Observational Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Feb 16, 2019; 11(2): 145-154
Published online Feb 16, 2019. doi: 10.4253/wjge.v11.i2.145
Narrow band imaging evaluation of duodenal villi in patients with and without celiac disease: A prospective study
James H Tabibian, Jean F Perrault, Joseph A Murray, Konstantinos A Papadakis, Felicity T Enders, Christopher J Gostout
James H Tabibian, Jean F Perrault, Joseph A Murray, Konstantinos A Papadakis, Christopher J Gostout, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States
James H Tabibian, Division of Gastroenterology, Olive View-UCLA Medical Center, Sylmar, CA 91342, United States
Felicity T Enders, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, United States
Author contributions: Tabibian JH, Perrault JF, Enders FT, and Gostout CJ designed the study; Tabibian JH, Perrault JF, Murray JA, and Papadakis KA acquired images; Tabibian JH, Perrault JF, Murray JA, Papadakis KA and Gostout CJ reviewed images; Tabibian JH drafted the manuscript; Enders FT provided statistical support; Perrault JF and Gostout CJ provided supervision; all authors provided critical input on and approved of the manuscript.
Supported by the National Institutes of Health, No. T32DK007198 in part during the study period.
Institutional review board statement: Exempt status was obtained from the Mayo Clinic IRB.
Conflict-of-interest statement: No conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: James H Tabibian, MD, PhD, Associate Professor of Medicine, Director of Endoscopy, Division of Gastroenterology, Olive View-UCLA Medical Center, 14445 Olive View Dr., 2B-182, Sylmar, CA 91342, United States. jtabibian@dhs.lacounty.gov
Telephone: +1-747-2103205 Fax: +1-747-2104573
Received: November 5, 2018
Peer-review started: November 5, 2018
First decision: November 28, 2018
Revised: January 9, 2019
Accepted: January 26, 2019
Article in press: January 26, 2019
Published online: February 16, 2019

Duodenal biopsies are commonly obtained during esophagogastroduodenoscopy (EGD) but are very often histopathologically normal. Therefore, a more strategic method for evaluating the duodenal mucosa and avoiding unnecessary biopsies is needed.


To examine the clinical utility of narrow band imaging (NBI) for evaluating duodenal villous morphology.


We performed a prospective cohort study of adult patients at Mayo Clinic Rochester from 2013-2014 who were referred for EGD with duodenal biopsies. A staff endoscopist scored, in real-time, the NBI-based appearance of duodenal villi into one of three categories (normal, partial villous atrophy, or complete villous atrophy), captured ≥ 2 representative duodenal NBI images, and obtained mucosal biopsies therein. Images were then scored by an advanced endoscopist and gastroenterology fellow, and biopsies (gold standard) by a pathologist, in a masked fashion using the same three-category classification. Performing endoscopist, advanced endoscopist, and fellow NBI scores were compared to histopathology to calculate performance characteristics [sensitivity, specificity, positive and negative, negative predictive value (NPV), and accuracy]. Inter-rater agreement was assessed with Cohen’s kappa.


112 patients were included. The most common referring indications were dyspepsia (47%), nausea (23%), and suspected celiac disease (14%). Duodenal histopathology scores were: 84% normal, 11% partial atrophy, and 5% complete atrophy. Performing endoscopist NBI scores were 79% normal, 14% partial atrophy, and 6% complete atrophy compared to 91%, 5%, and 4% and 70%, 24%, and 6% for advanced endoscopist and fellow, respectively. NBI performed favorably for all raters, with a notably high (92%-100%) NPV. NBI score agreement was best between performing endoscopist and fellow (κ = 0.65).


NBI facilitates accurate, non-invasive evaluation of duodenal villi. Its high NPV renders it especially useful for foregoing biopsies of histopathologically normal duodenal mucosa.

Keywords: Endoscopy, Digestive tract, Mucosa, Celiac disease, Minimally-invasive imaging, Esophagogastroduodenoscopy

Core tip: Duodenal mucosal biopsies are frequently obtained during upper endoscopy to assess villous architecture but are largely negative (i.e., histopathologically normal); thus, a method to better evaluate the duodenal mucosa and avoid unnecessary biopsies is needed. Narrow band imaging (NBI) permits superior inspection of mucosal surfaces via filter separation of conventional white light into only green and blue components. Based on the findings of this prospective study, NBI appears to have excellent diagnostic performance in evaluating duodenal villous morphology and can facilitate targeting of biopsies; its high negative predictive value renders it particularly useful in avoiding biopsies that are likely to reveal histopathologically normal mucosa.