Prior Endoscopy in Patients with Newly Diagnosed Celiac Disease: A Missed Opportunity?

Abstract

Background Celiac disease (CD) is under-diagnosed in the United States, and factors related to the performance of endoscopy may be contributory. Aims to identify newly diagnosed patients with CD who had undergone a prior esophagogastroduodenoscopy (EGD) and examine factors contributing to the missed diagnosis. Methods We identified all patients age ≥18 years whose diagnosis of CD was made by endoscopy with biopsy at our institution (n=316), and searched the medical record for a prior EGD. We compared those patients with a prior EGD to those with without a prior EGD with regard to age at diagnosis and gender, and enumerated the indications for EGD. Results Of the 316 patients diagnosed by EGD with biopsy at our center, 17 (5%) had previously undergone EGD. During the prior non-diagnostic EGD, a duodenal biopsy was not performed in 59% of the patients, and ≥4 specimens (the recommended number) were submitted in only 29% of the patients. On the diagnostic EGD, ≥4 specimens were submitted in 94%. The mean age of diagnosis of those with missed/incident CD was 53.1 years, slightly older than those diagnosed with CD on their first EGD (46.8 years, p=0.11). Both groups were predominantly female (missed/incident CD: 65% vs. 66%, p=0.94). Conclusions Among 17 CD patients who had previously undergone a non-diagnostic EGD, nonperformance of duodenal biopsy during the prior EGD was the dominant feature. Routine performance of duodenal biopsy during EGD for the indications of dyspepsia and reflux may improve CD diagnosis rates.

Clinical and Immunologic Features of Ultra-Short Celiac Disease

“…investigations that can be associated with a missed celiac diagnosis. 7 Furthermore it may also reduce the potential for long term sequelae of celiac disease such as lymphoma or osteoporosis. However, further long term follow up studies of patients with USCD are required to truly assess the long term implications of diagnosis.…”

“…5,6 Furthermore 5-13.6% of patients with newly diagnosed celiac disease have had a prior endoscopy where the chance to diagnose celiac disease was missed. 5,7 In many patients no consideration was given to duodenal biopsy however 41% of patients in a recent US study had a non-diagnostic duodenal biopsy. 7 Historically small bowel biopsies were taken from the jejunum with a Crosby capsule to diagnose celiac disease.…”

“…5,7 In many patients no consideration was given to duodenal biopsy however 41% of patients in a recent US study had a non-diagnostic duodenal biopsy. 7 Historically small bowel biopsies were taken from the jejunum with a Crosby capsule to diagnose celiac disease. 8 However with the advent of fibre-optic endoscopy biopsies from the distal duodenum were shown to be as accurate as jejunal biopsies for recognising celiac disease.…”

Celiac Disease: Clinch the Diagnosis When It Is Just Around the Corner

“…With a high index of suspicion, the liberal use of serologic screening tests in at-risk groups, and routine small intestinal biopsy during esophagogastroduodenoscopy (EGD), are feasible. Nevertheless, in this issue, Lebwohl et al [5] describe 17 cases in whom the diagnosis of celiac disease was delayed because no small intestinal biopsy was available, or it was reported as normal, prolonging disease in many patients. Almost all of these patients were symptomatic with complaints often suggestive of the presence of celiac disease.…”

“…Lebwohl et al [5] recommend considering small intestinal biopsy in individuals suffering from dyspepsia or reflux. Malabsorptive anemia, weight loss, and diarrhea are even more compelling indications.…”