Introduction Raised intraepithelial lymphocytes (IEL) (>30–40 IEL/100 enterocytes) in small bowel (SB) mucosa is associated with coeliac disease (CD) when accompanied by distorted villous architecture. In addition to CD, there are other causes of raised IEL including NSAIDs, autoimmune conditions, tropical sprue, H pylori associated gastritis and intestinal lymphoma. It is recommended that patients who have raised IEL without distorted villous architecture (Marsh classification Stage 1 criteria) undergo further serological testing along with HLA DQ2 DQ8 genotyping to assist in the diagnosis of CD. The aim of the study was to determine the further assessment in clinical practice of patients with raised IELs in otherwise normal SB biopsies to confirm the diagnosis of CD.
Method A single centre, retrospective analysis of patients with the histological finding of raised IELs on distal duodenal (D2) biopsies in a district general hospital was performed. A database of patients with raised IEL was obtained from the hospital histology database and data on the patients coeliac antibody result, symptoms, diagnosis and management was scrutinised using the electronic patient record system.
Results 121 patients had raised IEL on D2 biopsy specimens. 58 of these patients had a confirmed diagnosis of CD with villous atrophy. The remainder (63) had raised IEL with preserved villous architecture. 48/63 patients were negative for coeliac antibodies, 1 was positive and 14/63 (22.2%) were not tested. 15/63 (23.8%) were initiated on a gluten free diet and of this, 4 did not report an improvement in their symptoms despite adherence. Only 2 patients had HLA DQ2/DQ8 testing to aid in the diagnosis of CD. A final diagnosis of CD was made in 11/63 (17.5%) patients meeting Marsh 1 criteria. 32/63 (50.8%) patients had a diagnosis of gastrooesophageal reflux disease (GORD) including 10 patients (15.9%) with H pylori associated gastritis. H pylori was not tested in 13/32 patients with GORD (40.6%). A third of patients (20/63 = 31.7%) with raised IEL and normal SB mucosa did not undergo any further specific investigation to elucidate the cause of the raised IELs.
Conclusion There is marked variability in management of patients following the findings of raised IEL with normal SB mucosa. A fifth of patients did not have coeliac antibody tested and only 2 patients had HLA DQ2 DQ8 genotype assessment. Latent CD was diagnosed in almost a fifth (17.5%) of patients with raised IEL and preserved villi whilst GORD and H pylori gastritis were present in half of the patients with this finding. We recommend that all patients in whom raised IELs are identified have coeliac serology and HLA DQ2 DQ8 testing to exclude CD prior to entertaining other diagnoses in clinical practice.
Disclosure of interest None Declared.
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