The Clinical Significance of Duodenal Lymphocytosis With Normal Villus Architecture

Abstract

Context.-The finding of increased intraepithelial lymphocytes with normal villous architecture (Marsh I lesion) is seen in up to 3% of duodenal biopsies. The differential diagnosis includes a wide range of possibilities, including celiac disease, bacterial overgrowth, nonsteroidal antiinflammatory drug damage, reaction to Helicobacter pylori infection, tropical sprue, and chronic inflammatory bowel disease.Objectives.-To highlight the histologic features of the Marsh I lesion, review the diseases and conditions associated with that finding, and to provide pathologists with a rationale and a template for how to identify and report such cases.Data Sources.-A review of the literature regarding the histologic features and clinical associations of Marsh I lesions.Conclusions.-Marsh I lesions are a nonspecific finding associated with a number of disease conditions. Historically, between 9% and 40% of cases have been shown to represent celiac disease. Current data do not suggest histologic features to differentiate between diseases associated with this histologic change.

Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology

“…However, in some cases the diagnosis of CD may not be straightforward, for example, patients are already on a GFD and therefore antibodies are negative, biopsies were not oriented correctly (this could lead to false-negative or false-positive villous atrophy) or show solely intraepithelial lymphocytosis (lymphocytic duodenosis)74 without architectural changes. In these situations, the patient needs to be maintained on a gluten-containing diet and further evaluated with additional testing and, if necessary, referred to a centre or clinician with a specific interest in CD.…”

Diagnostic challenges in celiac disease

“…4 The antibody titers correspond with the degree of villous atrophy and in less destructive lesions are often lowlevel or negative. [6][7][8] Therefore, negative serology does not exclude diagnosis and if suspicion of CD is high, intestinal biopsy should be performed even if serology is negative.…”

“…6 The normal villous to crypt ratio ranges from 3:1 to 5:1. 12 The villous epithelium is composed primarily of absorptive cells and goblet cells, with IELs between them.…”

“…13 Plasma cells, lymphocytes and little amount of eosinophils and macrophages are usually present in the lamina propria. 6 …”

“…In most cases no cause for LD is found and these changes usually disappear on repeated biopsy. 6,16,18,19 There is a high prevalence of patients fulfilling irritable bowel syndrome (IBS) criteria in this group. 16 In fact, the association between IBS and LD has been reported in several studies, where immunocytochemical staining for T cells (CD3) was performed.…”