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AGA releases guideline on EGD biopsy in dyspepsia with normal-appearing mucosa
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The AGA’s Clinical Practice Guidelines Committee has developed new guideline recommendations on the role of upper gastrointestinal biopsy for evaluating dyspepsia in patients without visible mucosal lesions.
“Currently, there are no clinical standards or guidelines for the performance of … biopsies of normal-appearing mucosa [in patients with dyspepsia],” according to the guideline. “As a result, there is likely wide practice variation in whether or not such biopsies of normal-appearing mucosa are obtained. Additionally, how the results of such biopsies affect management is poorly understood.”
The guideline was developed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology and Institute of Medicine best practices, with the aim of establishing evidence-based standards for performing biopsies of normal-appearing mucosa in the upper GI tract of adult patients undergoing esophagogastroduodenoscopy for dyspepsia as the only indication.
Summary of recommendations
Routine biopsies of normal-appearing esophagus or gastroesophageal junction are not recommended regardless of immune status. Very low quality evidence shows these routine biopsies “would have very low probability of diagnosing esophageal abnormalities or have little impact on clinical management,” according to the guideline.
Routine biopsies of the normal-appearing gastric body and antrum for detecting Helicobacter pylori infection are recommended regardless of immune status if H. pylori status is unknown. When doing so, the five-biopsy Sydney System with all specimens placed in a single jar is recommended, while obtaining automatic special staining of the specimens is suggested against.
“Despite the overall low quality of the evidence, there are substantial data, including those from randomized controlled trials, supporting a clinically important benefit to detecting and eradicating [H. pylori] infection in patients with dyspepsia, both with respect to symptomatic relief and gastric cancer risk reduction,” the guideline authors wrote.
Routine biopsies of the normal-appearing duodenum for detecting celiac disease in patients without signs or symptoms are suggested against “based on very-low-quality evidence [that] the prevalence of biopsy-proven celiac disease among patients with dyspepsia is not significantly different from that in the U.S. general population in which screening for celiac disease is not recommended.”
Routine biopsies of the normal-appearing duodenum are suggested for detecting graft-vs-host disease in immunocompromised patients with post-allogeneic tissue transplantation or opportunistic infections, but “the magnitude of the potential benefit is likely small.” When doing so, routine special staining of the specimens is again suggested against.
“The AGA will continue to monitor and assess new and potentially relevant evidence to determine whether updating of these recommendations is justified,” the authors concluded. – by Adam Leitenberger
Disclosures: Healio Gastroenterology was unable to confirm relevant financial disclosures at the time of publication.
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