PWE-104 IDA patients with negative coeliac serology on straight to test pathway; is D2 biopsy necessary?

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Current BSG guidelines for Iron Deficiency Anaemia (IDA) recommend screening all adult patients for coeliac disease (CD). Duodenal biopsies are only required in patients with positive coeliac serology due to very low post-test probability for CD if serology is negative. BSG CD guidelines however recommend duodenal biopsies regardless of the serology result. We aimed to assess current practise and outcomes in the setting of a straight to test (STT) IDA pathway.


We conducted a retrospective analysis of all adult patients referred on STT IDA pathway over a 3 months period. Patients who did not ultimately undergo endoscopy or had a prior diagnosis of CD were excluded from the study.


During the study period 239 patients were referred under the STT IDA pathway. Of these, 175 (male 76, female 99) underwent endoscopic investigations and were included in the study. Mean age of male and female participants was 66 and 68 years respectively. The average haemoglobin on referral was 102 g/L. Pre-endoscopy coeliac serology was only available in 44/175 patients (25.1%). Serology was positive in 1 of these patients (2.3%)-CD was confirmed on duodenal biopsy. Duodenal biopsies were still taken in 31/43 (72.1%) patients with negative serology, histology was normal in all cases. 110/131 (84%) of patients without pre-endoscopy serology had duodenal biopsies taken. 9/110 (8.2%) had abnormal duodenal biopsies. 4 cases intraepithelial lymphocytosis, 2 duodenitis and 1 Giardiasis. 2 patients had villous atrophy with suspected CD-serology came back positive in 1 patient. Second patient awaiting further investigations. There was no difference in duodenal biopsy rate based on CD serology availability (72% vs 84% p=0.11).


Patients in STT IDA pathway with negative CD serology are unlikely to have CD. Duodenal histology is abnormal in a significant number of patients with negative serology however failure to check CD serology prior to endoscopy leads to diagnostic uncertainty and delays in diagnosis. A point of care test for CD performed in endoscopy could fill this gap. Incongruent anaemia and CD guidelines lead to uncertainty amongst clinicians and may explain variable practise.

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