The significance of routine duodenal biopsies in pediatric patients undergoing upper intestinal endoscopy

To determine the significance of performing routine duodenal biopsies during upper intestinal endoscopy in a pediatric population and to evaluate their contribution to the overall diagnosis.

Performing duodenal biopsy during every upper endoscopy regardless of the indication for endoscopy and the macroscopic findings, is a controversial topic. Advocates of performing routine biopsies argue that unexpected pathology such as villous atrophy, may have significant clinical implications. Opponents argue that the yield of performing a biopsy on an apparently normal mucosa is low.

Duodenal biopsies, routinely taken from 201 pediatric patients during upper endoscopy over a 26-month period were retrospectively reviewed. Duodenal biopsies taken during this period for suspected mucosal lesions were not included in the analysis. Indications for endoscopy included suspected peptic disease, gastroesophageal reflux, unexplained vomiting, abdominal pain, iron deficiency anemia and Crohn disease.

Of the 201 sets of biopsies reviewed, 159 (79.1%) were normal, 7 had insufficient material for evaluation and 35 (17.4%) carried abnormalities that included: 10 Giardia lamblia (4.9%), 13 mild chronic inflammation (6.5%), and 8 increased intraepithelial lymphocytes (3.9%). Two biopsies showed mixed acute and chronic inflammation, 1 showed lymphatic dilatation and 1 had a mild mucosal lesion. The risk for microscopic pathology in the duodenum was higher when Helicobacter pylori was present in the gastric biopsy (25.98% vs. 12.16% P < 0.02). The negative predictive value of a normal appearing duodenal mucosa was 81.5%, implying that a normal appearing mucosa does not rule out pathology. No complications were encountered in our series.

We suggest that the inclusion of routine duodenal biopsies as part of upper endoscopy in pediatric patients should be considered favorably. This practice may yield additional pathologic findings that otherwise could have been missed. It should be done regardless of the indication for endoscopy or the gross appearance of the mucosa. This practice does not increase the risk of the procedure.