Malabsorption Work-up: Utility of Small Bowel Biopsy Brian A. Babbin, Kelly Crawford, Shanthi V. Sitaraman  Clinical Gastroenterology and Hepatology  Volume 4, Issue 10, Pages 1193-1198 (October 2006) DOI: 10.1016/j.cgh.2006.07.022 Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions

Figure 1 Endoscopic appearance of celiac disease showing scalloping of the small bowel. Clinical Gastroenterology and Hepatology 2006 4, 1193-1198DOI: (10.1016/j.cgh.2006.07.022) Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions

Figure 2 Algorithm for work-up of malabsorption. Clinical Gastroenterology and Hepatology 2006 4, 1193-1198DOI: (10.1016/j.cgh.2006.07.022) Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions

Figure 3 Photomicrograph of normal duodenal mucosa. Villi are well-developed with a villous-to-crypt height ratio of 4–5:1 (A: V, villi; Cr, crypt). Brunner’s glands are present in submucosal tissues (A: Br, arrow). In more proximal duodenal mucosa, Brunner’s glands can be identified in the lamina propria as well (B: Br, arrow). Clinical Gastroenterology and Hepatology 2006 4, 1193-1198DOI: (10.1016/j.cgh.2006.07.022) Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions

Figure 4 Celiac disease. Low magnification photomicrograph of duodenal biopsies taken from celiac disease patient (A) showing a flat mucosal surface caused by loss of villi, increased mononuclear cells in the superficial lamina propria (A, arrows), and elongation of crypt structures. A superficial intraepithelial lymphocytosis is apparent at higher magnification (B). In addition to crypt elongation, reactive crypt epithelial changes are further evidenced by increased proliferative activity (C, arrowheads). Clinical Gastroenterology and Hepatology 2006 4, 1193-1198DOI: (10.1016/j.cgh.2006.07.022) Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions

Figure 5 Mycobacterum avium-intracellulare. Duodenal biopsies obtained from an immunocompromised patient showing abnormal or blunted villi distended with histiocytes (A & B, arrows). The acid-fast bacilli are identified within histiocytes on Ziehl-Neelsen stain (C). Clinical Gastroenterology and Hepatology 2006 4, 1193-1198DOI: (10.1016/j.cgh.2006.07.022) Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions

Figure 6 Amyloidosis involving the small bowel. Small bowel biopsy obtained from a multiple myeloma patient demonstrates deposition of amorphous material in the base of the lamina propria and in submucosal tissues (A & B, arrows). The overlying mucosa showed normal architecture and lacked inflammatory changes (A). This material stained positive (bright red) on Congo red staining (C). Clinical Gastroenterology and Hepatology 2006 4, 1193-1198DOI: (10.1016/j.cgh.2006.07.022) Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions

Figure 7 Crohn’s disease involving the small intestine. The surface of the mucosa is flattened with no identifiable villous structures. In addition, there is prominent chronic inflammation in the submucosal compartment (bracket). The inflammatory changes shown are not specific, and granulomatous inflammation was not seen in this case. Clinical Gastroenterology and Hepatology 2006 4, 1193-1198DOI: (10.1016/j.cgh.2006.07.022) Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions

Figure 8 Small intestinal lymphangiectasia. Small bowel biopsies obtained in the vicinity of a mass lesion demonstrating lymphatic ectasia in the tips of villous structures (A, arrow) and in the lamina propria surrounding crypts (B, arrows). No other histopathologic changes were identified in this biopsy material. Clinical Gastroenterology and Hepatology 2006 4, 1193-1198DOI: (10.1016/j.cgh.2006.07.022) Copyright © 2006 American Gastroenterological Association (AGA) Institute Terms and Conditions