The Diagnostic Yield of Upper GI Endoscopy in Patients Iron Deficiency Anemia and/or Chronic Diarrhea; With a Special Focus on Celiac Disease

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Austin J Gastroenterol. 2023; 10(1): 1124.

The Diagnostic Yield of Upper GI Endoscopy in Patients Iron Deficiency Anemia and/or Chronic Diarrhea; With a Special Focus on Celiac Disease

Voulgaris T*; Tampaki M; Laoudi E; Karatzas P; Karamanolis G; Vlachogiannakos J; Papaxoinis K; Kamberoglou D; Papatheodoridis G

Academic Department of Hepatology and Gastroenterology, National and Kapodistrian University of Athens, Laiko General Hospital, Athens

*Corresponding author: Voulgaris Theodoros Academic Department of Hepatology and Gastroenterology, National and Kapodistrian University of Athens, Laiko General Hospital, Athens. Email: thvoulgaris87@gmail.com

Received: September 11, 2023 Accepted: October 07, 2023 Published: October 13, 2023

Abstract

Aim of the Study: According to published guidelines, an upper Gastrointestinal (GI) endoscopy with duodenal biopsy sampling should be performed in patients with Iron Deficiency Anemia (IDA) and/or chronic diarrhea. The cost-effectiveness of this strategy in the absence of obvious endoscopic reason explaining patients symptoms has not been thoroughly investigated. Aim of our study was to access the clinical benefit of such a strategy.

Patients-Methods: All patients who underwent an upper GI endoscopy in our department due to IDA and/or chronic diarrhea during a 5-year period (1/2015-12/2019) were included in our study. Epidemiological, endoscopic and histologic data were analyzed.

Results: The indication for endoscopy was IDA in 350 and chronic diarrhea in 108 patients; histological reports were available in 311 and 100 patients, respectively. Visual abnormalities were observed in 157 patients (34.3% in total; IDA: 32.9%, chronic diarrhea: 38.9%) and were more frequent among males than females (44.6% vs 33.5%, p=0.019) and among older patients (mean age 60 vs 56 years old, p=0.006). The histology report provided a conclusive diagnosis in 71/413 patients (17.2% in total; IDA: 14.8 %, chronic diarrhea: 25%). Celiac Disease (CD) was diagnosed in 7.5% of our total study group. Normal endoscopic appearance of the duodenum was observed in 33% of patients, while bulb atrophy was associated more frequently with a conclusive histological report compared to other or no endoscopic findings (23/63 or 36.5% vs 48/350 or 13,7%, p<0,001).

Conclusions: Duodenal biopsy can aid significantly in the diagnosis of IDA or chronic diarrhea, even among patients without endoscopical abnormalities. Duodenal atrophy is an endoscopic marker that may lead to a conclusive histological diagnosis, most commonly CD, in 1 out of 3 patients.

Keywords: Upper GI endoscopy; Chronic diarrhea; Iron deficient anemia; Celiac disease

Introduction

Upper Gastro-Intestinal (GI) endoscopy plays a cardinal role in the diagnostic algorithm of both anemia due to Iron Deficiency (IDA) and chronic diarrhea [1,2]. Even if duodenal biopsies are often performed routinely in patients being submitted to upper GI endoscopy due to IDA or chronic diarrhea, there is no robust data behind this practice [3]. The rationality behind such a practice resides mainly to the fact that Celiac Disease (CD) is responsible for a great proportion of patients with either IDA or chronic diarrhea [4]. This is also reinforced by the absence of visual abnormalities of the small intestine during upper GI endoscopy in up to 1/3 of patients with CD. Therefore, Small Bowel Biopsies (SBB) may add to the diagnostic value of upper GI endoscopy towards a possible diagnosis of CD [4].

As far as IDA is concerned the data are conflicting. Few guidelines address this issue. According to the British guidelines for IDA, SBB should be obtained only if celiac serology was previously tested positive or not performed, while SBB should be obtained irrespective of serology in the presence of anemia or diarrhea according to the British guidelines for CD [1,5]. On the other hand, the ACG clinical guidelines for CD recommend routine SBB only when the probability for CD is at least 5% [6]. Thus, controversies about the exact prerequisites of obtaining SBB in the setting of IDA exist and the majority of studies focus in CD as this is main causative factor, though other diseases causing IDA can be diagnosed by duodenal SBB as well. Chronic diarrhea on the other hand is a common disorder affecting about 4-5% of Western population and CD is only one of its many causes [7]. According to guidelines, upper GI endoscopy with SBB may be undertaken in patients with undetermined causative factor by laboratory studies, stool exams and lower GI endoscopy [8]. However, the additive benefit of SBB in the diagnostic pathway of chronic diarrhea has not been thoroughly investigated and biopsy sampling remains to medical practitioner’ suspicion and mainly confers just to the diagnosis of celiac disease [8]. In addition, besides studies addressing the prevalence of CD among patients with chronic diarrhea, there is paucity of data about the value of duodenal biopsy sampling.

Given that SBB are routinely performed in patients undergoing upper GI endoscopy for IDA and/or chronic diarrhea, the aim of our study was to evaluate the clinical significance of duodenal sampling in such patients in a real-world setting.

Methods

We retrospectively collected data from all patients submitted to upper GI endoscopy with SBB sampling in our department during a five-year period (1/2015-12/2019). In total, 458 patients were included in the study, whereas histological report was available in 413 patients. Epidemiological, endoscopic and histological data were collected.

The study protocol conformed to the principles outlined in the Declaration of Helsinki. All patients signed an informed consent to undergo upper GI endoscopy. Since this study was a post hoc analysis of de-identified previously collected data from endoscopic studies with no direct link to individual patients, formal ethics approval and specific informed consent were not deemed to be necessary.

All endoscopies were performed by endoscopists with more than 3 years’ experience by the use of Olympus GIF-160 Adult Video Gastroscope with standard white balance analysis. A diagnosis of celiac disease was made in patients with at least a Marsh III stage according to Marsh Oberhuber classification in the histology report

Statistical Analysis

Statistical analysis was performed using SPSS software (version 27.0, IBM Corp., Armonk, NY, USA). Data were expressed as frequencies, mean with Standard Deviation (SD) or median with Interquartile Range (IQR), as appropriate. Quantitative variables were compared with Student’s t-test or Mann–Whitney test for normally and non-normally distributed variables, respectively. Qualitative variables were compared with the Chi-squared test or Fisher’s exact test, as appropriate. Relationships between parameters were assessed using Spearman’s correlation coefficient. All tests were two-sided and p values <0.05 were considered to be significant.

Results

Among 418 patients in whom endoscopy was performed, IDA was the main indication in 350 and chronic diarrhea in 108 patients; histological reports were available in 311 [males/females: 109/202), mean age 58 (range: 15-97) years] and 100 patients [males/females: 48/52, mean age: 55 (range: 16-86) years], respectively.

Total Cohort

Figure 1 summarizes the endoscopic findings in the total cohort: visual abnormalities were observed in 157 patients (34.3%) with flattening of duodenal mucosa being the most commonly observed abnormality. Visual abnormalities were more frequent among males than females (44.6% vs 33.5%, p=0.019) and among older patients (mean age: 60 vs 56 years, p=0.006). The rate of existence of pathologic duodenal endoscopic findings did not differ between patients having IDA as the procedures’ indication in comparison to patients who underwent upper GI endoscopy due to chronic diarrhea (p=0.249).