Is Routine Duodenal Biopsies (DBx) Necessary during Upper Gastrointestinal Endoscopies (EGD)?

Abstract

Purpose: Controversies exist whether DBx should be an integral part of EGD. Unsuspected celiac disease (CeDi), parasites when diarrhea is absent and stool yield is low can be found by routine Bxs. Polymorphs (PMNs) have been proposed as a reliable marker for acute duodenitis (AD) and chronic active duodenitis (CAD). The importance of chronic duodenitis (CD) who do not show PMNs remains unclear. Methods: DBx were done on 435 pts during EGD. Classification of duodenitis is based on Whitehead et al. criteria. Findings were correlated with age, sex, race, H pylori (HP) on gastric Bxs and histology. We had 136 males (M) and 299 females (F) age from 14–102, mean age of 57; 354 African American (AA), 57 Caucasian (CAU), 17 Hispanic (HI), 5 Asian (AS). 2 pts were less than 20 yrs old. Results: AD was present in 1 pt, CAD in 12 (2.8%). CD in 386 (88.7%); 365 had mild CD (83.9%). 21 moderate CD (4.8%). 26 Bxs were normal (N, 6%). 10 pts (2.3%) had findings of congestion in 2, lymphangiectasia 2, villous atrophy 4, pseudolipomatous 1, adenomatous change 1. When mild CD and N Bxs were excluded significant duodenal inflammation (SDI) were present in 10.1% of pts (11% of M, 9.7% F, 17.3% AA 8.7%, CAU and 20% AS pts, none in 17 HI). SDI is increased with increasing age (7.6% from 20–39, 9.4% 40–49, 11.7% over 60 yr of age). Although overall SDI was not different in H P+ and–pts (9.8% vs. 10.4%), HP– pts showed age related increased SDI and HP+ did not. Lymophoid aggregate and follicules are seen in 13 pts, 10 was HP+, only 1 had N gastric histology (p < 0.05). 0.9% of Bxs were compatible with CeDi: 3 had chronic active gastritis. Out of 199 pts with significant gastric inflammation (SGI), 23 had SDI (12.1%) as opposed to 21/246 with mild or no gastritis. (8.5%, p= 0.33). Out of 48 pts with intestinal metaplasia (IM) 7 (14.6%) had SDI; while 27/387 (9.5%) with no IM (p= 0.08). Conclusions: SDI occurred in 10.1% of pts; equally in M and F who are not suspected to have duodenal disease. CeDi was uncommon in our population (0.9%). SDI increased with increasing age and showed same age relation in HP- pts. SDI occurred with similar incidence with HP + and - pts. Severity of GI did not correlate with DI however more pt with IM had SDI when compared with no IM. Summary: DBx should be considered during EGD in view of SDI in 10% of pts especially in AAs, ASs, in pts older than 60 and who is also known to have IM.