Introduction Coeliac disease (CD) is a common autoimmune condition affecting 1% of the adult population. However large numbers of patients remain undiagnosed which may have significant health consequences. Guidelines suggest that at least 4 duodenal biopsies should be taken to rule out CD. A previous US study showed that biopsy guidelines were only followed in 35% of cases. The aim of the present study was to see whether guidelines were being followed in the UK and if adherence to the guidelines improved detection of CD.
Methods Endoscopy and histology reports were retrospectively reviewed for all patients who had a duodenal biopsy in a 3 month period between November 2012 and January 2013 from 4 UK hospitals. Indications for biopsy, role of the endoscopist, number of duodenal biopsies received by histopathology and the final diagnosis were recorded. The presence of villous atrophy was required for CD diagnosis. Patients were excluded if they had known CD. The difference between a double and single bite biopsy technique was also assessed.
Results 1423 patients underwent duodenal biopsy for possible CD across the 4 sites in the study period. 97 (6.8%) of these were diagnosed with CD. Guidelines to take at least 4 biopsies were met in 40% of patients and the median number of duodenal biopsies taken for all patients was 3. CD diagnosis was more likely guidelines were followed (10.1 vs. 4.6% p < 0.0001). The median number of biopsies was greater in patients diagnosed with CD (4 vs. 3) p < 0.0001. Gastroenterologists and nurse endoscopists were more likely than surgeons to follow guidelines (41.8% vs 51.2% vs 18.2% p < 0.0001) and took a higher median number of biopsies (3 vs. 4 vs. 2 p < 0.0001). As a result gastroenterologists and nurse endoscopists made a diagnosis of CD in more cases than surgeons (7.1 vs. 6.7% vs. 3.0% p 0.1). All presenting characteristics (other than positive serology in which guidelines were followed in 65%) were associated with poor adherence to guidelines. 12.4% of newly diagnosed CD patients had at least 1 non-diagnostic gastroscopy in the 5 years prior to diagnosis. Changing biopsy technique to single bites resulted in improvement of median D2 biopsies from 3 to 4. (p 0.02).
Conclusion We have shown that 12.4% of patients with CD had a previous gastroscopy 5 years prior to their diagnosis. Taking 4 duodenal biopsies results in increased detection of CD. We are the first investigators to demonstrate variation in biopsy rates based on the speciality of the endoscopist and biopsy technique. Furthermore this variability has a direct relationship with the detection rate of CD. Education of all groups of clinicians in duodenal biopsy techniques may result in more patients receiving a prompt diagnosis of CD.
Disclosure of Interest None Declared.