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