Introduction BSG guidelines for the investigation of iron deficiency anaemia (2011)1 recommend screening of these patients for coeliac disease (CD) by serology. Small bowel biopsy is recommended at OGD if coeliac serology is positive or not available. If coeliac serology is negative, small bowel biopsies need not be performed at OGD unless there is a high degree of suspicion for CD despite negative serology.
Methods We retrospectively evaluated the use of coeliac serology testing (tissue transglutaminase antibody, tTG) and upper gastrointestinal endoscopy (OGD) with duodenal biopsies in the evaluation of anaemia, according to BSG guidelines in our NW London teaching hospital cohort. All upper GI endoscopies performed for anaemia over a 6-month period were reviewed for rates of duodenal biopsy and results, and serological testing.
Results In 6 months, 206 OGDs were performed for anaemia. Duodenal biopsies were taken in 134/206 (65%). Of 72 (35%) procedures at which no duodenal biopsy was taken, another cause for anaemia found on OGD in 27, six had melaena or acutely falling haemoglobin as an indication for OGD, six had previous duodenal biopsies, and the procedure could not be completed in nine cases. Five patients with no duodenal biopsy taken at endoscopy had negative coeliac serology prior to OGD. 19/206 (9.2%) patients did not have duodenal biopsies taken at endoscopy, despite an indication for biopsy. 48/206 (23.3%) patients referred for an OGD with anaemia had coeliac serology performed (34 prior to OGD and 14 after OGD). All results were negative. 3/134 duodenal biopsies showed features suggestive of CD (tTG negative) and 11/134 (8.2%) duodenal biopsies showed lymphocytic duodenosis (LD) (normal villous architecture and increased intraepithelial lymphocytes >25/100 enterocytes) (5/11 tTG sent and negative, 6/11 not done).
Conclusion Coeliac disease is a major cause of iron deficiency anaemia in the UK. Tissue transglutaminase antibody is a simple, non-invasive test, which was underused in our cohort. It was performed prior to upper GI endoscopy in only 16.5% of patients. Duodenal biopsies were taken in the majority of cases when indicated in anaemia, though there is room for improvement. While 10.4% had biopsies suggestive of CD, serology to confirm this was only performed in 57.1%.
Competing interests None declared.
Reference 1. Goddard AF, James MW, McIntyre AS, et al. Guidelines for the management of iron deficiency anaemia (BSG). Gut 2011;60:1309–16.