Clinical Significance and Follow-Up of Patients with Duodenal Biopsy Revealing Intraepithelial Lymphocytosis with Preserved Villous Architecture
TC Rubinas, LJ Weinstein. University of North Carolina - Chapel Hill, Chapel Hill, NC
Background: Gluten sensitive enteropathy (GSE) is the most common cause of malabsorption in Europe and North America with a prevalence of 1%. Patients with GSE can develop many different clinical presentations (anemia, bloating, diarrhea, weight loss) and a spectrum of histologic findings can be seen in their duodenal biopsies. While the classic duodenal lesion consists of villous loss, intraepithelial lymphocytosis and crypt hyperplasia, patients with symptomatic GSE can have little to no histologic abnormality in the duodenum. Given this clinical and histologic variability, GSE is underrecognized. We sought to investigate the clinical significance of the histologic finding of preserved villous architecture with intraepithelial lymphocytosis in duodenal biopsies.
Design: We identified 63 patients who underwent duodenal biopsy and were noted to have preserved villous architecture and increase in intraepithelial lymphocytes (PVAIEL) on histologic examination. The histologic findings correspond to the type I lesion from the modified MarshOberhuber classification of GSE. Information regarding endoscopic findings, laboratory results [GSE associated serologies: tissue transglutaminase(T), endomysial (E), and gliadin, IgG and IgA (G) antibodies], and pertinent clinical information were obtained.
Results: Of the 63 patients noted to have PVAIEL on duodenal biopsy 53 (84%) had no duodenal abnormalities on endoscopy and 23 (37%) had follow-up GSE associated serology performed (10 T&E; 6 T; 4 T,E,G; 1E; 1E&G; and 1 T&G). All follow-up serologies were negative. Ig A measurement was performed on 13 patients with only one patient having low levels. Determination of HLA-DQ type was performed in 4 individuals revealing DQ2/3, DQ7/8, DQ7, and DQ9. None of the patients were considered to have GSE with a mean of 8.6 months (0-20 months) follow-up. Review of clinical history revealed that 2 of the 64 patients had prior diagnosis of GSE and 1 of 64 had positive GSE serologies performed at an outside institution.
Conclusions: Identification of PVAIEL in duodenal biopsies in patients with a low pre-test probability for GSE may have limited clinical significance. While endoscopy with biopsy remains the gold standard for the diagnosis of GSE, appropriate GSE-associated serological tests, HLA-DQ determination, and documentation of response to a gluten-free diet are important adjunctive tests when endoscopy and biopsy results are inconclusive.
Wednesday, March 11, 2009 9:30 AM
Poster Session V # 70, Wednesday Morning