Yield of Duodenal Biopsies in the Evaluation of Iron Deficiency Anemia

Abstract

Purpose: To determine the prevalence of celiac sprue in duodenal biopsies in patients undergoing esophagogastroduodenoscopy (EGD) as part of an evaluation of iron deficiency anemia. Methods: This was a retrospective pilot study of the prevalence of celiac disease in 570 consecutive patients who underwent duodenal biopsies during EGD as part of the evaluation of iron deficiency anemia at a major military medical center. These 570 patients represent all patients who underwent EGD and duodenal biopsies for the evaluation of iron deficiency anemia over a 10 year period. The center's endoscopy reporting database was queried for all patients who had undergone EGD for the indication “iron deficiency anemia” and the results of those biopsies where then taken and categorized as positive, intermediate, or negative. Biopsies with either some degree of blunting or increased intraepithelial lymphocytes were considered intermediate results. Pathology reports did not routinely include Marsh scores which led the authors to adapt the classification scheme above. From this data, a simple prevalence was calculated and compared with the reported prevalence of celiac sprue. Results: 570 patients (212 male, 358 female) underwent EGD to evaluate causes of iron deficiency anemia which included random duodenal biopsy to rule out celiac disease. Pathologists interpreted the samples as characteristic of sprue in 8 patients (1.4%, 4 male, 4 female). Intermediate features of celiac sprue were found in 12 patients (2.1%, 5 male, 7 female). The reported prevalence of celiac disease in the United States is 1:300-1:600. These results suggest a 4-8 fold increase in the prevalence of celiac disease in a preselected population of patients with iron deficiency anemia over that of the general U.S. population. If intermediate results are considered positive, the prevalence increases to 10-20 fold that of the general U.S. population. This study is limited by the lack of laboratory data confirming iron deficiency in these patients, unintentional exclusion of patients in whom the diagnosis of iron deficiency was incorrectly coded and by the elimination from consideration of patients who did not undergo duodenal biopsies. Additionally, the significance of an intermediate pathology result is uncertain. Conclusion: The results of this retrospective pilot study support the practice of routine duodenal biopsies during the endoscopic evaluation in patients with iron deficiency anemia. A prospective trial including concurrent ferritin, transferrin saturation, formalized protocol for pathology interpretation, and universal biopsy protocol is needed to confirm these results.