The Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions

American Gastroenterological Association Institute Guideline on the Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions

This document presents the official recommendations of the American Gastroenterological Association (AGA) on the role of upper gastrointestinal biopsy to evaluate dyspepsia in the absence of mucosal lesions. The guideline was developed by the AGA’s Clinical Practice Guidelines Committee and approved by the AGA Governing Board.
The authors of these guidelines present evidence-based recommendations for performing biopsies of normal mucosa in patients with dyspepsia who are undergoing EGD. The authors take into consideration the different segments of the upper GI tract as well as patient factors such as immune system status.  Please make sure to review the entire paper as linked.

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Esophagus:

• In patients undergoing EGD for dyspepsia as the sole indication, the AGA recommends against obtaining routine biopsies of the normal-appearing esophagus or GE junction regardless of immune status.

Stomach:

• In immunocompetent patients undergoing EGD for dyspepsia as the sole indication, the AGA recommends obtaining routine biopsies of the normal appearing gastric body and antrum for the detection of HP infection if the HP infection status is unknown.
• In immunocompromised patients undergoing EGD for dyspepsia as the sole indication, the AGA recommends obtaining routine biopsies of the normal-appearing gastric body and antrum for the detection of HP infection if the HP infection status is unknown.
• When obtaining biopsies from the normal-appearing gastric body and antrum for the detection of HP infection, the AGA suggests following the 5-biopsy Sydney System with all specimens placed in the same jar.
• When biopsies are obtained from the normal-appearing gastric body and antrum for the detection of HP infection, the AGA suggests not obtaining automatic special staining of the specimens.

Duodenum:

• In patients undergoing EGD for dyspepsia as the sole indication, and in the absence of signs or symptoms associated with an increased risk of celiac disease, the AGA suggests not obtaining routine biopsies of the normal-appearing duodenum to detect celiac disease.
• In immunocompromised patients undergoing EGD for dyspepsia as the sole indication, the AGA suggests obtaining routine biopsies of the normal-appearing duodenum for the detection of GVHD in post−allogeneic tissue transplantation patients and for opportunistic infections.
• When biopsies are obtained from the normal-appearing duodenum, the AGA suggests not performing routine special staining of the specimens.

Clarifications:

• The updated Sydney System protocol includes specimens from the lesser and greater curve of the antrum within 2−3 cm of the pylorus, from the lesser curvature of the corpus (4 cm proximal to the angularis), from the middle portion of the greater curvature of the corpus (8 cm from the cardia), and one from the incisura angularis. Although a 3-biopsy protocol (1 each from greater curvature of the corpus and antrum and 1 from incisura) also identifies 100% of HP, equivalency of the 3- vs 5-biopsy protocol cannot be definitively established. Given that the time and cost of specimen preparation and processing from the pathology standpoint are the same for a 3- vs 5-biopsy protocol, a conditional recommendation was made to follow the 5-biopsy protocol.
• Regarding Celiac disease the AGA argues that Celiac disease can be present in patients with endoscopically normal duodenum. The prevalence of biopsy-proven celiac disease among patients with dyspepsia is not significantly different from that in the US general population in which screening for celiac disease is not recommended. One must consider the potential for false-positive biopsy diagnosis in this setting, particularly when only early-grade celiac changes (eg, Marsh I−II) are detected. The AGA argues that this recommendation is primarily dependent on very-low-quality prevalence data, and thus a conditional recommendation is warranted (the possibility exists that the true prevalence of celiac disease among patients presenting with dyspepsia might be higher than what the current literature suggests, this recommendation might need to be updated when higher-quality evidence becomes available). Biopsy of the normal-appearing duodenum might be appropriate in patients who are at high risk for celiac disease, as specified by a previous AGA guideline on the diagnosis and management of celiac disease. If the suspicion for celiac disease is high, biopsies of the normal-appearing duodenum can be of value even if serologies (obtained while the patient is on a gluten-free diet) are negative.

http://www.gastro.org/guidelines/2015/10/19/endoscopic-biopsies
http://www.gastrojournal.org/article/S0016-5085%2815%2901065-3/pdf