Duodenal biopsies for the diagnosis of coeliac disease: are we adhering to current guidance?
Husnoo N, Ahmed W, Shiwani H. BMJ Open Gastro 2017;4:e000140. Doi:10.1136
Coeliac disease (CD) can present with a wide range of non-specific abdominal symptoms, alongside a number of atypical symptoms. As a result, it is important to ensure that when CD is a considered as a potential diagnosis, patients are adequately investigated to avoid missed or delayed diagnosis. British Society of Gastroenterology (BSG) guidelines regarding the diagnosis and management of CD recommend taking a minimum of 4 duodenal biopsies, including one from the duodenal bulb, if CD is suspected.
Coeliac disease (CD) can present with a wide range of non-specific abdominal symptoms, alongside a number of atypical symptoms. As a result, it is important to ensure that when CD is a considered as a potential diagnosis, patients are adequately investigated to avoid missed or delayed diagnosis. British Society of Gastroenterology (BSG) guidelines regarding the diagnosis and management of CD recommend taking a minimum of 4 duodenal biopsies, including one from the duodenal bulb, if CD is suspected.
This retrospective audit and reaudit of current endoscopy practice in a UK general hospital trust was designed to assess compliance to BSG guidance and any changes in practice following the implementation of measures to improve compliance.
A list of all patients who had undergone endoscopic duodenal biospsies over a 10 month period (Aug 2014- May 2015) was retrieved. Data recorded included; patient age & sex, clinician performing the biopsy, indication for biopsy, number of biopsy samples, histopathology report and results of IgA anti-tTG antibody tests if performed. Results of this first part of the study were then presented at a local Endoscopy User Group Meeting in Nov 2015, an event attended by endoscopists and endoscopy nurses. Posters were also displayed in endoscopy units to summarise the results of the audit, raise awareness of the importance of complying with guidelines and encourage endoscopists to take an appropriate number of biopsies. A readuit of endoscopy practice (using the same methodology) was then conducted over a 3-month period (feb 2016-May 2016).
A total of 924 endoscopies with duodenal biopsies were included in the first part of the study. For the reaudit, 278 endoscopies with biopsy were included. These figures represented approximately one quarter of total endoscopies performed in the trust during the full study period. There was no significant difference between the 2 groups in terms of demographics or reason for biopsy. Indications for biopsy in the first and second cohort, respectively, included: anaemia (50.8% and 55.8%); suspected coeliac disease/ malabsorption (13% and 10.8%); epigastric pain/dyspepsia (11.7% and 10.8%); weight loss (10.5 and 11.5); diarrhoea (8.8% and 5.8% ); reflux (2.4% and 1.8%); others indications (2.9% and 3.6%). In the first part of the study, ≥4 biopsy specimens were collected in 21.9% of cases, this increased to 60.8% in the reaudit period (p=<0.001). Even when ‘suspected coeliac disease/ malabsorption’ was the indication for biopsy, only 39.2% of patients had ≥4 biopsies taken in the first study period, this rose to 60% in the reaudit (p=0.0039). A total of 32 patients (3.5%) were found to have CD in the first cohort, and 21 (7.6%) in the second, representing a significant increase in diagnostic yield. As would be expected and has been shown in pervious studies, the diagnostic yield of CD when ≥4 biopsies were taken was significantly higher than when <4 biopsies were taken. This difference was applicable across both study groups.
The results of this audit demonstrate poor adherence to established national recommendations in patients with no known diagnosis of CD, but in whom this diagnosis is being considered at endoscopy. Although compliance remained suboptimal in the reaudit, it was clear that simple interventional measures were successful in significantly improving compliance to guidance. This study also reiterated that taking ≥4 biopsy samples significantly improves the diagnostic yield for CD. The results of this study should prompt other centres to assess their practice.
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A list of all patients who had undergone endoscopic duodenal biospsies over a 10 month period (Aug 2014- May 2015) was retrieved. Data recorded included; patient age & sex, clinician performing the biopsy, indication for biopsy, number of biopsy samples, histopathology report and results of IgA anti-tTG antibody tests if performed. Results of this first part of the study were then presented at a local Endoscopy User Group Meeting in Nov 2015, an event attended by endoscopists and endoscopy nurses. Posters were also displayed in endoscopy units to summarise the results of the audit, raise awareness of the importance of complying with guidelines and encourage endoscopists to take an appropriate number of biopsies. A readuit of endoscopy practice (using the same methodology) was then conducted over a 3-month period (feb 2016-May 2016).
A total of 924 endoscopies with duodenal biopsies were included in the first part of the study. For the reaudit, 278 endoscopies with biopsy were included. These figures represented approximately one quarter of total endoscopies performed in the trust during the full study period. There was no significant difference between the 2 groups in terms of demographics or reason for biopsy. Indications for biopsy in the first and second cohort, respectively, included: anaemia (50.8% and 55.8%); suspected coeliac disease/ malabsorption (13% and 10.8%); epigastric pain/dyspepsia (11.7% and 10.8%); weight loss (10.5 and 11.5); diarrhoea (8.8% and 5.8% ); reflux (2.4% and 1.8%); others indications (2.9% and 3.6%). In the first part of the study, ≥4 biopsy specimens were collected in 21.9% of cases, this increased to 60.8% in the reaudit period (p=<0.001). Even when ‘suspected coeliac disease/ malabsorption’ was the indication for biopsy, only 39.2% of patients had ≥4 biopsies taken in the first study period, this rose to 60% in the reaudit (p=0.0039). A total of 32 patients (3.5%) were found to have CD in the first cohort, and 21 (7.6%) in the second, representing a significant increase in diagnostic yield. As would be expected and has been shown in pervious studies, the diagnostic yield of CD when ≥4 biopsies were taken was significantly higher than when <4 biopsies were taken. This difference was applicable across both study groups.
The results of this audit demonstrate poor adherence to established national recommendations in patients with no known diagnosis of CD, but in whom this diagnosis is being considered at endoscopy. Although compliance remained suboptimal in the reaudit, it was clear that simple interventional measures were successful in significantly improving compliance to guidance. This study also reiterated that taking ≥4 biopsy samples significantly improves the diagnostic yield for CD. The results of this study should prompt other centres to assess their practice.
Read the full study
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