_Doganay

a

_,

_Eylem

_Sevinc

b

_,

_Kemal

_Deniz

c

_,

_Govind

_Chavhan

d

_,

Sureyya

B. Gorkem

a

_,

_Neslihan

_Karacabey

e

_,

_Mehmet

_S.

_Dogan

a

_,

_Abdulhakim

_Coskun

a

_,

Duran

Aslan

e

a_Erciyes_University_Faculty_of_Medicine,_Department_of_Pediatric_Radiology,_Kayseri,_Turkey

b_Kayseri_Research_and_Training_Hospital,_Emel-Mehmet_Tarman_Children’s_Hospital,_Department_of_Pediatric_{Gastroenterology,}

Kayseri,Turkey

c_Erciyes_University_Faculty_of_Medicine,_Department_of_Pathology,_Kayseri,_Turkey

d_University_of_Toronto,_The_Hospital_for_Sick_Children_and_Medical_Imaging,_Department_of_Diagnostic_Imaging,_Toronto,_Canada e_Erciyes_University_Faculty_of_Medicine,_Department_of_Pediatric_{Gastroenterology,}_Kayseri,_Turkey

Received15June2016;accepted3November2016 Availableonline31January2017

KEYWORDS Celiacdisease; Magneticresonance enterography; Pediatrics

Abstract

Objective: Toassessifmagneticresonanceenterographyiscapableofshowingevidence/extent

ofdiseaseinpediatricpatientswithbiopsy-provenceliacdiseasebycomparingwithacontrol group,andtocorrelate themagnetic resonanceenterographyfindingswith anti-endomysial antibodylevel,whichisanindicatorofgluten-freedietarycompliance.

Methods: Thirty-onepediatricpatients(meanage11.7±3.1years)withbiopsy-provenceliac

diseaseand40pediatricpatientsasacontrolgroupwererecruitedinthestudy.Themagnetic resonanceenterographyimagesofbothpatientswithceliacdiseaseandthoseofthecontrol groupwereevaluatedbytwopediatricradiologistsinablindedmannerforthemucosal pat-tern,presenceofwallthickening,luminaldistentionofthesmallbowel,andextra-intestinal findings.Patientchartswerereviewedtonoteclinicalfeatures andlaboratoryfindings.The histopathologicreviewoftheduodenalbiopsieswasre-conducted.

Results: Themeandurationofthediseasewas5.6±1.8years(range:3---7.2years).In24(77%)

ofthe patients,anti-endomysialantibody levels wereelevated(mean 119.2±66.6RU/mL). Magneticresonanceenterographyrevealednormalfoldpatterninallthepatients.Ten(32%) patientshadenlargedmesentericlymphnodes.

夽

Pleasecitethisarticleas:KocG,DoganayS,SevincE,DenizK,ChavhanG, GorkemSB,etal.Magneticresonanceenterographyin pediatricceliacdisease.JPediatr(RioJ).2017;93:413---9.

∗_{Corresponding}_author.

E-mail:[email protected](G.Koc). http://dx.doi.org/10.1016/j.jped.2016.11.003

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414 KocGetal.

Conclusion: Althoughamajorityofthepatientshadelevatedanti-endomysialantibody

lev-elsindicating poordietarycompliance,magnetic resonanceenterographydidnotshow any mucosal abnormality associated with the inability of magnetic resonance enterography to detectmild/earlychanges ofceliacdiseaseinchildren.Therefore,itmaynotbeuseful for thefollow-upofpediatricceliacdisease.

PALAVRAS-CHAVE Doenc¸acelíaca; Enterografiapor ressonância magnética; Pediatria

Aenterografiaporressonânciamagnéticanadoenc¸acelíacapediátrica

Resumo

Objetivo: Avaliarseaenterografiaporressonânciamagnéticaconseguecomprovar/mostrara

extensãodadoenc¸aempacientespediátricoscomdoenc¸acelíacacomprovadaporbiópsia com-parandocomumgrupodecontroleecorrelacionarosachadosdaenterografiaporressonância magnéticacomoníveldeanticorpoantiendomísioindicadordedietasemglúten.

Métodos: 31 pacientespediátricos (idade médiaentre11,7±3,1 anos)com doenc¸a celíaca

comprovadaporbiópsiae40pacientespediátricosemumgrupodecontroleforamrecrutados noestudo.Asimagensdaenterografiaporressonânciamagnéticadospacientescomdoença celíacaenogrupodecontroleforamavaliadaspordoisradiologistaspediátricosàscegaspara o padrão damucosa, presença de espessamento da parede, dilatação luminal do intestino delgadoeachadosextraintestinais.Osprontuáriosdospacientesforamrevisadosparaanotação de características clínicas e achadoslaboratoriais. A avaliação histopatológicadas biópsias duodenaisfoifeitanovamente.

Resultados: Adurac¸ãomédiadadoenc¸afoi5,6±1,8anos(faixade3-7,2anos).Em24(77%)dos

pacientes,osníveis anticorpoantiendomísioestavamelevados(média119,2±66,6RU/mL). A enterografiaporressonância magnéticarevelouum padrãodepregas normalem todosos pacientes.10(32%)dospacientesapresentaramgânglioslinfáticosmesentéricosaumentados.

Conclusão: Apesar de amaioria dos pacientespossuir níveis elevadosde anticorpo

antien-domísio,indicando umadietapobre, aenterografiaporressonânciamagnéticanão mostrou nenhumaanomalianamucosaassociadaàincapacidadedeaenterografiaporressonância mag-néticadetectaralteraçõesleves/precocesdedoençacelíacanascrianças.Portanto,elapode nãoserútilnoacompanhamentodadoençacelíacapediátrica.

Introduction

Celiac disease (CD), a malabsorption syndrome with an autoimmune origin, affects approximately 1% of the population.1,2 _The _incidence_of_CD _has_increased_over _the

decades,presumablyduetoincreasedexposuretogluten,

awarenessof thebroad spectrumofclinical presentation,

and the availability of sensitive and specific diagnostic

tools.3---6_However,_the_‘iceberg_model’_indicates_the_extent

ofundiagnosedpopulationwithCD.7_Thus,_CD_represents_a

substantialhealthproblemworldwide,affectingbothadults

andthepediatricpopulation.8

In genetically susceptible children, the disease is

triggeredbyexposuretogluten-containingfoods.It

predom-inantlyaffects the duodenumand jejunum; however, the

entiresmallbowelcanbeinvolved.Themucosalchangesare

characterizedby villous atrophy,crypt hyperplasia,

thick-ening of the basement membrane under the surface of

epithelium, reducednumber of goblet cells, and signs of

inflammation.9_The_clinical_features_are_broad_and

nonspe-cific.The spectrum of clinical presentation in CD maybe

classifiedas:(a)classicalform,relatedwithintestinal

symp-toms and predominantly diagnosed in pediatric patients;

(b) atypicalform,presentationoften withextra-intestinal

symptomssuchasirondeficiency;(c)silent form;and(d)

latentform,patientsareasymptomaticanddiagnosed

dur-ingscreeningduetopresenceoffamilyhistoryorCD-related

conditions, such as type 1 diabetes mellitus, Down

syn-drome,andjuvenileidiopathicarthritis.Inlatentform,the

serologictestsarepositivewhenaccompaniedwitheitherno

histopathologicchangeintheintestineoronlyanincreasein

intraepithelial lymphocytes(Marshstage1).Thepositivity

oftheserologicaltestsincludinganti-endomysial(EMA)and

anti-tissuetransglutaminase(tTG)antibodiesinthecourse

of exposure to gluten-containing food and both

serologi-calandclinicalimprovementfollowinggluten-freedietaid

in making the diagnosis of CD. The definitive diagnosis is

establishedbyendoscopicduodenalorjejunalbiopsy.10

Thecharacteristic imagingfindingof CDis smallbowel

mucosalfoldabnormality,whichincludesbluntingoffolds,

reductioninthenumberofjejunalfolds,andincreaseinthe

numberofilealfoldsdependingontheextentanddegreeof

involvement.Thesemucosalfoldchangeshavetraditionally

been evaluated usingbarium studies. Magnetic resonance

enterography(MRE)isarelativelynewbutwell-established

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Table1 PatientgroupsaccordingtoMarshclassification.

ClinicaltypeofCD Marshscore Numberofpatients

Latent 1 2(100%)

Silent 2 3(100%)

Atypical 2 2(40%)

3 3(60%)

Classical 2 2(10%)

3 19(90%)

CD,celiacdisease.

ininflammatoryboweldisease.11,12_Since_MRE_enables

visu-alization of theentire small bowel,it has been shown to

bebeneficialindeterminingtheextentofthedisease,

CD-relatedcomplicationsincludingulcerativejejunoileitisand

malignancies,andrefractoryCDinpatientswithpersisting

symptomsdespitegluten-freediet.13---16 _However,_the

stud-iesfocusedonCDusingMREwereconductedparticularlyin

adultstudygroupsandthereisscarcityofsuchstudiesinthe

literatureevaluatingfindingsofCDbyMREinchildren.17

ThehistopathologicexaminationofthepatientswithCD

does not give sufficient information about the extent of

the disease, since it is confined to duodenum and

proxi-maljejunum.Thus,thepurposeofthisprospective,single

centerstudy wastodetermineifMREis capableof

show-ingextentof thediseaseinpediatric patientswithbiopsy

provenCDbycomparingwithacontrolgroupandcorrelating

theMREfindingswithanti-EMAlevel,whichisanindicator

ofgluten-freedietarycompliance.18

Materials

and

methods

Patients

This studywasapprovedbytheinstitutional reviewboard and is compatible with Declaration of Helsinki. Written informed consent was obtained from the parents of all patients.ItwasconductedbetweenJanuary2014and Jan-uary2015. Thepatients whowerebeingfollowedupwith thediagnosisofCDbythepediatricgastroenterologyclinics ofthisinstitutionwererecruitedinthestudy.Theinclusion criteriaincludedchildrenabove5yearsofagewiththe abil-itytocomplywithbreath-holdinginstructionsandstaystill throughout the procedurewithout need for sedation.The diagnosis of CDwas basedonthe criteriaoutlinedby the EuropeanSocietyforPaediatricGastroenterology, Hepatol-ogy,andNutrition.8

Patientchartreview

Patient charts were reviewed prior to MRE examinations for clinical features and laboratory findings, and subse-quently recorded by a pediatric gastroenterologist (E.S.). Thehistopathologicexaminationsofthepreviouslyobtained (atthetimeofdiagnosis)duodenalbiopsiesofthepatients werere-analyzedby apathologist(K.D.)whowasblinded toclinicalfeatures.Thepatientswerescoredandgrouped accordingtotheMarshclassification,whichisobtainedfrom the histopathologic examination and reflects the severity

of the disease (Table 1). Marsh classification consists of

fourstages(0---3)constructedbasedonseveralfeaturesof

biopsyspecimen:Stage0reflectsnormalbiopsy,whilestage

1,stage2,andstage3 arepredominantly associatedwith

increased intraepithelial lymphocytes, crypt hyperplasia,

andvillousatrophy,respectively.19,9

MRenterographytechnique

Patients were scanned by a 1.5T clinical scanner (Mag-netom, Aera --- Siemens Healthcare; Erlangen, Germany) withan 18-channel body coil. Prior to MRE examination, 24patientswithCD werenon-compliant,whileeightwere compliantwith gluten-freediet. The preparationfor MRE consistedoffastingfor 4---6handadministrationof manni-tolsolution(3%)asanoralcontrastmedium.MREperformed in supine position with the following sequences: Coronal T2-weightedhalf-Fourieracquisitionsingle-shotturbo spin-echo (HASTE) in order to evaluate the distension of the smallintestine,CINEimagingwithcoronalfastimagingwith steady-statefreeprecession(True-FISP),axial(withfat sat-uration)andcoronalTrue-FISP,coronalT2-weightedHASTE with fat saturation, axial single-shot fast spin-echo echo planardiffusionweightedimaging(b=50,400,800s/mm2_), and prior to and following, intravenous gadolinium-based contrastmediuminjection(0.1mmol/kg)axialandcoronal 3DT1-weightedvolumetricinterpolatedbreath-hold exam-ination withfat saturation (VIBE). Hyoscine butylbromide (Buscopan;Boehringer ---Ingelheim,Germany)was admin-isteredintravenouslytwiceslowly over 2min at adose of 0.3mg/kg, with a maximum dose of 20mg to eliminate bowelmovementandcontraction;followingtheCINE imag-ingandpriortocontrastagentadministration.Thesequence parametersarepresentedinTable2.

Imageanalysis

TheMREexaminationsof40pediatric patients(meanage: 8.0±1.2years;agerange:5---8.4years),asacontrolgroup, whowerescannedwiththesuspicionofinflammatorybowel diseasebut had normal imaging findings, and thepatient groupwiththediagnosis ofCD wereanonymizedandsent backtoaclinicalpicture-archivingandcommunication sys-tembyapediatricradiologist(M.S.D.)whodidnottakepart intheimageevaluation.

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416 KocGetal.

Table2 SequenceparametersofMRIacquisition.

Sequences Parameters

TR(ms) TE(ms) Slicethickness(mm) Gap(mm) FA Matrix

T2HASTE 2000 91 5 1 --- 320×320

True-FISP 3.21 1.04 4 1 50 256×256

T1VIBE 4.36 1.91 3 0 10 256×180

Cinetrue-FISP 3.21 1.04 4 1 50 256×180

Diffusion 6810 62 5 5 --- 256×256

MRI,magneticresonanceimaging;HASTE,half-Fourieracquisitionsingle-shotturbospin-echo;True-FISP,fastimagingwithsteady-state freeprecession;VIBE,volumetricinterpolatedbreath-holdexamination;TR,timeofrepetition;TE,timeofecho;FA,flipangle.

preventoverestimationofthethickness.True-FISPandVIBE sequenceswere notpreferred due tovulnerability tothe blackboundaryartifactthatwouldresultinincorrect mea-surements.The mesenteric lymphnodeswitha short-axis diametermeasuringgreater than1cmwereconsidered as pathologic.

Additionally, the radiologists were asked to rate the images of each patient with an incremental three-point scale(0=inadequate,1=moderate,2=adequate)forsmall boweldistention.

Results

Atotalof45pediatricpatientswiththediagnosisofCDwere recruitedinthestudy initially.Nineofthepatientswhose duodenalbiopsyandhistopathologicexaminationwere car-ried out in another center and five patients who could nottoleratetheMREacquisition(duetoassociatedchronic diseasessuchasIgAdeficiency,Turnersyndrome,type1 dia-betesmellitus,andDownsyndromethatmighthavecaused thepatientstobeincompatible)wereexcluded.

Finally, 31 children with CD (ten boys and 21 girls; meanage11.7±3.1yearsandagerange6---16years)were included.Twenty-one(68%)patientsoutof31were catego-rizedasclassical,five(16%)asatypical,two(6%)aslatent, andthree(10%)assilentCD.Thepresentingsymptomforall thepatientswithclassicalCDwaschronicdiarrhea, abdomi-naldistension,andpain.PatientswithatypicalCDpresented withconstipationandaccompanyingirondeficiencyanemia resistanttooralFe. Therewerenosigns/symptomsofthe patientswithlatentandsilentCD.Theywerediagnosedby screeningconductedduetoincreasedriskforCDbecauseof familyhistory.

The mean duration of the disease was 5.6±1.8 years (range3---7.2years).In24patientswhowerenon-compliant withthegluten-freediet,EMAlevelswereelevated(mean 119.2±66.6RU/mLandrange0---200RU/mL). Inthis insti-tution,anti-EMAlevelsof0---20RU/mLareconsideredtobe withinnormallimitswhilelevelsof21---200RU/mLare con-sideredelevated.Theaveragetimebetweenmeasurement oftheserumEMAlevelandMREexamination was12±3.0 days(range8---16days).PriortoMREexamination,patients withnon-elevatedEMAandtenoutof24patientswith ele-vated EMA were all free of symptoms. Fourteen patients withelevatedEMApresentedwitheitherabdominalpainor diarrhea.Patientdemographicsandlaboratoryfindingsare listedinTable3.

The tworadiologists rated all the examinations of the

patients with CD and the control group as ‘0’: fold

pat-tern wasinterpreted as normalin all the patients. There

wasnoduodenalfoldloss,ilealizationofthejejunum,

jeju-nization ofthe ileum,or global lossof valvulae.The wall

thickness waswithin normal limits (mean: 1.5±0.26 and

1.58±0.28mmforjejunumandileum,respectively).

Abnor-malenhancementordiffusionrestrictionofthebowelwall

wasnotencountered(Fig.1).

Ten patients out of 31 (32%) were detected to have

mesentericlymphnodeswith>1cmshort-axisdiameter.No

otherextra-intestinalabnormalitiesweredetected.

TheradiologistsratedtheimagesofpatientswithCDas

‘adequate’in25(81%)and27(87%)outofthe31

examina-tions(substantialinterreaderagreement,=0.73),andthe

imagesofcontrolgrouppatientsas‘adequate’in34(85%)

and32(80%)outof40,respectively(almostperfect

inter-readeragreement,=0.82),whiletherestwerescoredas

‘moderate’forsmallboweldistention.

Examinations were well tolerated and no significant

adverseeffectsoccurred.

Discussion

This studyperformed toassessMREfindings ofCD in chil-dren did not reveal any imaging abnormalities. Several studies have shown fold pattern abnormalities on imag-ing in patients with uncomplicated CD.20,21 _The _findings

include decreased number of jejunal folds (<three per

inch) and increasednumber of ileal folds (>five folds per

inch); the combination of these two findings is known as

‘reversedjejunoilealfoldpattern.’Theotherintestinal

find-ings included distention and increased wall thickness of

smallintestine,especiallyaffectingthejejunum.However,

Laghietal.17 _and_Tomei_et_al.13 _have_reported_absence_of

MREfindingsin29%and42%oftheirpatients,respectively,

including adultsand children with biopsy-proven CD. The

current study group, being exclusivelypediatric patients,

may not have developed the intestinal mucosal damage

observed in adult patients. This is supported by the fact

that29% (9/31)ofthe childrenhadmild mucosalchanges

reflectedbyMarshstage1and2,whichmaynotbeshown

byMRE.

Fiveout of 31 (16%) patients in the study group were

diagnosedwitheither latentor silentCD. The

histopatho-logicexaminationoftheduodenalbiopsiesofthesepatients

(5)

in

pediatric

celiac

disease

417

Table3 Clinicalandlaboratoryfeaturesofthestudygroup.

Patients Gender Age(years) Height(cm) Weight(kg) BMI EMA(RU/mL) Marshscorea _Clinical_type _Duration_of_follow-up_(years)

1 F 16 170(25p) 43(25p) 14.9 0 1 Latent 7

2 M 7 105(<3p) 15(<3p) 13.6 100 3 Classical 3

3 F 13 160(50---75p) 43(10---25p) 16.2 10 2 Atypical 5

4 F 9 128(25p) 25(25p) 15.3 120 2 Silent 3

5 F 9 131(50p) 27(10---25p) 15.7 140 2 Atypical 6

6 F 16 163(3---10p) 70(50p) 26.3 0 3 Classical 7

7 M 9 156(90p) 32(75p) 13.1 150 1 Latent 5

8 F 14 134(<3p) 37(3---10p) 20.6 10 3 Classical 7

9 F 11 129(3---10p) 26(<3p) 15.6 200 2 Classical 5

10 F 13 160(75p) 46(75p) 18 200 3 Classical 7

11 F 13 150(10---25p) 38(3---10p) 17 200 3 Classical 7

12 M 13 178(90p) 45(50p) 14.2 150 3 Atypical 7

13 F 16 168(25---50p) 46(10---25p) 16.3 10 2 Silent 7

14 M 14 168(50p) 27(3p) 9.6 130 3 Classical 7

15 M 6 105(<3p) 18(10---25p) 16.3 120 3 Classical 3

16 F 9 130(75p) 43(90---97p) 25.4 10 2 Silent 4

17 F 15 169(25---50p) 44(<3p) 15.4 150 3 Classical 7

18 F 10 155(97p) 33(50---75p) 14 160 3 Classical 3

19 M 16 169(25---50p) 54(3---10p) 18.9 170 3 Classical 7

20 M 11 136(10---25p) 43(10---25p) 23.2 10 3 Atypical 7

21 F 12 168(97p) 33(10---25p) 11.7 167 3 Classical 5

22 M 17 176(50---75p) 54(10p) 17.4 145 3 Classical 7

23 F 8 118(3---10p) 29(50---75p) 20.8 140 3 Classical 3

24 F 7 97.5(<3p) 17(<3p) 18.7 200 3 Atypical 3

25 M 11 170(>97p) 35(25---50p) 12.1 133 3 Classical 3

26 M 12 157(50p) 23.8(<3p) 9.7 122 3 Classical 7

27 F 16 170(25---50p) 50(<3p) 17.3 166 3 Classical 3

28 F 9 156(>97p) 45(>97p) 18.5 150 3 Classical 7.2

29 F 12 158(50---75p) 40(25---50p) 16 110 3 Classical 7

30 F 11 165(>97p) 33(25---50p) 12.1 145 3 Classical 7

31 F 9 135(50---75p) 23(3---10p) 12.6 177 2 Classical 4

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418 KocGetal.

Figure1 16-Year-oldfemalepatientwithdiagnosisofceliacdisease;T2-weightedHASTE(A)andT1-weightedfat-saturatedVIBE (B)imagesacquiredfollowingintravenouscontrastadministrationrevealnofoldpatternabnormalitiesoftheintestines.HASTE, half-Fourieracquisitionsingle-shotturbospin-echo;VIBE,volumetricinterpolatedbreath-holdexamination.

that90%oftheirpatientsdiagnosedwithsilentCDhad nor-mal fold pattern. Although there is a limited number of studiesfocusingonMREfindingsofCD,thelargeexperience inCrohn’sdiseasehasrevealedtheinabilityofMREtoexhibit mucosalchanges,butforinflammatorywallinvolvement.22

In accordancewiththis fact, in the current study all the

patients diagnosedwith either silent or latent CD had no

fold pattern abnormalities on MRE. In fact, in this study

that consisted of a majority (68%) of children with the

classical form, no fold abnormalities were seen in any

patients.

Increased levels of EMA were detected in 77% of the

patientspriortoMREacquisition.The antibodiesincluding

EMAandtTGareessentialforthefollow-upofpatientswith

CDandhavebeenreportedtohaveagoodcorrelationwith

gluten-freedietarycomplianceinbothadultandpediatric

patients.23_Increased_levels_of_EMA_indicate_{non-compliance}

of the patient, i.e., not strictly adhering to gluten-free

diet.24 _van _den _Bosch _et _al. _reported _a _good _correlation

betweenresponsetogluten-freedietandenteroclysis

find-ings ascomparedtobiopsy in adultswith CD.23 _However,

thereare no such studies related to MRE.An alternative

explanation,atleastinpart,forabsenceofimagingfinding

inpatientswithnormalanti-EMAlevelscouldbeprevention

ofmucosaldamagewithgluten-freediet.

TheextraluminalradiologicmanifestationsofCDinclude

enlarged mesenteric lymph nodes, mesenteric vascular

engorgement, and transient intussusceptions. Enlarged

(>1cmshort-axisdiameter)mesentericlymphnodesarethe

mostcommonextraluminalfindingassociatedwithCD,seen

in up to 42% cases.25 _The _size _of _lymph _nodes _decreases

with treatment with gluten-free diet and their

persis-tence should raise the suspicion of lymphoma.25,26 _These

hypertrophiclymphnodesmayactasaninceptionpointfor

intussusception,whichcanbetheinitialpresentationin57%

ofthepatientswithCD.27_Mesenteric_vascular_engorgement

isanonspecificsignofthedisease.Whileenlarged

mesen-teric lymph nodes were the only and the most common

extraluminalfindinginthecurrentpatients,intussusception

andvascularengorgementwerenotdetected.

Thisstudyhasafewlimitations.Althoughthetotal

num-berofstudypatientswasrelativelyacceptable,thepatient

group wasdiverse, includingpatientswithclassical,

atyp-ical, silent, and latent CD. Since the both patients with

silentandlatentCDhadlowerMarshscoresassociatedwith

mild mucosal changesthat might have resulted in lack of

MREfindings,astudyconductedwithalarger,homogenized

patient group may be worth further investigation. Since

radiologicalfollow-upwasnotperformed,serialMREimages

acquired at the timeof diagnosis and following initiation

of gluten-freedietwould help assessradiological changes

inthecourseofdisease.Lastly,thehistopathologic

exam-inationoftheduodenal biopsywasperformed atthetime

of diagnosis. The comparisonof recentlyobtained biopsy

resultswithimagingfindingswould enablemaking amore

plausiblehypothesisontherelationofimagingfindingsand

histopathologicchanges.

In conclusion, despite elevated EMA levels in the

majority of children, indicating poor dietary compliance,

this study did not show any significant MRE findings in

biopsy-provenCD,indicatinginabilityofMREtodetectmild

and/or early mucosal damage (suggested by lower Marsh

score)seen inchildren withCD.Therefore,it maynotbe

usefulasadiagnostictestforCDorforfollow-up.However,

as indicated by some authors previously,17 _MRE _may _be

(7)

asstrictureandlymphoma,evaluationofCDnon-responsive

togluten-freediet,andtoexcludealternativediagnoses.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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