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AIMS--To highlight the pitfalls in the diagnosis of coeliac disease and to make recommendations for its diagnosis and the management of refractory cases with equivocal histology. METHODS--Six patients, referred since 1989 with a diagnosis of coeliac disease based on duodenal biopsy specimens taken at endoscopy, and who failed to respond to a gluten-free diet were studied. All patients were subjected to peroral jejunal biopsy. Morphometric analysis of villus height:crypt depth ratios, surface enterocyte cell heights, and intraepithelial counts was used to aid in the assessment of equivocal histology. RESULTS--Subsequent small intestinal biopsy specimens both taken when the patients were following a gluten-free diet and after gluten challenge were normal in all cases. Morphometric analysis and intraepithelial counts were normal. CONCLUSIONS--Misinterpretation of the original slides was often due to poor sample quality and tangential sectioning. Failure to respond to a gluten-free diet should always raise doubt regarding the initial diagnosis, especially when the findings are normal. For correct diagnosis at least three distal duodenal biopsy specimens should be taken simultaneously, and these should be of an adequate size and correctly orientated. Review by a histopathologist experienced in gastrointestinal diagnosis is essential in difficult cases. Quantitative morphometric analysis is helpful in equivocal cases, and jejunal suction biopsy, following a gluten challenge, may be necessary in patients refractory to treatment. [ABSTRACT FROM PUBLISHER]

This article focuses on a study related to early linear endoscopic ultrasound and fine needle aspiration experience in a district general hospital. Linear endoscopic ultrasound with fine needle aspiration cytology (FNA) is a relatively new modality of gastrointestinal investigation of limited availability in Great Britain. Although the service was rapidly established resulting in a major referral rate, the difficult operator learning curve resulted in a 10% complication rate related to FNA in the first year, while there were no complications in the second year.

Standard diagnostic methods may sometimes fail to achieve a bacteriological diagnosis in patients with tuberculosis (TB). Linear endoscopic ultrasound (EUS) is a sensitive technique for the detection of mediastinal lymphadenopathy, offering the additional possibility of guided fine needle aspiration (EUS-FNA) For cytology and bacteriology. EUS-FNA of mediastinal lymphadenopathy in patients with suspected TB revealed a variety of diagnoses but was also able to identify patients with a diagnosis of TB. Patients investigated by EUS did not require mediastinoscopy and had no procedure related complications. Trans-oesophageal EUS/FNA is a sensitive technique and is a useful alternative in the diagnosis of tuberculosis, when other non-invasive methods fail.