Variation in small bowel biopsy performance among diverse endoscopy settings: Results from a national endoscopic database

BACKGROUND: The diagnostic gold standard for celiac sprue requires performance of small bowel biopsy to identify characteristic mucosal changes. The current biopsy practice among endoscopists for celiac sprue is unknown. METHODS: The CORI (Clinical Outcomes Research Initiative) national endoscopic database was analyzed to determine the rate of small bowel biopsy in patients undergoing EGD for the evaluation of anemia, iron deficiency without anemia, weight loss, and diarrhea. RESULTS: Between January 2000 and September 2003, 3,992 patients underwent EGD for the evaluation of anemia, iron deficiency, weight loss, and diarrhea with normal EGD findings. Overall, 438 patients (11%) underwent small bowel biopsy. Small bowel biopsy performance varied with procedure indication: anemia 10%, iron deficiency 7%, weight loss 6%, and diarrhea 19%, p < 0.0001. Biopsy rates declined with advancing patient age; 12% (<50 yr), 12% (50-69 yr), and 9% (≥70 yr), p = 0.002, and also differed with patient race (12%, Whites vs 8%, non-Whites), p = 0.0007. Biopsy performance varied among endoscopy sites: community (9%), academic (13%), and VAMC (15%), p < 0.0001. Multivariate analysis identified age ≥70 yr (OR: 0.52, p = 0,0007), non-White race (OR: 0.60, p = 0.0007) and an Indication of weight loss (OR: 0.60, p = 0.01) to be associated with not performing a biopsy. CONCLUSION: Among diverse endoscopy sites, the majority of patients with anemia, iron deficiency, weight loss, and diarrhea do not undergo small bowel biopsy at EGD. The diagnosis of celiac sprue should be considered in such cases. Endoscopy provides an opportunity to obtain tissue to diagnose sprue, and should be strongly considered in this setting.