Duodenal Biopsies for Coeliac Disease: Does Size Matter?

Background/Objectives: Most adult patients require endoscopy and duodenalbiopsies to diagnose coeliac disease. However, individuals who are unwilling or unable toundergo conventional endoscopy are left without diagnostic options or a formal diagnosis.We aimed to determine whether the small‑sized biopsy forceps used during the more toler‑able transnasal endoscopy (TNE) can provide adequate duodenal biopsy specimens for di‑agnosing coeliac disease. Methods: We prospectively recruited adult patients (≥18 years)with suspected coeliac disease between May and July 2024. All patients underwent per‑oral endoscopy, with four biopsies taken from the second part of the duodenum (D2) andone from the duodenal bulb (D1) using standard 2.8 mm biopsy forceps. The biopsy pro‑tocol was then repeated using smaller 2 mm biopsy forceps. Expert pathologists evaluatedall samples for size, quality, and Marsh classification. Results: Ten patients (median age45 years, 50% female) were included in this study, of whom seven (70%) were diagnosedwith coeliac disease. In total, 100 duodenal biopsy specimens were collected and anal‑ysed (50 using standard biopsy forceps and 50 using smaller biopsy forceps). The size ofD2 biopsies was significantly larger when using standard biopsy forceps compared withsmaller forceps (4.5 mm vs. 3 mm, p = 0.001). Similarly, biopsies from D1 were also largerwith standard forceps (3 mm vs. 2 mm, p = 0.002). Smaller forceps provided sufficient ma‑terial for accurate classification in all cases, and the agreement between biopsies obtainedusing both forceps in D2 and D1 was 100% (k = 1.0). Conclusions: This pilot study demon‑strates that small‑sized biopsy forceps, used during TNE, can provide adequate tissue forhistopathological diagnosis in patients with suspected coeliac disease. These findings pavethe way for considering TNE as a more tolerable alternative to conventional endoscopy indiagnosing coeliac disease.