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Is a raised intraepithelial lymphocyte count with normal duodenal villous architecture clinically relevant?
S Mahadeva1, J I Wyatt, P D Howdle
1Department of Medicine, St James's University Hospital, Beckett Street, Leeds LS9 7TF, UK.
Insights
A raised intraepithelial lymphocyte (IEL) count with normal villous architecture is a common finding, potentially indicating latent coeliac disease. This finding warrants attention in duodenal biopsy reports due to its clinical relevance.
Area of Science:
- Gastroenterology
- Histopathology
- Immunology
Background:
- A raised intraepithelial lymphocyte (IEL) count with normal villous architecture is recognized in latent coeliac disease.
- Limited data exists on this finding in adults without overt gluten-sensitive enteropathy.
Purpose of the Study:
- To determine the frequency of increased IELs with normal villous architecture in routine practice.
- To assess the clinical relevance of this histological finding.
Main Methods:
- Prospective identification of patients with increased IELs as the sole abnormality in duodenal biopsies.
- Re-examination of biopsy specimens and quantitative IEL counts.
- Clinical data collection via interviews and medical records approximately 12 months post-biopsy.
Main Results:
- Increased IELs with normal villous architecture were found in 2.2% of duodenal biopsies.
- Significantly higher IEL counts were observed in these cases compared to controls (mean 38 vs 12.4; p < 0.0001).
- Positive coeliac antibodies were present in 3/14 cases, with other diagnoses including unexplained anemia and chronic liver disease.
Conclusions:
- Raised IEL counts with normal villous architecture are not uncommon.
- This finding may suggest latent coeliac disease in some individuals.
- The clinical significance necessitates highlighting this finding in duodenal biopsy reports.
Background:
A raised intraepithelial lymphocyte (IEL) count with normal villous architecture is a recognised finding in latent coeliac disease. Little information is available in cases without gluten sensitive enteropathy in adults.
Aims:
To assess the frequency of such a finding in routine practice and to determine whether it is clinically relevant.
Methods:
Patients with subjectively increased IELs as the only abnormality were identified prospectively from a routine duodenal biopsy series over a 12 month period. The biopsy specimens in these index cases were re-examined together with two controls with normal histology for each case, and three counts of IEL/100 epithelial cells were made in all samples. The index cases were then contacted and interviewed to obtain clinical information, approximately 12 months from the initial biopsy. Further data were obtained from their clinical records.
Results:
Fourteen of 626 (2.2%) patients who had duodenal biopsies over the 12 month period had a subjective increase in IELs with normal villous architecture. Fifteen patients with newly diagnosed gluten sensitive enteropathy were also identified during the study period. Formal counting of the index cases and controls revealed a significant difference in IELs/100 epithelial cell counts between the two (mean, 38 (SD, 6.2) v 12.4 (4.6); p < 0.0001). Three of the 14 index cases tested had a positive coeliac antibody test compared with 12 of 15 newly diagnosed patients with coeliac disease and 10 of 93 patients with normal histology. The major clinical diagnostic categories in raised IEL cases were those with positive coeliac serology (n = 3), unexplained anaemia (n = 3), and chronic liver disease (n = 3). Six of 10 patients who were interviewed had ongoing gastrointestinal symptoms one year later. Three patients had had follow up duodenal biopsies, at the discretion of their responsible clinicians, with no change in IEL counts despite the commencement of a gluten free diet in two patients.
Conclusion:
A raised IEL count with normal villous architecture is not uncommon. Six of the 14 patients may have had latent coeliac disease. The cause in at least half of cases is not obvious at present. The finding of a raised IEL count with normal villous architecture is of sufficient clinical importance to be highlighted in routine duodenal biopsy reports.
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