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Limited utilization of serologic testing in patients undergoing duodenal biopsy for celiac disease.

Wiland HO, Henricks WH, Daly TM - BMC Gastroenterol (2013)

Bottom Line: The objective of this study was to determine the underlying causes for this low diagnostic yield.The majority of patients had no record of serologic testing prior to biopsy, and evidence of positive serology results was found in only 5% of patients.In patients where celiac serology testing was performed, the results were a good predictor of the likelihood of findings on biopsy.

View Article: PubMed Central - HTML - PubMed

Affiliation: Robert J, Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Clinical Pathology, LL3-3, 9500 Euclid Avenue, 44195 Cleveland, OH, USA. dalyt@ccf.org.

ABSTRACT

Background: Clinical algorithms for the workup of celiac disease often recommend the use of serologic assays for initial screening, followed by duodenal biopsy for histologic confirmation. However, the majority of duodenal biopsies submitted to pathology for "rule out celiac" are negative. The objective of this study was to determine the underlying causes for this low diagnostic yield.

Methods: We performed a retrospective review of pathology reports from 1432 consecutive duodenal biopsies submitted for pathologic assessment to "rule out celiac" and correlated biopsy results with results for concurrent serologic testing for celiac autoantibodies.

Results: The majority of patients had no record of serologic testing prior to biopsy, and evidence of positive serology results was found in only 5% of patients. Most duodenal biopsies were submitted as part of a multi-site GI sampling strategy that included biopsies from other locations. In this context, serologic results correlated with the likelihood of significant duodenal and non-duodenal findings, and were also helpful in evaluating patients with indeterminate duodenal histology.

Conclusions: The presence of a positive screening test for celiac autoantibodies does not appear to be a major driver in the decision to submit duodenal biopsies for evaluation of celiac disease, which accounts for the low incidence of findings in these samples. In patients where celiac serology testing was performed, the results were a good predictor of the likelihood of findings on biopsy.

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Flow chart of data analysis. Initial EMR searches for pathology reports and serology results were performed using the criteria described in methods. Serology totals include patients with either pre- or post-biopsy testing.
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Figure 1: Flow chart of data analysis. Initial EMR searches for pathology reports and serology results were performed using the criteria described in methods. Serology totals include patients with either pre- or post-biopsy testing.

Mentions: An automated query was run on the pathology laboratory information system (CoPath, Cerner Corp, Waltham MA) to identify any biopsy submissions that contained the words “celiac”, “gluten”, or “sprue” in the clinical data field (which is the field completed by the ordering physician to describe the reason for the submission). Case finding and subsequent chart review were performed following protocol approval by the institutional review board of the Cleveland Clinic Foundation. All biopsy specimens were initially reviewed and signed out by one of twelve pathology staff members belonging to the subspecialty gastrointestinal pathology group at the Cleveland Clinic, each of whom has fellowship training in gastrointestinal pathology or extensive experience in the field. Only samples with adequate material for a final report to be issued were included in the analysis. 1465 unique patients were identified during the 6 month period covered by the study (Figure 1). A manual review of reports eliminated 33 patients without duodenal biopsies, leaving 1432 for final review. Gender ratio of this cohort was 34:66 M:F, with a median age of 45 (IQR 24–61). Histologic findings as reported by the gastrointestinal pathologist who signed out the original specimen were classified into one of four categories; villous atrophy consistent with celiac disease (CD), intact villous architecture with increased intraepithelial lymphocytes (IVA-IEL) [20,21], normal duodenum, or other findings. Samples were not classified in a graded system (such as the Marsh score). Additionally, we examined reports to determine if biopsies were simultaneously submitted from sites other than the duodenum, and what additional findings were present in those sites.


Limited utilization of serologic testing in patients undergoing duodenal biopsy for celiac disease.

Wiland HO, Henricks WH, Daly TM - BMC Gastroenterol (2013)

Flow chart of data analysis. Initial EMR searches for pathology reports and serology results were performed using the criteria described in methods. Serology totals include patients with either pre- or post-biopsy testing.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4225746&req=5

Figure 1: Flow chart of data analysis. Initial EMR searches for pathology reports and serology results were performed using the criteria described in methods. Serology totals include patients with either pre- or post-biopsy testing.
Mentions: An automated query was run on the pathology laboratory information system (CoPath, Cerner Corp, Waltham MA) to identify any biopsy submissions that contained the words “celiac”, “gluten”, or “sprue” in the clinical data field (which is the field completed by the ordering physician to describe the reason for the submission). Case finding and subsequent chart review were performed following protocol approval by the institutional review board of the Cleveland Clinic Foundation. All biopsy specimens were initially reviewed and signed out by one of twelve pathology staff members belonging to the subspecialty gastrointestinal pathology group at the Cleveland Clinic, each of whom has fellowship training in gastrointestinal pathology or extensive experience in the field. Only samples with adequate material for a final report to be issued were included in the analysis. 1465 unique patients were identified during the 6 month period covered by the study (Figure 1). A manual review of reports eliminated 33 patients without duodenal biopsies, leaving 1432 for final review. Gender ratio of this cohort was 34:66 M:F, with a median age of 45 (IQR 24–61). Histologic findings as reported by the gastrointestinal pathologist who signed out the original specimen were classified into one of four categories; villous atrophy consistent with celiac disease (CD), intact villous architecture with increased intraepithelial lymphocytes (IVA-IEL) [20,21], normal duodenum, or other findings. Samples were not classified in a graded system (such as the Marsh score). Additionally, we examined reports to determine if biopsies were simultaneously submitted from sites other than the duodenum, and what additional findings were present in those sites.

Bottom Line: The objective of this study was to determine the underlying causes for this low diagnostic yield.The majority of patients had no record of serologic testing prior to biopsy, and evidence of positive serology results was found in only 5% of patients.In patients where celiac serology testing was performed, the results were a good predictor of the likelihood of findings on biopsy.

View Article: PubMed Central - HTML - PubMed

Affiliation: Robert J, Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Clinical Pathology, LL3-3, 9500 Euclid Avenue, 44195 Cleveland, OH, USA. dalyt@ccf.org.

ABSTRACT

Background: Clinical algorithms for the workup of celiac disease often recommend the use of serologic assays for initial screening, followed by duodenal biopsy for histologic confirmation. However, the majority of duodenal biopsies submitted to pathology for "rule out celiac" are negative. The objective of this study was to determine the underlying causes for this low diagnostic yield.

Methods: We performed a retrospective review of pathology reports from 1432 consecutive duodenal biopsies submitted for pathologic assessment to "rule out celiac" and correlated biopsy results with results for concurrent serologic testing for celiac autoantibodies.

Results: The majority of patients had no record of serologic testing prior to biopsy, and evidence of positive serology results was found in only 5% of patients. Most duodenal biopsies were submitted as part of a multi-site GI sampling strategy that included biopsies from other locations. In this context, serologic results correlated with the likelihood of significant duodenal and non-duodenal findings, and were also helpful in evaluating patients with indeterminate duodenal histology.

Conclusions: The presence of a positive screening test for celiac autoantibodies does not appear to be a major driver in the decision to submit duodenal biopsies for evaluation of celiac disease, which accounts for the low incidence of findings in these samples. In patients where celiac serology testing was performed, the results were a good predictor of the likelihood of findings on biopsy.

Show MeSH
Related in: MedlinePlus