Celiac Disease in an Urban VA Population with Iron Deficiency: The Case Against Routine Duodenal Biopsy

Celiac disease is considered an under-recognized cause of iron deficiency. Small intestinal biopsy is proposed to be part of routine evaluation for iron deficiency. To determine the prevalence of celiac disease in an urban, mostly male, mostly minority population with iron deficiency. Clinical, endoscopic, and pathologic records of veterans who had undergone esophagogastroduodenoscopy (EGD) and duodenal biopsy for iron deficiency at an urban, tertiary care Veterans Affairs Medical Center were reviewed. The yield of positive duodenal biopsies for celiac disease and pre-defined clinically important findings on EGD were calculated. Confounding factors were assessed in multivariate analysis. The main outcome measures were prevalence of celiac disease and prevalence of clinically important findings on upper gastrointestinal endoscopy. The records of 310 veterans were reviewed. Mean age was 63, range 32-91 years old. Most were male (89%) and African-American (73%). Five of 306 small intestinal biopsies were consistent with celiac disease (type 1 lesions), but tissue transglutaminase obtained in four of the patients was normal, making the prevalence of potential celiac disease 0.33% (95% CI: 0.06-1.83%). Fifty of 310 EGDs demonstrated findings that were considered to have a moderate or high probability of producing iron deficiency (16.1, 95% CI: 12.5-20.6%). The prevalence of celiac disease is low in an urban, predominately male, African-American population with iron deficiency. Routine small intestinal biopsy for celiac disease in similar populations should not be done. EGD remains clinically important.