Duodenal biopsies for the diagnosis of celiac disease: are we adhering to current guidance?
Husnoo N, Ahmed W, Shiwani H. BMJ Open Gastro 2017;4:e000140. Doi:10.1136
Celiac 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 considered as a potential diagnosis, patients are adequately tested 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.
Celiac 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 considered as a potential diagnosis, patients are adequately tested 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 re-audit of current endoscopy practice 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 biopsies over a 10-month period (Aug 2014--May 2015) was retrieved. Data recorded included: patient age and gender, 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 summarize 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 re-audit 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 was included in the first part of the study. For the re-audit, 278 endoscopies with biopsy were included. These figures represented approximately one quarter of total endoscopies performed during the full study period. There was no significant difference between the 2 groups in terms of demographics. Indications for biopsy in the first and second cohort, respectively, included: anemia (50.8% and 55.8%); suspected celiac disease/malabsorption (13% and 10.8%); epigastric pain/dyspepsia (11.7% and 10.8%); weight loss (10.5 and 11.5); diarrhea (8.8% and 5.8%); GERD (2.4% and 1.8%); other 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 re-audit period (p=<0.001). Even when ‘suspected celiac 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 re-audit (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 previous studies, the diagnostic yield of CD when ≥4 biopsies were taken was significantly higher than when <4 biopsies were taken.
A list of all patients who had undergone endoscopic duodenal biopsies over a 10-month period (Aug 2014--May 2015) was retrieved. Data recorded included: patient age and gender, 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 summarize 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 re-audit 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 was included in the first part of the study. For the re-audit, 278 endoscopies with biopsy were included. These figures represented approximately one quarter of total endoscopies performed during the full study period. There was no significant difference between the 2 groups in terms of demographics. Indications for biopsy in the first and second cohort, respectively, included: anemia (50.8% and 55.8%); suspected celiac disease/malabsorption (13% and 10.8%); epigastric pain/dyspepsia (11.7% and 10.8%); weight loss (10.5 and 11.5); diarrhea (8.8% and 5.8%); GERD (2.4% and 1.8%); other 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 re-audit period (p=<0.001). Even when ‘suspected celiac 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 re-audit (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 previous studies, the diagnostic yield of CD when ≥4 biopsies were taken was significantly higher than when <4 biopsies were taken.
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