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Routine duodenal biopsies: is it time to change our minds?

2004; Elsevier BV; Volume: 59; Issue: 2 Linguagem: Inglês

10.1016/s0016-5107(03)02146-1

1097-6779

Emilio Brocchi, Miriam Bonora, G. Epifanio, Paola Tomassetti, Guido Biasco, Roberto Corinaldesi,

Gastrointestinal disorders and treatments

To the Editor: We read with great interest the article by Hopper et al.1.Hopper A.D. Cross S.S. McAlindon M.E. Sanders D.S. Symptomatic giardiasis without diarrhea: further evidence to support the routine duodenal biopsy?.Gastrointest Endosc. 2003; 58: 120-122PubMed Google Scholar and the related editorial by Green and Murray2.Green P.H.R. Murray J.A. Routine duodenal biopsies to exclude celiac disease?.Gastrointest Endosc. 2003; 58: 92-95PubMed Scopus (41) Google Scholar dealing with the issue of routine duodenal biopsies at EGD irrespective of the specific indication for the examination. Because giardiasis can cause symptoms other than diarrhea,1.Hopper A.D. Cross S.S. McAlindon M.E. Sanders D.S. Symptomatic giardiasis without diarrhea: further evidence to support the routine duodenal biopsy?.Gastrointest Endosc. 2003; 58: 120-122PubMed Google Scholar and because of the high prevalence of celiac disease (CD) in the general population,2.Green P.H.R. Murray J.A. Routine duodenal biopsies to exclude celiac disease?.Gastrointest Endosc. 2003; 58: 92-95PubMed Scopus (41) Google Scholar these investigators strongly suggest that duodenal biopsies should be standard at upper endoscopy. We substantially agree with this view and wish to add several comments. Data are conflicting as to the true frequency of CD in unselected patients undergoing upper endoscopy. In studies from various countries, values range from one in 193.Dickey W. Hughes D. Prevalence of celiac disease and its endoscopic markers among patients having routine upper gastrointestinal endoscopy.Am J Gastroenterol. 1999; 8: 2182-2186Crossref Scopus (129) Google Scholar, 4.Ryan J. Case 5-2001: unsuspected celiac disease.N Engl J Med. 2001; 344 ([letter]): 1950-1951Crossref PubMed Scopus (3) Google Scholar to one in 235.Yassin K. Lachter J. Suissa A. Chermesh I. Eliachim R. Undiagnosed celiac disease in adults unmasked by endoscopy.Harefuah. 2003; 142 (79): 14-16PubMed Google Scholar to one in 866.Bardella M.T. Minoli G. Radaelli F. Quatrini M. Bianchi P.A. Conte D. Reevaluation of duodenal endoscopic markers in the diagnosis of celiac disease.Gastrointest Endosc. 2000; 51: 714-716Abstract Full Text Full Text PDF PubMed Google Scholar to one in 967.Voutilainen M. Juhola M. Farkkila M. Sipponen P. Gastric metaplasia and chronic inflammation at the duodenal bulb mucosa.Dig Liver Dis. 2003; 35: 94-98Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar patients, despite a similar prevalence of CD in the general populations of these countries (one in 130 to one in 200).8.Fasano A. Catassi C. Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum.Gastroenterology. 2001; 3: 636-651Abstract Full Text Full Text PDF Scopus (1063) Google Scholar The explanation for these discrepancies is unknown.9.Brocchi E. Bonora M. Epifanio G. Corinaldesi R. Hunting for celiac patients.Dig Liver Dis. 2003; ([in press])PubMed Google Scholar If the higher values for the proportion of patients with CD in an unselected population undergoing endoscopy are confirmed, this would reinforce the concept of routine duodenal biopsies. Because duodenal biopsy specimens were routinely obtained to rule out CD by Hopper et al.,1.Hopper A.D. Cross S.S. McAlindon M.E. Sanders D.S. Symptomatic giardiasis without diarrhea: further evidence to support the routine duodenal biopsy?.Gastrointest Endosc. 2003; 58: 120-122PubMed Google Scholar it would be interesting to know how often CD was found over the 3-year period of their study. This datum would make it possible to determine the cost-effectiveness of routine duodenal biopsies. It is clearly possible, however, that the yield of such biopsies would be high among patients undergoing upper endoscopy in some countries. With regard to giardiasis without diarrhea as described by Hopper et al.,1.Hopper A.D. Cross S.S. McAlindon M.E. Sanders D.S. Symptomatic giardiasis without diarrhea: further evidence to support the routine duodenal biopsy?.Gastrointest Endosc. 2003; 58: 120-122PubMed Google Scholar Walker and Ruhl10.Walker S. Ruhl U. 4199 biopsies from the endoscopic normal lower duodenum.Z Gastroenterol. 2003; 41: 69-74Crossref PubMed Scopus (5) Google Scholar also noted that only 6 of 22 patients with Giardia lamblia detected in endoscopic duodenal biopsy specimens had diarrhea. This is further support of the practice of obtaining duodenal biopsy specimens routinely. Giardiasis generally is more common in developing nations, but it is difficult to assess its true prevalence in developed countries because patients are often asymptomatic or have non-specific symptoms.11.Lebwohl B. Deckelbaum R.J. Green P.H. Giardiasis.Gastrointest Endosc. 2003; 57: 906-913Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar However, it is likely that the reported data probably represent an underestimate of the true prevalence. Nevertheless, it would be extremely difficult to determine the cost-effectiveness of routine duodenal biopsies for giardiasis. There are some relatively minor but important considerations with respect to processing of duodenal biopsy specimens. It is well recognized that orientation of the specimen on filter paper is essential for correct histopathologic assessment for CD.8.Fasano A. Catassi C. Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum.Gastroenterology. 2001; 3: 636-651Abstract Full Text Full Text PDF Scopus (1063) Google Scholar This should be done carefully in the endoscopy procedure room before placing biopsy specimens in fixative solution. Moreover, conventional staining with H&E may not highlight the trophozoites as clearly as Giemsa stain does.12.Oberhuber G. Kastner N. Stolte M. Giardiasis: a histologic analysis of 567 cases.Scand J Gastroenterol. 1997; 32: 48-51Crossref PubMed Scopus (173) Google Scholar Thus, both staining methods should be applied routinely, although pathologists may resist or dispute this point. Based on the work of Hopper et al.1.Hopper A.D. Cross S.S. McAlindon M.E. Sanders D.S. Symptomatic giardiasis without diarrhea: further evidence to support the routine duodenal biopsy?.Gastrointest Endosc. 2003; 58: 120-122PubMed Google Scholar and the observations of Green and Murray,2.Green P.H.R. Murray J.A. Routine duodenal biopsies to exclude celiac disease?.Gastrointest Endosc. 2003; 58: 92-95PubMed Scopus (41) Google Scholar perhaps it is time to change the traditional approach and consider duodenal biopsies as an integral part of standard upper endoscopy.