BACKGROUND Celiac disease (CD) may cause changes throughout the gastrointestinal tract. Patchy distribution of duodenal mucosal lesions has been described in adults as well as in children. This study aimed to verify the concept and to evaluate the frequency of histologic lesion variability of the duodenal mucosa in Indian children with CD. METHODS We enrolled 67 children prospectively who underwent upper gastrointestinal endoscopy because of positive tissue transglutaminase antibodies and biopsy as the final evaluation for suspected CD. Four biopsies were taken from the descending duodenum distal to the papilla, and duodenal bulb. The histologic lesions were classified according to the Oberhuber classification with modification proposed by our group. RESULTS Forty-three CD children (64.2%) had a "mixed" type 3 lesion characterized by a different degree of villous atrophy at different biopsy sites. Eight children (11.9%) showed two different types of histologic lesions in the same patient at different biopsy sites. The overall variability of histologic lesion (variability in the grade of villous atrophy [type 3a, 3b, or 3c], and coexistence of villous atrophy and type 2 lesion) was seen in 51 (76.1%) of the CD patients. CONCLUSIONS Children with CD show a high frequency of variability of histologic lesions. Therefore, multiple endoscopic biopsy specimens should be obtained not only from the distal duodenum but also from the bulb.