The diagnosis of celiac disease has definitely become more complex due to the interplay of serology, genetic markers, clinical response to gluten-free diets, and histology. The Mayo clinic pediatric experience with duodenal intraepithelial lymphocytosis (IELs) with normal villous architecture highlights this issue (JPGN 2013; 56: 51-55).
Between 2000-2009, 56 children from the Mayo clinic pathology database of duodenal biopsies (n=1290) were identified. Among this group, 48 had serological testing for celiac disease (CD). Ultimately, 9 were labeled with CD, though only 5 met the ‘definite’ criteria. Other conditions that were associated with increased IELs included the following:
- Medication exposure
- Inflammatory bowel disease
- H pylori infection
- Autoimmune conditions
- IgA deficiency
So, which patients with duodenal IELs had CD?
- “Definite” CD was used to define patients with elevations in two different serologic markers (TTG and EMA) or those with elevation in one serologic marker along with a documented clinical response to a gluten-free diet (GFD).
- “Possible” CD described patients with normal serology, but serologic titer and clinical response was noted on a GFD.
- “Unlikely” CD categorized patients with two negative serology markers who had compatible human leukocyte antigen haplotype and had clinical response to GFD.
In addition, if the IELs were predominantly on the villi tips, this increased the likelihood of CD.
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