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Editor’s note: The study below, investigating whether the degree of villous atrophy (intestinal damage) correlates with the symptoms that are presented, found they do not. Therefore, more research is needed to find out why symptoms do not correlate with the degree of intestinal damage.
The pathologic range of villous atrophy seen on small intestinal biopsies ranges from severe (total villous atrophy and subtotal villous atrophy) to milder, partial villous atrophy.
The investigators state, “It would appear intuitive that the more severe forms of intestinal damage are correlated with the more severe and dramatic presentations.” With this in mind, one would think that those with total villous atrophy would experience more severe digestive symptoms like diarrhea. However, their study of medical records of all patients who had biopsy-proven CD did not bear this out.
“Atypical, or silent, mode of presentation included anemia, osteoporosis, dermatitis herpetiformis, screening high risk groups and those detected incidentally at endoscopy performed for reasons apart from diarrhea or iron deficiency anemia.”
It is important to note that “biopsies of the entire length of the small intestine, terminal ileal biopsies taken at colonoscopy and more recently video capsule colonscopy, reveal that the whole length of the intestine, including the large intestine, may be involved in the inflammatory process.”
MEDICAL RESEARCH: “Lack of correlation of degree of villous atrophy with severity of clinical presentation of coeliac disease”
Brar P, Kwon GY, Egbuna II, Holleran S, Ramakrishnan R, Bhagat G, Green PHR
Department of Medicine, Pediatrics and Pathology, Columbia University College of Physicians and Surgeons, New York, NY 10032
Digestive and Liver Diseases 39 2007 26-29.
Background and aim: Both the clinical presentation and the degree of mucosal damage in celiac disease vary greatly. In view of conflicting information as to whether the mode of presentation correlates with the degree of villous atrophy, we reviewed a large cohort of patients with coeliac disease.
Patients and methods: We correlated mode of presentation (classical, diarrhea predominant or atypical/silent) with histology of duodenal biopsies and examined their trends over time.
Results: The cohort consisted of 499 adults, mean age 44.1 years, 68% females. The majority had silent coeliac disease (56%) and total villous atrophy (65%). There was no correlation of mode of presentation with the degree of villous atrophy (p=0.25). Sixty-eight percent of females and 58% of males had a severe villous atrophy. (p=0.052. There was a significant trend over time for a greater proportion of patients presenting as atypical/silent coeliac disease and having partial villous atrophy although the majority still had total villous atrophy.
Conclusions: Among our patients the degree of villous atrophy in duodenal biopsies did not correlate with the mode of presentation, indicating that factors other than the degree of villous atrophy must account for diarrhea in coeliac disease.
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Author Information: Cleo Libonati, RN, BSN
Cleo Libonati is president/CEO and co-Founder of Gluten Free Works, Inc. She is the author of Recognizing Celiac Disease.
She can be reached by E-mail.
This research reinforces the importance of a biopsy as part of the diagnosis process because it’s real value is providing an accurate assessment of GI damage. And by knowing this, it’s possible to estimate a timeline for recovery. In general, those with the most severe GI damage will take longer to heal on GFD (gluten-free diet) than those with lesser damage, regardless of symptoms. When a patient isn’t progressing as expected after 6+months on GFD, biopsy is a helpful tool to idenitfy addition problems or complications. In those with the most severe damage, however, this biopsy could still find evidence of significant damage since, even though damage is much improved from its initial state. Without a pre-GFD biopsy for comparison, there is no way to verify healing while questions on dietary compliance and accurately of diagnosis would have to be considered.
While the necessity of biopsy to confirm diagnosis can be questioned, the initial benchmark of damage it provides is the insurance policy one needs when recovery doesn’t procede as expected. Hopefully, most won’t need in cash in that policy, but once gluten has been eliminated, you can never go back in time to capture the full extent of the damage.