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

Abstract

Background Celiac disease (CD) is common but under-diagnosed in the United States. Serological screening studies indicate that, although CD occurs at the same frequency in both genders, 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 esophagogastroeduodenoscopy (EGD) for symptoms consistent with CD. Design Retrospective cohort study. Setting Clinical Outcomes Research Initiative National Endoscopy Database, spanning the years 2004–2009. Patients Adults undergoing EGD for the indication of diarrhea, anemia, iron deficiency, or weight loss, in which the endoscopic appearance of the upper gastrointestinal tract was normal. Main outcome measurement performance of duodenal biopsy. Results Of 13,091 individuals (58% females, 9% blacks) who met the inclusion criteria, duodenal biopsy was performed in 43%, 45% of females and 39% of males (p<0.0001). Blacks underwent duodenal biopsy in 28% of EGD’s, compared to 44% for whites (p<0.0001). On multivariate analysis, male gender (OR 0.81 95%CI 0.75–0.88), older age (OR for ≥70 compared to 20–49 0.51 95%CI 0.46–0.57), and black race (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 multi-region endoscopy database spanning 2004–2009, rates of duodenal biopsy increased modestly over time, but overall remain low in patients with possible clinical indications for biopsy. Non-performance of duodenal biopsy during endoscopy may be contributing to the under-diagnosis of CD in the United States.

393 Prior Endoscopy in Patients With Newly Diagnosed Celiac Disease; a Missed Opportunity

“…But these data show that it is possible for CD patients to undergo multiple encounters with healthcare providers, including gastroenterologists, and undergo invasive testing including endoscopy and biopsy, while still eluding a CD diagnosis. Our observations are not unexpected because previous studies of large national databases have shown that patients undergoing EGD with symptoms compatible with CD often do not undergo duodenal biopsy, 8 and that the majority of patients who have a duodenal biopsy do not have the recommended number of specimens submitted. 9 Most of these patients with missed/incident CD had a clinical indication for dyspepsia or esophageal reflux during their prior EGD.…”

Celiac disease diagnosis still significantly delayed – Doctor's but not patients’ delay responsive for the increased total delay in women

“…In view of these facts, diagnosis of or confusion with IBS at best partially explains the longer diagnostic delay in women. Diagnostic awareness of CeD in physicians performing upper gastrointestinal endoscopy does not seem to be lower for women, since duodenal biopsies were significantly less often obtained in men then in women [22]. One might thus speculate, that the discrepancy according to gender is related to the initiation of a proper evaluation and diagnostic testing in response to reported symptoms rather than specific testing for CeD once a medical evaluation has been initiated.…”

Prediction of celiac disease at endoscopy

“…Some patients have undergone EGD in the 5 years preceding their diagnosis without having duodenal biopsies [23]. Hence, the number of patients who undergo biopsies is still insufficient, leading to missed cases and a delay in the diagnosis [24]. The current study used parallel biopsy, serology, and prospective collection of potential risk factors in a cross-sectional sample of patients presenting for EGD to determine 1) the reliability of standard clinical judgement, 2) endoscopic findings, and 3) serologic testing to diagnose celiac disease (confirmed by positive histological evidence).…”