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Biopsy Volume Influences Adherence to Celiac Disease Guidelines

Celiac.com 12/04/2013 - About 1 of of 100 Americans has celiac disease, but most cases remain undiagnosed, partly because of failure on the part of physicians to collect at least four specimens during duodenal biopsy, as per current recommendations.

Photo: CC--jovikeA team of researchers recently set out to determine whether physician and practice characteristics are associated with these failures.

The research team included Benjamina Lebwohl, Robert M. Genta, Robert C. Kapel, Daniel Sheehan, Nina S. Lerner, Nina, Peter H. Green, Alfred I. Neugut, and Andrew Rundle.

For their study, the team used a large national pathology database to identify all adult patients who underwent duodenal biopsy during 2006–2009.

They used hierarchical modeling to determine whether procedure volume, the number of gastroenterologists per endoscopy suite, and the number of gastroenterologists per capita of the zip code of the practice were associated with adherence to recommendations.

The team identified 92,580 patients who met their inclusion/exclusion criteria. Patient group was 67% female, averaging 53.5 years of age.

The team received biopsy specimens from 669 gastroenterologists from 200 endoscopy suites, located in 191 zip codes, with a mean of 3.4 gastroenterologists per suite.

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Multivariate analysis showed that higher procedure volume was associated with decreased adherence to specimen recommendations [odds ratio (OR) for each additional 100 procedures, 0.92; 95% confidence interval (CI), 0.88–0.97; P=0.002].

Gastroenterologists employed in suites with higher numbers of gastroenterologists reported higher levels of adherence (OR for each additional gastroenterologist, 1.08; 95% CI, 1.04–1.13; P<0.001)

However, that was not the case for a higher gastroenterologist density in the zip code of the practice (OR for each additional gastroenterologist per capita, 1.01; 95% CI, 0.99–1.03; P=0.21).

This study suggests that high-volume physicians exhibit lower rates of adherence to biopsy guidelines, possibly because of the additional time required to submit the minimum of four specimens.

In contrast, doctors working in endoscopy suites with high numbers of colleagues showed higher rates of adherence, possibly because of peer education.

Basically, doctors who do large numbers of biopsies are more likely to submit too few samples for accurate analysis, whereas doctors working in close contact with large numbers of peers are more likely to follow current recommendations, and to produce better, more accurate results.

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Thank you for posting this I've never been to South America, it's the only continent, bar the poles, I've yet to visit. It's really nice to read that my gluten sensitivity hasn't ruled it out. Maybe I'll get to the land of Luis Suarez yet!

I know this post is a year ago... however it is still on the first page of the travel section! I am from Uruguay, (South America) and I can answer this question for people that may look at it in the future. As a South American - I can say that the cuisine varies greatly. In cities, you shouldn't have any more than the normal amount of difficulty finding food. For example, in Montevideo, the city I am from, you'll have no problem finding dedicated entire Celiac stores. Meat is a large part of restaurant menus, so parilladas (similar in theory to steakhouses, would be very easy to navigate). Uruguayans do eat a lot of pastries, and just like in the states... Most mainstream bakeries are not gluten free, but like I mentioned there are places that specialize. In Uruguay, there is knowledge of Celiac and a large health awareness. Some of the foods can be costly, cost of living in general is not low. In large swaths of South America, the foods you mentioned - Potatoes, rice, meat, etc are abundant, as are fresh fruits and veggies. Avoiding corn does make it tricky. Peru can be a great place for non-gluten eaters. Peru uses very little gluten (they are the original quinoa eaters) but there is a lot of corn in the diet (and since you are corn sensitive, that would be a food you would need to navigate). Latin America spread over two continents! In this area you will find a great variety in cultures, cuisines, and knowledge of celiac. There is no reason why If you want to experience Latin America, that you have to rule out an entire region of the world because of Celiac. Navigating it will be different, but it is doable!

Recently diagnosed last week does the pain ever get better??

George, i am sorry that you are not feeling well! ?? I am not a doctor, but just trying out drugs to stop your symptoms just seems like a band aid approach. It sounds like he suspects IBS which is really, in my opinion, "I be stumped". Has inflammatory bowel disorder (IBD) (more lovely autoimmune disorders) been ruled out? This includes both Crohn's and Colitis. My niece was diagnosed with Crohn's finally with a pill camera after all other tests were given. The damage was not within reach of any scope. I am just throwing out suggestions. Hopefully, you and your doctor will figure it out soon!

Celiac disease is an autoimmune disease that happens to have a known trigger -- gluten. Flare-ups develop (antibodies) causing damage. Not just in the small intestine, but systemically. One gluten exposure can cause antibodies to increase for days or months! Antibodies are being measured during the celiac blood tests. If there is no gluten exposure, there will be no antibodies. These antibodies can come down in some people in as little as two weeks. Recommendations require gluten 2 to 4 weeks daily for the biopsies taken via endoscopy in order to be sure to catch damage, but 8 to 12 weeks for the blood tests. The endoscopy is considered the "gold standard" in helping to diagnose celiac disease, but there are other things that can damage the small intestine. So, the blood test helps solidify the diagnosis. So, if you want a good result on your endoscopy, you need to be eating gluten daily for two week prior at a minimum. I know it is tough and you are feeling sick. Wish there was a better way to catch active celiac disease.