Routine Duodenal Biopsies in the Absence of Endoscopic Markers of Celiac Disease Are Not Useful: An Observational Study

Background. European studies have shown the utility of limiting endoscopic biopsies to diagnose celiac disease (CD) to patients that have high-risk symptoms or present with positive serology. However, many centers in the U.S. have open access endoscopy. Patients are referred without prior serologic testing, and endoscopists often decide whether or not to biopsy at the time of procedure. Aims. Evaluate the yield of duodenal biopsies for the diagnosis of CD in patients undergoing upper endoscopy without prior serologic testing. Methods. This retrospective study evaluated the frequency of CD diagnosis based duodenal biopsies. Researchers were interested in the yield of endoscopic stigmata findings in patients with high-risk symptoms versus low risk. Results. Eight hundred and ten patients met entry criteria at the Cleveland Clinic Florida between 2004 and 2008; 320 presented with high-risk symptoms; and 490 low risk. Sixty-one (7.5%) displayed endoscopic stigmata, and 10/61 (16.3%) were diagnosed with CD. Only patients who exhibited endoscopic stigmata were later diagnosed based on histologic findings. The presence of endoscopic stigmata greatly increased the probability of diagnosing CD, with a positive likelihood ratio of 15.6. Conclusions. When performing upper endoscopy without known serological markers for CD, clinicians should limit duodenal biopsies to patients with high-risk symptoms or endoscopic stigmata. 1. Introduction The diverse presentations of celiac disease (CD) often delay diagnosis. Although serological tests are reliable, endoscopic biopsies are essential in diagnosing the disease because they allow for direct observation of histologic abnormalities compatible with CD [1–6]. Therefore some centers encourage routine endoscopic biopsies in all patients with upper gastrointestinal symptomatology [7, 8]. One advantage of early diagnosis and treatment can be reduced medical costs. However, excessive biopsying of endoscopic patients can lead to unnecessary medical expenditures. Therefore developing stricter guidelines for biopsying to rule out CD may help reduce endoscopy costs and waste. Hopper et al. found that restricting duodenal biopsies to only patients that presented with high-risk symptoms of CD as defined by weight loss, anemia, diarrhea, or a positive immunoglobulin tissue transglutaminase antibody (IgA tTGA) serology would have successfully diagnosed all individuals who had the disease [8]. Our study examines the effectiveness of duodenal biopsying in patients with whom the presence of IgA tTGA, or other serologic markers, is