Introduction
The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Expert Consensus Report published in 2016 (1) recommends taking at least 4 biopsies from the second portion of the duodenum (D2) and 2 biopsies from the duodenal bulb during endoscopies for children suspected of having celiac disease (CeD). This quality improvement project aimed to assess providers’ adherence to these recommendations at our institution.
Methods
We performed a chart review of 418 patients undergoing endoscopy to rule out CeD at our institution between 2016-2025. Follow-up procedures and biopsy reports that did not specify the number of samples taken were excluded. In cases where a single specimen cup was used for samples from the bulb and D2, the standard was met if there were at least 6 specimens. In cases where bulb and D2 samples were in separate containers, the standard was met if at least 2 specimens from bulb and at least 4 specimens from D2 were collected.
Results
In 34/418 (8.%) cases, duodenal specimens were placed in a single cup. Of these, only 8/34 (24%) met the NASPGHAN standard recommending at least 6 specimens. In cases where specimens were separated for bulb and D2, 231/384 (60%) met the NASPGHAN standard. 245/384 (64%) cases had at least 4 samples from D2, and 357/384 (93%) had at least 2 samples from the bulb. Percentage of cases meeting the standard varied widely by year of endoscopy (21.43%-84.0%). Adherence to the standard improved during 2016-2019 but declined from 2020-2025. Ultimately, 240/418 (57%) of all samples (unseparated and separated) met NASPGHAN standards.
Conclusion
Adherence to NASPGHAN biopsy recommendations was inconsistent, particularly pertaining to the number of specimens collected from D2. These findings highlight the need for periodic provider education and reminders to standardize biopsy practices, which may improve accurate diagnosis of CeD.