Endoscopic biopsy technique in the diagnosis of celiac disease: one bite or two?

Background: The diagnosis of celiac disease is dependent on the quality of biopsy specimens obtained at EGD. Endoscopists may obtain a single- or double-biopsy specimen with each pass of the forceps.

Objective: To compare the quality of biopsy specimens obtained with the single-biopsy and double-biopsy techniques.

Design: Prospective cohort study.

Setting: U.S. tertiary-care university hospital.

Patients: Patients undergoing upper endoscopy with confirmed, suspected, or unknown celiac disease status.

Interventions: Four biopsy specimens from the second portion of the duodenum: 2 by using the single-biopsy technique (1 bite per pass of the forceps) and an additional 2 by using the double-biopsy technique (2 bites per pass of the forceps). Specimens were blindly reviewed to determine orientation, consecutive crypt-to-villous units, and Marsh score.

Main outcome measurements: Proportion of well-oriented biopsy specimens.

Results: Patients (N = 86) were enrolled, 47% with known celiac disease, 36% with suspected celiac disease, and 17% with an unknown celiac disease status. Well-oriented biopsy specimens were noted in 66% of patients with the single-biopsy technique and 42% of patients with the double-biopsy technique (P < .01). Analysis of matched pairs showed improved orientation with the single-biopsy technique (odds ratio 3.1; 95% confidence interval, 1.5-7.1; P < .01). This persisted in subgroup analysis of patients with known celiac disease (P = .02), villous atrophy (P = .02), and a final diagnosis of celiac disease (P < .01).

Limitations: A single-center trial.

Conclusion: The single-biopsy technique improves the yield of well-oriented duodenal biopsy specimens. Endoscopists should consider taking only 1 biopsy specimen per pass of the forceps in patients undergoing biopsies of the duodenal mucosa.