Following Celiac Biopsy Guidelines Increases Positive Diagnosis of Celiac Disease more than Two-Fold

By Peter Olins, PhD on July 9, 2011.

Current guidelines for the use of biopsy in the diagnosis of celiac disease recommend that at least four duodenal tissue specimens should be taken. However, in a nationwide study of US cases where biopsy was used to investigate potential celiac disease, only 39.5% of doctors adhered to this guideline (Ref. 1). Remarkably, the probability of a positive diagnosis was increased over 2-fold (1.8% versus 0.7%) when four or more tissue samples were taken.

The study reviewed the results of 3,261 duodenal biopsies taken when celiac disease was suspected, or when there was evidence of malabsorption of food. The authors at the Celiac Disease Center at Columbia University reviewed data from a pathology laboratory which operates in 43 US States, and found that diagnostic guidelines were often ignored.

Ref. 1: Lebwohl, B., et al., Gastrointest Endosc. 2011 74(1):1030109. Adherence to biopsy guidelines increases celiac disease diagnosis.

Why Don’t Physicians Follow Celiac Biopsy Guidelines?

There is a host of reasons why a physician may choose not to adopt the current guidelines for diagnosis or treatment of a disease. Obviously, a doctor relies on his/her experience and judgment to make the best decision on how to proceed, and medical practice is seldom simply black or white.  However, a published review (Ref. 2) of factors that influence why doctors don’t always comply with current recommendations uncovered a wide range of motivations: lack of knowledge or experience, disagreement about the value of the procedure, simple inertia based on previous practice, or external factors, such as cost.

Ref. 2: Cabana, MD et al., JAMA. 1999;282(15):1458-1465. doi: 10.1001/jama.282.15.1458 Why Don’t Physicians Follow Clinical Practice Guidelines?

Celiac Disease is Under-Diagnosed

It is well-established that only a small fraction of cases of celiac disease are actually detected, partly because of the lack of symptoms, but also because the disease can often result in a wide range of symtoms which are caused by a variety of other conditions. Even when celiac disease is suspected, there are many cases where the diagnosis is ambiguous. This latest study, however, suggests that one important factor may be the reluctance of some doctors to take sufficient biopsy samples.

It is ironical that the over-use of diagnostic procedures in the US is often blamed on a fear of malpractice, which can increase the overall cost of medical care. In contrast, for celiac disease, the current study suggests that many physicians are not following the current diagnostic guidelines. It may also be helpful for patients to be more assertive in their doctor’s office when a celiac biopsy is being considered.