Introduction The prevalence of iron deficiency anaemia (IDA) in adult men and postmenopausal women in the developed world is 2–5%.1British Society of Gastroenterology (BSG) IDA Guidelines recommend tissue transglutaminase (tTG) antibody as a screening test for coeliac disease. Indications for duodenal biopsies include patients with diarrhoea, weight loss and positive tTG serology. Where coeliac serology is positive, duodenal bulb and D2 biopsies should be taken.2 BSG IDA Guidelines do not recommend duodenal biopsy for tTG negative, asymptomatic patients.3However a separate BSG guideline for diagnosis of coeliac disease recommends duodenal biopsies in IDA patients irrespective of Coeliac serology due to the finding of seronegative coeliac disease.2
Method This audit was carried out to assess adherence to BSG IDA Guidelines for duodenal biopsies in patients referred for IDA investigation with negative tTG antibodies. The study also set out to establish the positive diagnostic yield where biopsies were taken in the same cohort. Patients referred to Newcastle upon Tyne NHSFT adult IDA service between 2011 and 2014 identified as ttG negative and who underwent endoscopy were included.
Results Two hundred patients were identified, median age 66 (range 19–91); 126 (63%) female and 74 (37%) Male. 114 (57%) patients had duodenal biopsies taken despite tTG being negative and asymptomatic. 28 (19.7%) patients were symptomatic and duodenal biopsies taken, though only 8 (28%) of these patients had 4 biopsy samples and none were from duodenal bulb. Where biopsies were taken, none confirmed coeliac disease. 5/142 (3.5%) patients biopsied had lymphocytic duodenitis but none of them were subsequently diagnosed or treated as coeliac disease.
Conclusion Duodenal sampling in tTG negative patients did not yield any additional positive diagnosis of coeliac disease. This confirms the recommendations of BSG IDA guidelines. The results of this audit do not appear to support the recommendations made within the BSG coeliac disease guideline for duodenal biopsy being performed regardless of coeliac serology. However, the fact that only 4.9% of patients who had duodenal biopsies taken had duodenal bulb sampled, may limit this conclusion. More efficient use of local endsoscopy and pathology resources can occur by appropriate selection of patients on whom to perform duodenal biopsies.
Disclosure of interest None Declared.
Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anaemia. Blood 2004;104:2263e8
Diagnosis and management of adult coeliac disease: Guidelines from British Society of Gastroenterology June10, 2014(10.1136/gutjnl-2013-306578)
BSG Guidelines for the management of Iron deficiency anaemia May 2011