Sex and racial disparities in duodenal biopsy to evaluate for celiac disease

doi:10.1016/j.gie.2012.05.011

Gastrointestinal Endoscopy

Volume 76, Issue 4, October 2012, Pages 779-785

https://doi.org/10.1016/j.gie.2012.05.011 Get rights and content

Background

Celiac disease (CD) is common but underdiagnosed in the United States. Serological screening studies indicate that, although CD occurs at the same frequency in both sexes, women are diagnosed more frequently than men (2:1). CD is less frequently diagnosed among black patients, though the seroprevalence in this group is not known.

Objective

To measure the rates of duodenal biopsy during EGD for symptoms consistent with CD.

Design

Retrospective cohort study.

Setting

Clinical Outcomes Research Initiative National Endoscopy Database, spanning the years 2004 through 2009.

Patients

Adults undergoing EGD for the indication of diarrhea, anemia, iron deficiency, or weight loss, in which the endoscopic appearance of the upper GI tract was normal.

Main Outcome Measurement

Performance of duodenal biopsy.

Results

Of 13,091 individuals (58% female patients, 9% black patients) who met the inclusion criteria, duodenal biopsy was performed in 43%, 45% of female patients and 39% of male patients (P < .0001). Black patients underwent duodenal biopsy in 28% of EGDs performed compared with 44% for white patients (P < .0001). On multivariate analysis, male sex (odds ratio [OR] 0.81; 95% CI, 0.75-0.88), older age (OR for 70 years and older compared with 20-49 years, 0.51; 95% CI, 0.46-0.57), and black patients (OR 0.55; 95% CI, 0.48-0.64) were associated with decreased odds of duodenal biopsy.

Limitations

Lack of histopathologic correlation with CD prevalence.

Conclusions

In this multiregional endoscopy database spanning the period from 2004 through 2009, rates of duodenal biopsy increased modestly over time, but overall remained low in patients with possible clinical indications for biopsy. Nonperformance of duodenal biopsy during endoscopy may be contributing to the underdiagnosis of CD in the United States.

Section snippets

Methods

We performed a cross-sectional study of the CORI National Endoscopic Database. This database was established in 1995 with the goal of establishing a network of gastroenterologists to prospectively collect data related to endoscopy for clinical and research purposes.¹¹ Participating sites agree to use a structured computerized report generator to produce all endoscopic reports and comply with quality control requirements. The site's data files are transmitted electronically to a central data

Results

We identified 13,091 individuals who underwent EGD who met the inclusion criteria during this 6-year period (Table 1). The majority of patients (7576; 58%) were female, and 11,489 (88%) were white. The majority of examinations (8490; 66%) were performed in a community or health maintenance organization setting. Anemia was the most common indication for endoscopy (9074; 69%), followed by diarrhea (2039; 16%), weight loss (1601; 12%), and iron deficiency (377; 3%).

Duodenal biopsy was performed in

Discussion

In this analysis of a national endoscopy database encompassing a broad spectrum of endoscopy settings during the period 2004 through 2009, duodenal biopsy was performed in 43% of patients undergoing EGD for anemia, iron deficiency, diarrhea, or weight loss. Although the rate of biopsy increased over time, even in the last year of the analysis (2009), only 51% underwent duodenal biopsy. Older individuals, males, blacks, and Hispanics were less likely to undergo biopsy than younger individuals,

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Citation Excerpt :
A systematic review and meta-analysis found a slight increase in seropositivity among female participants in screening studies,10 although some studies of adults found that men and women have similar seroprevalences.11,12 Men are less likely to undergo duodenal biopsy examination during upper endoscopy for indications such as diarrhea and weight loss, which might contribute to underdiagnosis.13 The risk of celiac disease varies within countries.
The incidence of celiac disease is increasing, partly because of improved recognition of, and testing for, the disease. The rise in incidence is also due to a real increase of this immune-based disorder, independent of disease detection. The reasons for this true rise in recent decades are unknown but may be related to environmental factors that may promote loss of tolerance to dietary gluten. Strategies to reduce the development of celiac disease have not been proven successful in randomized trials, but the quantity of early-life gluten exposure has been a major focus of prevention efforts. The criteria for the diagnosis of celiac disease are changing, but in adults, diagnosis still depends on the presence of duodenal villous atrophy while the patient is on a gluten-containing diet, along with findings from serology analysis. Although guidelines in the United States continue to mandate a biopsy at all ages, some children receive a diagnosis of celiac disease without a biopsy. If proven accurate and scalable, assays that detect gluten–HLA tetramer complexes might be used in diagnosis to be made in the context of a gluten-free diet without intestinal biopsy.
AGA Technical Review on Gastrointestinal Evaluation of Iron Deficiency Anemia
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Delay in Diagnosis of Celiac Disease in Patients Without Gastrointestinal Complaints
2017, American Journal of Medicine
Citation Excerpt :
The decreased prevalence may partially be due to lack of evaluation. In a study by Lebwohl et al,26 rates of duodenal biopsies during esophagogastroduodenoscopy for classical symptoms of celiac disease were measured. They found African Americans and Hispanics were less likely to undergo duodenal biopsies.
The purpose of our study is to investigate the delay in diagnosis of patients with biopsy-proven celiac disease in those who present with gastrointestinal complaints vs nongastrointestinal complaints at our tertiary care center. Celiac disease is an autoimmune disorder that affects approximately 1% of the population worldwide. Celiac disease can have variable clinical presentations; it can be characterized by predominately gastrointestinal symptoms, or it may present without any gastrointestinal symptoms.
We retrospectively reviewed the charts of 687 adult patients who carried the diagnosis of celiac disease. Patients included had biopsy-proven celiac disease and were categorized based on presence or absence of gastrointestinal symptoms prior to their diagnosis.
There were 101 patients with biopsy-proven celiac disease that met inclusion criteria. Fifty-two patients presented with gastrointestinal symptoms and 49 had nongastrointestinal complaints. Results from Mann-Whitney statistical analysis showed a median delay in diagnosis of 2.3 months for the gastrointestinal symptoms group and 42 months for the nongastrointestinal group (P <.001); 43.2% of patients with nongastrointestinal symptoms had abnormal thyroid-stimulating hormone, as opposed to 15.5% in the gastrointestinal symptom group (P = .004). Of patients with nongastrointestinal symptoms, 69.4% had anemia, compared with 11.5% of the gastrointestinal symptom group (P <.001). The majority of patients in the nongastrointestinal symptom group, 68%, were noted to have abnormal bone density scans, compared with 41% in the gastrointestinal symptom group. No sex differences were noted on chi-squared analysis between the 2 groups (P = .997).
Although there is growing awareness of celiac disease, the delay in diagnosis for patients without gastrointestinal symptoms remains prolonged, with an average delay of 3.5 years.
Analysis of Biopsies From Duodenal Bulbs of All Endoscopy Patients Increases Detection of Abnormalities but has a Minimal Effect on Diagnosis of Celiac Disease
2016, Clinical Gastroenterology and Hepatology
In patients with positive results from serologic tests for celiac disease, analysis of tissues samples from the duodenal bulb, in addition to those from other parts of the small bowel, might increase the diagnostic yield. However, biopsies are not routinely collected from the duodenal bulb because of concerns that villous atrophy detected there could be caused by other disorders (Brunner glands or peptic duodenitis, gastric metaplasia, shorter villi, or lymphoid follicles). We investigated whether analysis of biopsies from duodenal bulbs of all patients undergoing endoscopy (a population with a low probability for celiac disease) increases diagnoses of celiac disease.
We performed a retrospective analysis of data from 679 patients (63% female; mean age, 50 years) from whom duodenal bulb and small bowel biopsies were collected during endoscopy at 3 Mayo Clinic sites, from January 1, 2011 through December 31, 2011. Records were reviewed for age, sex, pathology findings, serology test results (HLA DQ2 or DQ), indications for biopsy analyses, and adherence to a gluten-free diet. Patients with celiac disease were identified on the basis of increased intraepithelial lymphocytosis, with or without villous atrophy and crypt hyperplasia, and results from serology tests. Findings from duodenal bulbs were compared with diagnoses using the Fisher exact test.
Of all patients undergoing endoscopy, 16 patients (2%) were found to have celiac disease. Analysis of the duodenal bulb biopsies identified 1 patient (0.1%) with celiac disease limited to this region. Of 399 patients whose celiac serology was not known before endoscopic examination, only 2 patients had histologic changes consistent with celiac disease but not limited to duodenal bulb. Abnormal duodenal histology was detected in 265 patients (39%), most commonly in the bulb (n = 241; P < .0001). Of abnormal bulb histologies, chronic peptic duodenitis was most common (observed in 114 patients, 47%). In patients with a normal distal duodenum (n = 576), the duodenal bulb had abnormal histology in 162 (28%).
In a low pretest probability cohort, separate sampling of the duodenal bulb had minimal effect on celiac disease detection. Abnormal histologic findings are more commonly detected in the duodenal bulb; although they do not seem to impair identification of celiac disease, their clinical implications are unclear.

View all citing articles on Scopus

: DISCLOSURE: The following author disclosed a financial relationship relevant to this publication: Dr Lieberman is the executive director of the Clinical Outcomes Research Initiative, a nonprofit organization that receives funding from federal and industry sources. This potential conflict of interest has been reviewed and managed by the OHSU and Portland VA Conflict of Interest in Research Committees. The other authors disclosed no financial relationships relevant to this publication. Dr. Lebwohl has received funding from the National Center for Research Resources, a component of the National Institutes of Health (KL2 RR024157). Dr Lieberman has been funded by NIH grant NIDDK U01DK57132. The practice network (Clinical Outcomes Research Initiative) has received support from the following entities to support the infrastructure of the practice-based network: AstraZeneca, Novartis, Bard International, Pentax USA, ProVation, Endosoft, GIVEN Imaging, and Ethicon. The commercial entities had no involvement in this research.

: If you would like to chat with an author of this article, you may contact Dr Lebwohl at [email protected].

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Original articleClinical endoscopySex and racial disparities in duodenal biopsy to evaluate for celiac disease

Background

Objective

Design

Setting

Patients

Main Outcome Measurement

Results

Limitations

Conclusions

Section snippets

Methods

Results

Discussion

Gastroenterology

Am J Med

Clin Gastroenterol Hepatol

Gastrointest Endosc

Am J Gastroenterol

Am J Gastroenterol

Am J Gastroenterol

Am J Gastroenterol

Gastroenterology

Gastroenterology

Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study

Arch Intern Med

Celiac disease

N Engl J Med

Small-intestinal histopathology and mortality risk in celiac disease

JAMA

Incidence and prevalence of diagnosed coeliac disease in Finland: results of effective case finding in adults

Scand J Gastroenterol

The coeliac iceberg in ItalyA multicentre antigliadin antibodies screening for coeliac disease in school-age subjects

Acta Paediatr Suppl

Variation in small bowel biopsy performance among diverse endoscopy settings: results from a national endoscopic database

Am J Gastroenterol

Clinical Outcomes Research Initiative

Original article
Clinical endoscopy
Sex and racial disparities in duodenal biopsy to evaluate for celiac disease