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Efficacy of Duodenal Bulb Biopsy for Diagnosis of Celiac Disease: a Systematic Review and Meta-Analysis

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Efficacy of Duodenal Bulb Biopsy for Diagnosis of Celiac Disease: a Systematic Review and Meta-Analysis Original article Efficacy of duodenal bulb biopsy for diagnosis of celiac disease: a systematic review and meta-analysis Authors Thomas R. McCarty1,CoreyR.O’Brien1, Anas Gremida2, Christina Ling2,TarunRustagi2 Institutions nalysis to evaluate the diagnostic utility of endoscopic duo- 1 Department of Internal Medicine, Yale University School denal bulb biopsy for celiac disease. of Medicine, New Haven, Connecticut, United States Patients and methods Searches of PubMed, EMBASE, 2 Division of Gastroenterology and Hepatology, University Web of Science, and Cochrane Library databases were per- of New Mexico, Albuquerque, New Mexico, United formed from 2000 through December 2017. Review of States titles/abstracts, full review of potentially relevant studies, and data abstraction was performed. Measured outcomes submitted 7.5.2018 of adult and pediatric patients included location of biopsy, accepted after revision 23.7.2018 mean number of biopsies performed, and diagnosis of ce- liac disease as defined by the modified Marsh-Oberhuber Bibliography classification. DOI https://doi.org/10.1055/a-0732-5060 | Results A total of 17 studies (n=4050) were included. Sev- Endoscopy International Open 2018; 06: E1369–E1378 en studies evaluated adults and 11 studies assessed pedia- © Georg Thieme Verlag KG Stuttgart · New York tric populations. Mean age of adults and pediatric patients ISSN 2364-3722 was46.70±2.69and6.33±1.26years,respectively.Over- all, sampling from the duodenal bulb demonstrated a 5% Corresponding author (95% CI 3– 9; P <0.001) increase in the diagnostic yield of Tarun Rustagi, MD, Division of Gastroenterology and celiac disease. When stratified by pediatric and adult popu- Hepatology, University of New Mexico, MSC10 5550, 1 lations, duodenal bulb biopsy demonstrated a 4% (95% CI: University of New Mexico, Albuquerque NM 87131 1to9;P < 0.001) and 8% (95% CI: 6 to 10; P <0.001) in- Fax: +1-505-272-9751 crease in the diagnostic yield of celiac disease. Non-celiac [email protected] histologic diagnoses including Brunner gland hyperplasia and peptic duodenitis were reported more commonly in the duodenal bulb as compared to the distal duodenum ABSTRACT with an increase in diagnostic yield of 4% (95% CI 3– 5; P < – P Background and study aims Although duodenal biopsy is 0.001) and 1% (95% CI 1 2; <0.001), respectively. considered the “gold standard” for diagnosis of celiac dis- Conclusions Based upon our results, biopsy and histologic ease, the optimal location of biopsy within the small bowel examination of duodenal bulb during routine upper endos- for diagnosis remains unclear. The primary aim of this study copy increases the diagnostic yield of celiac disease. was to perform a structured systematic review and meta-a- vitamin D deficiency, vitamin B12 deficiency, and intestinal Introduction lymphoma, thus signifying a need to ensure an accurate diag- Celiac disease is an immune-mediated gluten-dependent en- nosis [1,6]. teropathy that affects the small bowel [1]. While reports of Despite the need to ensure appropriate identification, diag- prevalence vary, celiac disease is estimated to affect 0.5% to nosis of celiac disease is often challenging and delayed as there 1 % of the United States population [2– 4]. Gluten is a ubiqui- is a considerable overlap between celiac disease and other gas- tous protein present in foods like wheat, barley, and rye [1,5] troenterological disorders such as irritable bowel syndrome [7]. Celiac disease, often called gluten-sensitive enteropathy, can Diagnosis includes serologic testing, typically via tissue trans- result in symptomatic malabsorption and may present with a glutaminase antibody (TTG-IgA), with or without the use of breadth of symptoms including diarrhea, bloating, and fatigue. duodenal biopsy. Duodenal biopsy is generally performed if ser- If untreated, celiac disease may lead to iron deficiency anemia, ologic testing is positive, if there is a high pre-test probability McCarty Thomas R et al. Efficacy of duodenal… Endoscopy International Open 2018; 06: E1369–E1378 E1369 Original article for celiac disease, or if there are discordant results of serologic patients were excluded. Participants included patients of any testing [7]. Pathologic diagnosis is established or confirmed ac- age in whom the presence of celiac disease was suspected cording to the modified Marsh-Oberhuber classification, which based upon clinical symptoms alone or positive serologic mar- accounts for the number of intraepithelial lymphocytes, crypt kers were included. The Preferred Reporting Items for Systema- hyperplasia, and villous atrophy [8,9]. tic Reviews and Meta-Analyses (PRISMA) statement outline for As celiac disease may result in patchy histologic changes in reporting systematic reviews and meta-analyses was used to the small bowel, the site and number of duodenal biopsies be- report findings [14]. comes of considerable importance. Biopsies were classically ob- tained from the distal duodenum (i.e., sections duodenal stage Outcome measures 2 [D2] through D4). However, there have been an increasing The primary outcome measurement in this study was efficacy number of studies that have evaluated biopsy of the duodenal of endoscopic duodenal bulb biopsy in patients with suspected bulb (i.e., section D1) for diagnosis of celiac disease in the adult celiac disease. Location of biopsy within the duodenum was de- and pediatric populations [7,10– 12]. When compared to distal fined as duodenal bulb (i.e., section D1) versus distal duodenal duodenal biopsies alone, duodenal bulb biopsies may increase (i.e., sections D2 through D4). Secondary measured outcomes the diagnostic yield; however, studies to date have shown var- in addition to location of biopsy included mean number of ied results. biopsies performed, confirmatory diagnosis of celiac disease as The primary aim of this study was to perform a systematic defined by the modified Marsh-Oberhuber classification, and review and meta-analysis to evaluate the feasibility, efficacy, type and number of alternative diagnoses potentially identified and tolerability of duodenal bulb biopsy for the diagnosis of ce- (i.e., Brunner gland hyperplasia, peptic duodenitis, gastric me- liac disease in the adult and pediatric populations. We hypothe- taplasia, or other). Information on type and year of study, aver- sized that duodenal bulb biopsy would improve the diagnostic age patient age (years), and gender were also collected. Sensi- yield of celiac disease as compared to distal duodenal sampling tivity and subgroup analyses were also performed for only high- alone. quality studies (i.e., inclusion of only randomized controlled trials or prospective studies), diagnostic yield as stratified by Methods pediatric and adult populations, and number of small bowel biopsies. Literature search A comprehensive search of the literature was performed to Statistical analysis identify articles that examined endoscopic duodenal biopsy This meta-analysis was performed by calculating pooled pro- for the diagnosis of celiac disease. We followed previously cited portions. After appropriate studies were identified through sys- recommendations for search strategies to identify diagnostic tematic review, the individual study proportion was trans- accuracy studies [13]. Systematic searches of PubMed, EM- formed into a quantity using the Freeman-Tukey variant of the BASE, Web of Science, and the Cochrane Library databases arcsine square root transformed proportion. Then the pooled were performed from 2001 through December 31, 2017.The proportion was calculated as the back transform of the weight- search terms included: “endoscopic duodenal biopsy”, “celiac ed mean of the transformed proportions, using inverse arcsine disease”, “gluten-sensitive enteropathy”, “celiac sprue”, “non- variance weights for the fixed effects model and DerSimonian- tropical sprue”, “endemic sprue”,and“duodenal bulb”. Laird weights for the random effects model [15,16]. All relevant articles irrespective of language, year of publica- Measured outcomes comparing site of duodenal biopsy tion, type of publication, or publication status were included. were obtained. From this, standardized mean difference was The titles and abstracts of all potentially relevant studies were calculated and transformed to the natural logarithm before screened for eligibility. The reference lists of studies of interest pooling, and the variance was calculated. Fixed-effects models were then manually reviewed for additional articles by cross were applied to duodenal bulb and distal duodenal biopsy data checking bibliographies. Two reviewers (TRM and CRO) inde- to determine effect size and corresponding 95% confidence in- pendently screened the titles and abstracts of all the articles ac- tervals (CIs). Since this was a cumulative meta-analysis, publi- cording to predefined inclusion and exclusion criteria. Any dif- cation bias was not assessed. Combined weighted proportions, ferences were resolved by mutual agreement and in consulta- and meta-regression were determined by use of the Stata 13.0 tion with the third reviewer (TR). In the case of studies with in- software package (Stata Corp LP, College Station, TX). complete information, contact was attempted with the princi- pal authors to obtain additional data. Results Study selection criteria Patient characteristics of included studies Only studies investigating use of endoscopic biopsy for the di- This meta-analysis included a total of 17 studies [10– 12,17– agnosis of celiac disease
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