Introduction
Dyspepsia is a prevalent clinical syndrome with a broad differential diagnosis. Functional dyspepsia is the most frequent aetiology, followed by peptic ulcer disease, gastro-oesophageal reflux, and biliary disorders. Less commonly, it may be due to chronic pancreatitis, malignancy, or coeliac disease.
Coeliac disease may present with dyspepsia, malabsorptive diarrhoea, and weight loss. Laboratory findings often reveal protein malnutrition, iron deficiency, and occasional hypocalcaemia due to duodenal atrophy. Thus, excluding coeliac disease is essential when such features are present. Initial assessment should include serological testing and nutritional profiling.
In routine practice, due to celiac iceberg theory, there is a growing tendency to obtain duodenal biopsies during endoscopy for dyspepsia, regardless of macroscopic findings or clinical suspicion, aiming to rule out atrophic pathology.
Aims & Methods
We hypothesised that routine duodenal biopsies in dyspepsia without pathological signs or symptoms are inefficient, both clinically and economically.
We performed a retrospective, observational, descriptive study analysing 403 duodenal biopsies taken between January 2023 and January 2024. All cases had “dyspepsia” as the endoscopic indication and were requested by gastroenterologists.
We assessed histological and macroscopic duodenal atrophy, positivity for anti-transglutaminase (tTG) and anti-DGP antibodies, and clinical and laboratory features suggestive of coeliac disease. “Clinical suspicion” was defined as symptoms or abnormal tests; “serological suspicion” as antibody positivity. A high pre-test probability was defined as the presence of either.
Results
Mean age was 48.7 ± 15.9 years, with a female predominance (77.2%). Clinical features and laboratory findings suggesting coeliac disease are detailed in Table 1. Clinical suspicion was present in 31.5% of patients. Only one patient had both clinical and serological suspicion and was the sole case (1/403) with Marsh 3A changes in relation with coeliac disease.
Although serology is recommended in low pre-test probability cases, only 67.4% (271/403) underwent antibody testing; of these, 2.2% (6/271) were positive.
Three patients (0.007%) had endoscopic signs of atrophy. Nine biopsies showed non-specific lymphocytic infiltration (Marsh 1).
In 400 macroscopically normal duodenums, 127 patients (31.7%) had a high pre-test probability. The other 273 (68.3%) had no clinical suspicion yet underwent biopsy. At our centre, each biopsy costs about €50 and requires 30 minutes of staff time. Based on our data, €20,100 and over 25 labour working days could have been saved.
Finding | Yes | No | Not determined | Total |
Positive Antibodies (Anti-TG and/or Anti-DGP) | 6/271 (2.2%) | 265/271 (97.8%) | 132/403 (32.7%) |
|
Selective IgA deficiency | 7 (1.7%) | 199 (49.4%) | 197 (48.9%) | 403 |
Hypoalbuminaemia | 8 (2%) | 341 (84.6%) | 54 (13.4%) | 403 |
Hypoferritinemia | 58 (14.4%) | 301 (74.7%) | 44 (10.9%) | 403 |
Hypocalcemia | 14 (3.5%) | 333 (82.6%) | 56 (13.9%) | 403 |
Significant weight loss | 15 (3.7%) | 343 (85.1%) | 45 (11.1%) | 403 |
Chronic Diarrhoea | 53 (13.2%) | 308 (76.4%) | 42 (10.4%) | 403 |
Clinical OR Serological suspicion | 130 (32.3%) | 273 (67.7%) | - | 403 |
Clinical AND serological suspicion | 1 (0.004%) | 270 (99.6%) | - | 271 |
Table 1. Clinical and serological findings defining high pre-test probability of coeliac disease
Conclusion
Of 403 duodenal biopsies performed for dyspepsia, only one case of coeliac disease was detected. Routine biopsies in low pre-test probability patients appear not to be cost-effective. Notably, one third of patients underwent gastroscopy without prior antibody determination—highlighting the need to align clinical practice with diagnostic guidelines.
References
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