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Celiac Disease Histological Findings

The findings on a duodenal biopsy must be interpreted in detail by a pathologist experienced and interested in this condition and according to Marsh’s criteria (modified), which stratify this disease into four types or stages. Biopsy samples are usually collected during an upper GI endoscopy in the second portion of the duodenum close to the Vater ampulla; at least 4-6 well-oriented samples should be submitted, as the celiac disease lesions are often irregular and patchily distributed[22].

Celiac disease may be diagnosed with a normal duodenal biopsy (Stage 0), with an increased percentage of intraepithelial lymphocytes (IELs) above 30% (Stage 1), the presence of crypt hyperplasia and infl ammatory infi ltrates in the lamina propria (Stage 2), and all of them with well-preserved villi. It is not until Stage 3, that villous atrophy develops, which is divided into three different categories: Mild (A), Moderate (B), and Total or Subtotal (C). Finally, Stage 4, or total hypoplasia of the mucosa, is now rarely seen.

Routine use of Marsh’s classification in the study of duodenal biopsies, is of great help, when recognizing occult, doubtful cases, and must always be used when performing a diagnostic upper endoscopy in patients belonging to so-called “at risk groups” regarding CD, including those with chronic diarrhea, refractory ferropenic anemia, or both[23].

Duodenal biopsy is still considered by most authors the “gold standard” in the diagnostic process, albeit its usefulness in the adult is still slightly controversial. If results of the histological study are negative but serologic tests are positive and celiac disease is strongly suspected, the results of the biopsy should be reviewed with an expert gastrointestinal pathologist before additional biopsies are considered.

In addition, if the histological exam yields equivocal results, it is useful to proceed with HLA typing. Although almost 40% of the general population has the HLA-DQ2 or HLA-DQ8 markers, nearly 90%-95% of celiac disease patients have them[24].

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