ALIMENTARY TRACT:CLINICAL RESEARCH Small Intestinal Contrast Ultrasonography-Based Scoring System A Promising Approach for the Diagnosis and Follow-Up of Celiac Disease Paola Dell’Aquila, MD,* Lorena Pietrini, MD,† Michele Barone, MD,‡ Ester M. Cela, MD,§ Nicola Della Valle, MD,‡ Anacinzia Amoruso, MD,‡ Maria F. Minenna, MD,§ Antonio Penna, MD, k Vincenzo De Francesco, MD,§ Carmine Panella, MD,† and Enzo Ierardi, MD† Background: Small intestinal ultrasonography with anechoic con- trast agents (SICUS) has been shown to have a diagnostic accuracy on small bowel morphology similar to X-ray barium follow-through. Although extremely investigated by transabdominal ultrasonography, celiac disease, a common disorder of the small bowel, has been never studied by SICUS. Aim: To asses SICUS characteristics of celiac disease patients. Patients and Methods: SICUS was performed using PEG 4000 as contrast agent. Twenty-three patients with celiac disease at the first diagnosis were enrolled and 30 healthy volunteers, matched for sex and age, were selected as control group. Celiac disease diagnosis was based on anti-gluten, anti-endomysium, and anti-transglutaminase positivity as well as jejunal histology. The following seven echographic parameters were considered: liquid endoluminal content before con- trast, loop diameter, Kerckring’s folds, peristaltic waves, ileal jejunaliza- tion, mesenteric lymphoadenomegaly, and Doppler resistance index (RI) of mesenteric superior artery. Statistical analysis was performed by Student’s t test for unpaired data; one-way analysis of variance was used to correlate echographic and histologic pictures. Results: Loop diameter, Kerckring’s fold number, peristaltic waves, and Doppler RI appeared to be significantly different between celiac disease patients and controls. Additionally, liquid content, ileal jejunaliza- tion, and mesenteric lymphoadenomegaly were present only in the celiacs (52.1%, 47.7%, and 95.6%, respectively), but not in controls. Only Doppler RI values significantly correlated with the histologic degree of damage. Conclusions: SICUS could be a reliable and noninvasive technique to confirm a diagnosis of celiac disease performed using conventional investigations. The possibility of investigating the whole small bowel and the safety of repeating examinations could be useful in the follow-up of celiac patients. Key Words: small intestinal ultrasonography with anechoic contrast agents, celiac disease, diagnosis, follow-up (J Clin Gastroenterol 2005;39:591–595) S ome B-mode ultrasonographic alterations suggestive of celiac disease in the active phase have been identified. In detail, modifications of content, wall, and motility of the small bowel, mesentery lymphoadenomegaly, dilatation of both superior mesenteric artery and portal vein, as well as hepatic steatosis, were described. 1,2 Moreover, superior mesenteric artery blood flow evaluation with power Doppler showed an increase of systolic and diastolic peaks with reduction of the index of resistance (RI), indicating a fall of peripheral re- sistance due to arterial dilatation in celiac patients. 3–6 Such B-mode and power Doppler alterations were observed only in untreated patients, disappearing after dietetic therapy. 4,6,7 An anechoic contrast agent (polyethylenglicole: PEG 4000) has been recently introduced to obtain a satisfactory distension of the entire small bowel, improving its inves- tigation by ultrasonography. This new method (enteroultraso- nography: small intestine contract ultrasonography [SICUS]) has been shown to be highly accurate for detecting small bowel diseases with a sensitivity of 72% and a specificity of 100%, using barium x-ray investigation as gold standard. 8–12 More- over, because of its isotonic property, such contrast agent en- hances the visualization of intra- and extra-intestinal details without changing intestinal motility. On these bases, we have studied morphologic and func- tional alterations of celiac disease by SICUS with the fol- lowing aims: 1) to assess the ultrasonographic peculiarities of celiac disease when a contrast agent is used; and 2) to express the ultrasonographic features of the disorder by numerical values to emphasize the diagnostic value, while minimizing intraobserver variations. PATIENTS AND METHODS Patients Between January and December 2003, 23 patients (2 male and 21 female; median age, 34.1 years; range, 22–50 years) were enrolled at the moment of the first diagnosis of celiac disease. Clinical pattern, as reported in Table 1, was not Reprints: Enzo Ierardi, MD, Cattedra di Gastroenterologia, Universita ` di Foggia, c/o Ospedali Riuniti, Viale L. Pinto 71100, Foggia, Italy (e-mail: e.ierardi@virgilio.it). Copyright Ó 2005 by Lippincott Williams & Wilkins Received for publication September 30, 2004; accepted January 14, 2005. From *‘‘Umberto I’’ Hospital, Altamura, Bari, Italy; †Section of Gastroen- terology, Department of Medical Sciences, University of Foggia, Foggia, Italy; ‡Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy; §Gastroenterology Unit ‘‘OORR’’ Foggia, Foggia, Italy; and k Digestive Endoscopy Unit, IRCCS, Castellana Grotte, Bari, Italy. 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