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Are Marsh Patients Really Celiac Patients?

2008; Lippincott Williams & Wilkins; Volume: 103; Linguagem: Inglês

10.14309/00000434-200809001-00254

1572-0241

C.C. Cortelezzi, M. Parravicini, Giuseppe Chianese, M. Lombardini, Sergio Segato,

Microscopic Colitis

Purpose: The duodenal biopsy is regarded as the gold standard in the diagnosis of celiac disease when biopsy samples are correctly orientated. The endomisyal antibodies (EMA) are virtually 100% specific for celiac disease, but sensitivity correlates with the degree of villous atrophy. According to Marsh's classification, the increase in intraepithelial lymphocytes (IEL) is one of the histological abnormalities which is compatible with the diagnosis of celiac disease. The experts disagree as to whether a gluten-free diet is necessary in this condition. The aim of the study was to investigate the histological and clinical effects of the gluten free diet in patients with increase in IEL. Methods: The study was made on 17 patients (12 women, 5 men, median age 42 yrs, range 23–69) who were negative for AGA/EMA, infections caused by H. Pylori, autoimmune disorders, IBD and for use of NSAIDS (group A). All patients underwent upper gastrointestinal endoscopy and duodenal biopsy; immunohistochemical staining with anti-CD3 monoclonal antibody was used to visualize intraepithelial lymphocytes on forceps biopsy. Each patient was examined according to symptoms and quality of life and this was reported with visual analogic scale (VAS) In the same way the study was made on 12 patients (8 women, 4 men, median age 41 yrs, range 25–51) as a control group (group B). Data of IEL were analysed by t-Student's test and data of quality of life were analysed by the Wilcoxon test Then, group A was kept on gluten free diet and group B was kept on normal gluten containing diet. Results: One year later, after the second examination, group A showed an improvement in quality of life (P 0,0001) and histological condition (P 0,0004) with statistically significant difference. On the contrary group B showed an improvement in histological condition (P 0,0255) but not in quality of life (P 0,825) Conclusion: The clinical improvement on a gluten-free diet is not diagnostic for celiac disease: the improvement might be due to a placebo response in IBS patients or to a generic intolerance to gluten. The relationship between IEL and diet is ambiguous and variations in the number of intraepithelial lymphocytes occur also in diet-free patients. Patients with increase of IEL should not be kept on a gluten -free diet.