Alimentary Tract
The diagnostic value of the duodenal biopsy: A clinico-pathologic analysis of 28,000 patients

https://doi.org/10.1016/j.dld.2009.11.010Get rights and content

Abstract

Background

Duodenal biopsies are frequently obtained to investigate malabsorption, diarrhoea, and aneamia. The proportion of patients who have duodenal biopsies and their diagnostic yield are unclear.

Aims

To determine what proportion of patients undergoing esophagogastroduodenoscopy in a private setting has duodenal biopsies and to evaluate the diagnostic yield relative to clinical indications and endoscopic findings.

Methods

Records of patients who had duodenal biopsies diagnosed at a United States gastrointestinal pathology laboratory in a single year were analysed.

Results

28,210 patients with and 75,175 without duodenal biopsies were studied. Duodenal biopsy patients were younger (52 years versus 58 years, p < 0.001) and more likely to be female (OR 1.46; p < 0.0001); 87% of children and 27% of adults had duodenal biopsies. Suspicion of malabsorption or sprue, diarrhoea, aneamia, and weight loss were strong predictors of duodenal biopsy. More than 80% of patients had normal duodenum, except those biopsied for sprue, 64% of whom had normal findings. Marsh II–IIIc lesions were diagnosed in 23% of patients with suspected sprue, but in 3.0% of those with diarrhoea, weight loss, or aneamia, and in 1.5% of patients with dyspepsia or GERD.

Conclusions

A clinical suspicion of sprue produces the highest yield of histopathologic abnormalities; women are biopsied more often than men despite having less duodenal pathology.

Introduction

Mucosal biopsies of the gastrointestinal tract are obtained during endoscopic procedures for a wide variety of reasons. Whereas some clinicians subscribe to the notion that an endoscopic procedure without biopsies, irrespective of the macroscopic findings, is an incomplete one [1], [2], others target their biopsies to address each patient's signs and symptoms. One of the most common indications for obtaining duodenal biopsies is believed to be the suspicion of celiac sprue as a cause of malabsorption, bloating, diarrhoea, and aneamia. Therefore, most studies designed to evaluate the scope of duodenal biopsies have focused on their sensitivity and specificity for the diagnosis of celiac disease [3], [4], [5], [6], [7], [8]. However, the proportion of patients who have duodenal biopsies during esophagogastroduodenoscopy (EGD) remains unknown; furthermore, we are aware of only one study that has evaluated the diagnostic yield of such biopsies and the potential impact of the resulting histopathologic diagnoses on the patient's management [9]. The answers to these questions are unlike to be found in single-centre studies, in which results may be biased by local expertise, individual clinical interests, and financial considerations. Such studies are also likely to include limited numbers of subjects, unless they span retrospectively over long periods of time. When they do, changing practice guidelines, evolving management strategies, and operator and pathologist turn-over can cause remarkable shifts in the results during the course of the study.

To evaluate the current status of the duodenal biopsy in private gastroenterology practice in the United States, we have carried out a nation-wide study of more than 100,000 patients who underwent EGDs over the course of a single 12-month period. The goals of this study were to determine what subsets of patients undergoing EGD in a private setting have a duodenal biopsy, and why. We also sought to assess the diagnostic yield of the biopsies with respect to the clinical indications and the endoscopic findings.

Section snippets

Study setting

This study was conducted at Caris Diagnostics, a specialised gastrointestinal laboratory receiving specimens from gastroenterologists operating in private outpatient endoscopy centres in 34 states, the District of Columbia, and Puerto Rico. Biopsies are interpreted by an experienced group of gastrointestinal pathologists who share a common approach to biopsy evaluation and have achieved a high level of diagnostic uniformity through a pre-determined approach to specimen handling, diagnostic

Duodenal biopsies

During the study period 103,385 unique patients, including 1099 children 17 years of age or younger, underwent an EGD with at least one biopsy specimen from esophagus, stomach, or duodenum. Duodenal biopsies were obtained from 28,210 of these patients, including 958 children (3.4%); the median age was 52 years, range 0–95; and 65.5% were female. Of the 75,175 patients (including 141 children, or 0.2%) who had biopsies from other organs of the upper gastrointestinal tract but did not have a

Discussion

Data analysed for this study were derived from a pathology database, which by its very nature includes only patients who had at least one biopsy specimen. Therefore, we have no information about those patients who, during the same period, had EGDs without biopsies at the same centres. Nevertheless, existing data suggest that a reasonable estimate can be made. In a 2000 CORI study of 6788 EGDs performed in 37 private practices distributed throughout the country [14], biopsies were obtained in

Conflict of interest statement

Dr. Robert Genta is an employee of Caris Diagnostics, Irving, TX. No conflicts of interest relevant to this manuscript are declared. This manuscript was written entirely by the authors, with no external assistance. No grant support was received for this study.

References (19)

There are more references available in the full text version of this article.

Cited by (18)

  • AGA Technical Review on Gastrointestinal Evaluation of Iron Deficiency Anemia

    2020, Gastroenterology
    Citation Excerpt :

    The pooled diagnostic yield of random duodenal biopsies to assess for celiac sprue-like histologic changes in patients with IDA in the United States was low at 1.15% (95% CI, 0.89%–1.44%). The studies included data from 7993 patients and certainty of evidence was very low due to increased risk of bias (mainly selection bias) and serious imprecision16–18,76,99–105 (Figure 7). We identified a systematic review conducted by the Southern California Evidence–based Practice Center, which assessed the diagnostic accuracy of serologic testing for celiac disease.106

  • Chronic Diarrhea: Diagnosis and Management

    2017, Clinical Gastroenterology and Hepatology
    Citation Excerpt :

    In a large study evaluating the diagnostic value of duodenal biopsies, there was a significant finding in 8.6% of patients with diarrhea,62 all related to the spectrum of CD. For patients with suspected or confirmed sprue, the yield of small bowel biopsies was even higher, with intraepithelial lymphocytosis in 8.9%, variable villous atrophy in 11.2%, and overt sprue in 12%.62 Endoscopic signs such as scalloping and furrowing have been linked to CD but are neither sensitive nor specific.62

  • Increased Risk of Esophageal Eosinophilia and Eosinophilic Esophagitis in Patients With Active Celiac Disease on Biopsy

    2015, Clinical Gastroenterology and Hepatology
    Citation Excerpt :

    Pathologic findings for these lesions included villous atrophy (3a, partial; 3b, subtotal villous atrophy, 3c, total villous atrophy or flat mucosa), with concurrent increase in the ratio of intraepithelial lymphocytes to enterocytes, with >40 intraepithelial lymphocytes/100 enterocytes.28,29 Although less advanced Marsh scores can represent subtler histologic forms of celiac disease, because of the lower specificity of these lesions for celiac disease, only Marsh class 3 was included in our case definition, as has been described previously in this dataset.30–32 Clinical characteristics of patients were identified on the basis of upper gastrointestinal symptoms or conditions that were noted as the indication for endoscopy (ie, suspected EoE, dysphagia symptoms, reflux symptoms, or gastroesophageal reflux disease [defined as a report of heartburn, regurgitation, or reflux], suspected celiac disease, nausea and/or vomiting, weight loss or failure to thrive, diarrhea, abdominal pain or dyspepsia, chest pain, and screening or follow-up of a known diagnosis of Barrett's esophagus).

View all citing articles on Scopus
View full text