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Intestinal Villous Biopsy – Procedure and Results

An intestinal villous biopsy is a diagnostic tissue sampling procedure from the small intestinal mucosa used to examine the villi for pathological changes.

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Things worth knowing about "Intestinal Villous Biopsy"

An intestinal villous biopsy is a diagnostic tissue sampling procedure from the small intestinal mucosa used to examine the villi for pathological changes.

What Is an Intestinal Villous Biopsy?

An intestinal villous biopsy is a medical diagnostic procedure in which small tissue samples are taken from the mucosa of the small intestine. The aim is to examine the intestinal villi (Villi intestinales) – finger-like projections of the intestinal lining responsible for nutrient absorption – under a microscope for any pathological changes. The procedure is a key component in diagnosing various diseases of the gastrointestinal tract.

When Is an Intestinal Villous Biopsy Performed?

A villous biopsy is ordered when there is a justified suspicion of certain small intestinal conditions. Common indications include:

Coeliac disease: An autoimmune condition triggered by gluten, in which the intestinal villi may be characteristically flattened or completely destroyed.
Whipple disease: A rare infectious disease caused by the bacterium Tropheryma whipplei that leaves typical changes in intestinal tissue.
Giardiasis: A parasitic infection of the small intestine.
Refractory sprue: A form of coeliac disease that does not respond to standard treatment.
Malabsorption syndromes: Conditions in which nutrients cannot be adequately absorbed.
Intestinal lymphomas: Malignant lymphoid tumours in the intestinal region.

How Is the Procedure Performed?

The biopsy is typically performed during an oesophagogastroduodenoscopy (OGD) – a gastroscopy in which a thin, flexible endoscope with a camera is passed through the mouth, oesophagus, and stomach into the duodenum or upper small intestine (jejunum). Using a small biopsy forceps passed through the working channel of the endoscope, several tissue samples (usually 4–6 samples) are taken from different sites of the intestinal mucosa. The procedure is minimally invasive and is often performed under mild sedation.

Preparation

Patients are required to fast for several hours before the procedure (typically 6–8 hours). The attending physician will provide prior information about potential risks and advise on any medications that may need to be temporarily discontinued (e.g. blood thinners).

Tissue Analysis

The collected tissue samples are fixed in formalin and then processed histologically. The pathologist evaluates the villous architecture, crypt depth, and the type and number of specific immune cells such as intraepithelial lymphocytes. For coeliac disease, the Marsh classification is commonly used to grade the severity of mucosal changes.

What Do the Results Show?

Depending on the findings, different disease patterns can be identified:

Villous blunting or atrophy: Suggests coeliac disease or refractory sprue.
Elevated intraepithelial lymphocyte count: May be an early sign of coeliac disease or another inflammatory condition.
Foamy macrophages (PAS-positive material): Characteristic of Whipple disease.
Parasitic structures: Indicative of giardiasis or other parasitic infections.

Risks and Side Effects

The intestinal villous biopsy is considered a safe and well-tolerated procedure. Possible but rare complications include:

Minor bleeding at the biopsy site
Infections (very rare)
Perforation of the intestinal wall (extremely rare)
Reactions to the sedative agent

After the procedure, mild sore throat or a feeling of fullness may temporarily occur. Serious complications are very uncommon.

Diagnostic Significance

For certain conditions, the intestinal villous biopsy represents the gold standard in diagnostics. This is especially true for coeliac disease, where positive blood markers alone (e.g. anti-tissue transglutaminase antibodies) are insufficient in most cases to confirm the diagnosis. Histological confirmation of villous atrophy is required to establish the diagnosis and serves as the basis for a lifelong gluten-free diet.

References

Ludvigsson JF et al. - European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease. United European Gastroenterology Journal, 2019. doi:10.1177/2050640619844125
Rubio-Tapia A et al. - ACG Clinical Guidelines: Diagnosis and Management of Celiac Disease. American Journal of Gastroenterology, 2013. doi:10.1038/ajg.2013.79
World Gastroenterology Organisation (WGO) - Celiac Disease: Global Guidelines. Available at: www.worldgastroenterology.org

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