Modified Marsh Grade 2 Change in Duodenal Biopsies Is as Suggestive of Serological Positivity in Celiac Disease as Are Higher Grades
A Patel, D Bradly, M McIntire, D Giusto, S Jakate. Rush University Medical Center, Chicago, IL
Background: The diagnostic algorithm of celiac disease or gluten-sensitive enteropathy, a chronic immune-mediated enteropathy due to gluten intolerance, is complex and based upon serological and histological concordance. Antibodies against tissue transglutaminase (TTG) and endomysium (EMA) have the highest specificity and sensitivity in comparison with other serological tests. Proximal small intestinal biopsies are graded according to the modified Marsh criteria, adopted by the National Institite of Health. When intestinal biopsies display greater than Marsh 2 changes (variable villous shortening or Marsh 3), diagnosis of celiac disease is made with seropositivity. However, when serological studies are normal, celiac disease may still be diagnosed clinically by HLA studies (presence of DQ2/DQ8). Since data correlating histology with serology is limited, we correlated modified Marsh grading of duodenal biopsies with serological positivity and HLA positivity when serology is negative.
Design: Review of clinical and pathology databases from our medical center from 2004 to 2008 identified 135 adult patients clinically suspected of celiac disease who had duodenal biopsies. The following characteristics were reviewed: modified Marsh grading of the duodenal biopsies (0 = normal, 1 = IELs only, 2 = IELs + crypt proliferation, 3 a,b,c = 2 + mild, moderate and severe shortening of villi), serological positivity (TTG and EMA), and when serology was negative, presence of HLA-DQ2 or HLA-DQ8.
Correlation between Marsh grade of duodenal biopsy, serology, and HLA status.
|Marsh 0||Marsh 1||Marsh 2||Marsh 3|
|Patients||67/135 (50%)||7/135 (5%)||14/135 (10%)||47/135 (35%)|
|Serology||0/7 (0%)||14/14 (100%)||38/47 (81%)|
|HLA||2/5 (40%)||N/A||6/9 (67%)|
Conclusions: In our experience, lower grade (modified Marsh 2) histological changes are just as predictive of celiac disease as higher grades with villous shortening. This makes further subclassifications in modified Marsh grades 3a, 3b and 3c, less clinically useful than the recommendations currently adopted. Furthermore, our study reduces the stringency involved in the orientation of the duodenal biopsies to evaluate the shortening and puts greater emphasis in evaluating intraepithelial lymphocytes (IELs), chronic duodenitis and crypt proliferative changes.
Monday, March 9, 2009 9:30 AM
Poster Session I Stowell-Orbison/Autopsy Award # 102, Monday Morning