As these words shot from his mother's mouth for the third day in a row, I wondered how the child remembered to breathe. Will he ever learn? Will we be texting him reminders to pick up his clothes and comb his hair every day of his adult life?
It is difficult to follow rules. And, I'm giving my son a hard time, but truly the kettle is calling the pot black. There's a wake of broken rules in our house every time I shut off hte nightstand light: a TV left on, a tie on the closet floor, a pair of shoes by the comfy living room chair. The list goes on, and my wife would be happy to detail it for you...
But, it's one thing to break the laws of the house. It's another to ignore the collective voice of respected medical societies. In the October 2015 issue of JPGN, Ofei and colleagues report on their center's adherence to clinical practice guidelines for upper endoscopy biopsies for Celiac disease published by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) and the American College of Gastroenterology (ACG). Link provided below. These guidelines recommend four distal duodenal biopsy specimens and at least one specimen from the duodenal bulb. The recommendations stem from the fact that gastroenterologists have opportunities to identify celiac disease in patients that may not be otherwise discovered due to the patchy nature of histologic changes and good - but not infallible - screening tests.
While faculty generally obtained the recommended number of duodenal biopsies in patients with histologic celiac disease, a number did not obtain the recommended biopsy specimens in patients not initially suspected of celiac disease. As the authors state, patients undergoing upper endoscopy for any reason represent an opportunity to identify celiac disease. Celiac disease is estimated to occur in 1% of the general population, but the majority of persons with the disease may remain undiagnosed. With a good portion of the population at risk and the possibility of significant long-term complications of the disease (iron deficiency, bone health among others), we as pediatric gastroenterologists should work to ensure that the silent cases are brought to light.
What is your practice? Do your partners or colleagues routinely obtain 4-6 biopsies from the duodenum in all patients for upper endoscopy? Would procedural checklists be helpful at your institution? Regardless, careful thought to our routines during endoscopy is important. Guidelines are typically not made to add to our work, but are suggested to help improve patient care.
So is this a case of pediatric gastroenterologists not making their bed?
Ryan Fischer, MD
Associate Professor of Pediatric Gastroenterology
Liver Care Center
Children's Mercy Hospital