14 Those authors concluded that at least 4 duodenal biopsy specimens should be taken to rule out CD. A second study, investigating 56 patients with known CD,15 found that 3 biopsy specimens were sufficient as long as 1 specimen was obtained from the duodenal bulb; however, 5 biopsy specimens were necessary to recognize the most severe extent of villous atrophy. These studies are limited by their small sample size and single-center settings. To our knowledge, no previous study has evaluated the diagnostic yield of submitting ≥4 specimens for patients without known CD in accordance with these proposed guidelines. The incremental yield of submitting ≥4 specimens has not

been evaluated in a population undergoing endoscopy for a variety of indications, in Fluorouracil chemical structure which EPZ-6438 research buy only a small proportion of patients will have celiac disease, and in which such patients may have a more patchy distribution of pathologic abnormalities. Moreover, adherence was low even for those who consider ≥3 specimens to be satisfactory,20 because the most common submitted number of specimens was 2 (Fig. 1). These results indicate that this proposed standard appears to be slowly diffusing into clinical practice, because the proportion of individuals undergoing duodenal biopsy who have ≥4 specimens submitted increased

between the years 2006 and 2009. Nevertheless, this practice was performed in a minority of patients even in 2009, when only 37% of patients had ≥4 specimens submitted. Guidelines are adopted by physicians HSP90 at variable rates, and at times this variability creates

new racial or socioeconomic disparities.21 In our study, we did not have access to socioeconomic or racial data to determine whether these individual patient characteristics were associated with the submission of the recommended number of specimens. In this study, the incremental diagnostic yield of submitting ≥4 specimens was large, because the proportion of patients diagnosed with CD was doubled when ≥4 specimens were submitted. This incremental yield varied by indication and was greatest when the indication was malabsorption/suspected CD (OR 7.37; 95% CI, 4.70-11.57) or anemia (OR 2.65; 95% CI, 2.13-3.30). However, submitting ≥4 specimens also increased the diagnostic yield of CD even when the indication was GERD (OR 1.84; 95% CI, 1.33-2.55). We therefore conclude that, although the increased diagnostic yield of adherence varies in magnitude, it is present and should be adhered to regardless of indication. Why were ≥4 specimens submitted only 35% of the time? One possibility is that this proposed guideline is new and not fully accepted.1, 13 and 20 Another possibility is that knowledge of the appropriate amount of specimens to submit is not yet widespread. This explanation is supported by the finding that the submission of ≥4 specimens has modestly increased over time (OR for 2009 vs 2006, 1.58; 95% CI, 1.27-1.97).