The correct methodological approach to the diagnosis of celiac disease: the point of view of the pathologist

Abstract

The diagnosis of celiac disease relies on the assessment of serological data and the presence of histological alterations in the duodenal mucosa. The duodenal biopsy is pivotal in adults, and in some circumstances in children, to confirm the clinical suspicion of celiac disease. The correct interpretation of duodenal biopsies is influenced by numerous variables. The aim of this overview is to describe the correct methodological approach including the procedures of biopsy sampling, orientation, processing, staining and histopathological classification in order to avoid or minimize the errors and the variability in duodenal biopsy interpretation. Multiple biopsies taken from different sites of the duodenum during endoscopy maximize the diagnostic yield of duodenal histological sampling. Proper orientation of the biopsy samples is of the utmost importance to assess histological features of pathological duodenal mucosa and to avoid artifacts that may lead even an experienced pathologist to a wrong histological interpretation with subsequent misdiagnosis of celiac disease. An immunohistochemical stain for CD3 can be invaluable to aid the pathologist in obtaining a more accurate intra-epithelial T lymphocytes count. A simplified histological classification facilitates the clinician's work and improves the communication between pathologist and clinician. An integrated clinical and pathological approach is required for a correct diagnosis of celiac disease since a relatively large number of conditions may cause duodenal damage with a histological appearance similar to that of celiac disease.

Keywords: Biopsy handling; Biopsy orientation; Celiac disease; Duodenal biopsies; Histopathological classification.

Figure 1

Acetate cellulose filter

Figure 2

A-B-C-Biopsy non oriented: evaluation of villous height and the villous/crypt ratio is difficult (H&Ex4), D-An imperfect orientation causes overlap of enterocytes leading to overestimate intraepithelial T lymphocytes count (CD3 immunostain x20).

Figure 3

A-B D: Normal duodenal mucosa: villus/crypt ratio over 3:1, C number of intraepithelial T lymphocytes < 25 per 100 epithelial cells (A H&E x4, B H&E x10, C H&E x20, C: CD3 immunostain x10)

Figure 4

A-B-C-D: Type 1 – Grade A lesion; normal villi but with a pathological increase of intraepithelial T lymphocytes > 25 per 100 epithelial cells (A-C H&E x10, B-D CD3 immunostain x10). E-F-G-H: Type 3A-3B-Grade B1 lesion: mild to moderate villous atrophy with pathological increase of intraepithelial T lymphocytes (E-G H&E and CD3 immunostain x10, G-H H&E and CD3 immunostain x40). I-L-M-N: Type 3C - Grade B2 lesion; severe villous atrophy with pathological increase of intraepithelial T lymphocytes. I-L H&E and CD3 immunostain x10, M-N H&E and CD3 immunostain x20