Whipple disease

Definition

A biopsy is a diagnostic procedure in which tissue or cells are removed from a part of the body and specially prepared for examination under a microscope. When the tissue involved is part of the small intestine, the procedure is called a small-intestine (or small-bowel) biopsy.

Purpose

The small-bowel biopsy is used to diagnose and confirm disease of the intestinal mucosa (the lining of the small intestine).

Precautions

Due to the slight risk of bleeding during or after this procedure, aspirin, aspirin-containing medications, nonsteroidal anti-inflammatory drugs, and anticoagulants and antiplatelet drugs should be withheld for at least five days before the test.

Description

The small intestine is approximately 21 feet long. It has three sections: the duodenum (a short, curved segment fixed to the back wall of the abdomen), the jejunum, and the ileum (two larger, coiled, and mobile segments). Some digestion occurs in the stomach, but the small intestine is mainly responsible for digestion and absorption of foods.

Malabsorption syndromes occur when certain conditions result in impaired absorption of nutrients, vitamins, or minerals from the diet by the lining of the small intestine. For example, injury to the intestinal lining can interfere with absorption, as can infections, some drugs, blockage of the lymphatic vessels, poor blood supply to the intestine, or diseases like sprue.

Malabsorption is suspected when a patient not only loses weight, but has diarrhea and nutritional deficiencies despite eating well (weight loss alone can have other causes). Laboratory tests like fecal fat, a measurement of fat in stool samples collected over 72 hours, are the most reliable tests for diagnosing fat malabsorption, but abnormalities of the small intestine itself are diagnosed by small-intestine biopsy.

Several different methods are used to detect abnormalities of the small intestine. A tissue specimen can be obtained by using an endoscope (a flexible viewing tube), or by using a thin tube with a small cutting instrument at the end. This latter procedure is ordered when larger specimens than those provided by endoscopic biopsy are needed, because it allows removal of tissue from areas beyond the reach of an endoscope.

Several similar types of capsules are used for tissue collection. In each, a mercury-weighted bag is attached to one end of the capsule, while a thin polyethylene tube about 60 inches long is attached to the other end. Once the bag, capsule, and tube are in place in the small bowel, suction on the tube draws the tissue into the capsule and closes it, cutting off the piece of tissue within. This is an invasive procedure, but it causes little pain and complications are rare.

Small-intestine biopsy procedure

After application of a topical anesthetic to the back of the patient's throat, the capsule and the tube are introduced, and the patient is asked to swallow as the tube is advanced. The patient is then placed on the right side and the instrument tip is advanced another 20 inches or so. The tube's position is checked by fluoroscopy or by instilling air through the tube and listening with a stethoscope for air to enter the stomach.

The tube is advanced two to four inches at a time to pass the capsule through the stomach outlet (pylorus). When fluoroscopy confirms that the capsule has passed the pylorus, small samples of small intestine tissue are obtained by the instrument's cutting edge, after which the instrument and tube are withdrawn. The entire procedure may be completed in minutes.

Preparation

This procedure requires tissue specimens from the small intestine through means of a tube inserted into the stomach through the mouth. The patient is to withhold food and fluids for at least eight hours before the test.

Aftercare

The patient should not have anything to eat or drink until the topical anesthetic wears off (usually about one to two hours). If intravenous sedatives were administered during the procedure, the patient should not drive for the remainder of the day. Complications from this procedure are uncommon, but can occur. The patient is to note any abdominal pain or bleeding and report either immediately to the doctor.

Risks

Complications from this procedure are rare, but can include bleeding (hemorrhage), bacterial infection with fever and pain, and bowel puncture (perforation). The patient should immediately report any abdominal pain or bleeding to the physician in charge. Note: Biopsy is contraindicated in uncooperative patients, those taking aspirin or anticoagulants, and in those with uncontrolled bleeding disorders.

Normal results

Normal results are no abnormalities seen on gross examination of the specimen(s) or under the microscope after tissue preparation.

Abnormal results

Small-intestine tissue exhibiting abnormalities may indicate Whipple's disease, a malabsorption disease; lymphoma, a group of cancers; and parasitic infections like giardiasis and coccidiosis. When biopsy indicates celiac sprue (a malabsorption disorder), infectious gastroenteritis (inflammation of the gastrointestinal tract), folate and B₁₂ deficiency, or malnutrition, confirmation studies are needed for conclusive diagnosis.

Key Terms

Sprue

A disorder of impaired absorption of nutrients from the diet by the small intestine (malabsorption), resulting in malnutrition. Two forms of sprue exist: tropical sprue, which occurs mainly in tropical regions; and celiac sprue, which occurs more widely and is due to sensitivity to the wheat protein gluten.

Whipple's disease

A disorder of impaired absorption of nutrients by the small intestine. Symptoms include diarrhea, abdominal pain, progressive weight loss, joint pain, swollen lymph nodes, abnormal skin pigmentation, anemia, and fever. The precise cause is unknown, but it is probably due to an unidentified bacterial infection.

Further Reading

For Your Information

Books

• Cahill, Mathew. Handbook of Diagnostic Tests. Springhouse, PA: Springhouse Corporation, 1995.
• Jacobs, David S. Laboratory Test Handbook, Fourth Edition. Hudson, OH: Lexi-Comp, Inc., 1996.
• Pagana, Kathleen Deska. Mosby's Manual of Diagnostic and Laboratory Tests. St. Louis, MO: Mosby, Inc., 1998.

Gale Encyclopedia of Medicine. Gale Research, 1999.