4204 Clin Pathol 1993;46:420-424 with histological features of peptic duodenitis: Value of assessment of intraepithelial lymphocytes J Clin Pathol: first published as 10.1136/jcp.46.5.420 on 1 May 1993. Downloaded from

M D Jeffers, D O'B Hourihane

Abstract phonuclear leucocyte infiltrate and absence of Aims-To determine if a clinically gastric metaplasia in coeliac disease. important polymorphonuclear leucocyte We present four cases in which mucosal infiltrate and surface gastric epithelial biopsy specimens of the second part of the metaplasia occur in the second part of presented histological appear- the duodenum in coeliac disease; to eval- ances suggesting non-specific duodenitis but uate the utility of these morphological in which the diagnosis of coeliac disease was criteria in the differential diagnosis of subsequently confirmed on clinical, immuno- coeliac disease and peptic duodenitis. logical, and histological grounds. Methods-49 mucosal biopsy specimins of the second part of the duodenum reported as showing were Methods reviewed. Sections were prepared with All mucosal biopsy specimens of the second haematoxylin and eosin, periodic acid part of the duodenum reported as showing Schiff, and Warthin-Starry stains. Clini- inflammation were reviewed for the 6 months cal presentation, outcome, and immuno- from January to July 1991. This included logical investigations were assessed. cases reported as coeliac disease, peptic duo- Results-Four cases confirmed as coeliac denitis, non-specific inflammation and other disease on clinical and immunological specific diseases. Sections 4 pm thick were grounds showed acute inflammation and prepared with haematoxylin and eosin, peri- surface epithelial gastric metaplasia. odic acid Schiff (PAS), and Warthin-Starry Increased intraepithelial lymphocytes silver stains. Sections were reviewed with par- (IELs) were found in each ofthe four. ticular emphasis on villous atrophy, crypt Conclusions-Clinically important poly- hyperplasia, chronic inflammation, intraep- morphonuclear leucocyte infiltration and ithelial lymphocytes, acute inflammation, sur- surface epithelial gastric metaplasia may face epithelial abnormalities and surface http://jcp.bmj.com/ occur in the duodenal mucosa in coeliac epithelial gastric metaplasia. On the basis of disease and should not be used as diag- morphology, cases were designated as coeliac nostic features to exclude the diagnosis disease, peptic duodenitis, non-specific of coeliac disease in the absence of con- inflammation and other specific inflammatory firmatory clinical and immunological disorders. information. Case notes were reviewed with particular reference to clinical presentation, endoscopic on September 26, 2021 by guest. Protected copyright. (7 Clin Pathol 1993;46:420-424) appearance, response to gluten withdrawal and serum a gliadin and endomysial antibody titres. Intraepithelial lymphocytes were count- Inflammation of the duodenal mucosa occurs ed for 300 surface epithelial cells, and the in many different diseases. Specific morpho- result expressed as a mean, with the range per logical features are present which point to 100 surface epithelial cells. Alpha gliadin aetiology in some cases, while the remainder antibodies are present from 0-3 units/ml in are often grouped together under the collec- healthy subjects. tive title of non-specific (peptic) duodenitis. Coeliac disease is characterised on mucosal biopsy specimens by villous atrophy, surface Results epithelial cell disarray, mixed chronic inflam- The morphological diagnoses of the 49 biop- matory cell infiltrate of the lamina propria, sy specimens from 48 patients were as fol- and a sharp increase in intraepithelial lym- lows: coeliac disease n = 13; peptic phocytes, chiefly of the T8 + subtype. In duodenitis n = 12; peptic ulceration n = 3; peptic duodenitis the inflammation includes non-specific inflammation n = 16; Crohn's Department of prominent foci of polymorphonuclear leuco- disease n = 1; coeliac disease/peptic duodeni- Pathology, St James's cytes, and flattening of surface (villous atro- tis n = 4. Hospital and Trinity College, Dublin phy), and may be difficult to distinguish from -like organisms were identified in Ireland the changes seen in coeliac disease. Features four cases of peptic duodenitis, and were pre- M D Jeffers which have been proposed as useful diagnos- sent only on gastric type epithelium. D O'B Hourihane tic pointers in distinguishing severe peptic Serum a gliadin antibody titres were raised Correspondence to: Professor D O'B Hourihane duodenitis from coeliac disease include the in 10 cases (coeliac disease nine cases, range Accepted for publication relative lack of architectural changes in non- 6 to 30 units/ml, mean 13-1 units/ml, 4 November 1992 specific duodenitis, and the scanty polymor- Crohn's disease one case, 32 units/ml). Coeliac disease with histologicalfeatures ofpeptic duodenitis 421

Serum endomysial antibody titre was avail- other symptoms. able in four cases of coeliac disease and was There was no family history of coeliac dis- positive in two cases. eae, although one sibling also had iron defi- Gastric metaplasia was present in 15 cases, ciency anaemia. At the 12 cases of peptic duodenitis, and three cases oesophagus, stomach, and duodenum were J Clin Pathol: first published as 10.1136/jcp.46.5.420 on 1 May 1993. Downloaded from of coeliac disease originally reported as most all macroscopically normal. A biopsy speci- suggestive of peptic duodenitis. Biopsy speci- men of the second part of the duodenum mens from these three patients showed archi- showed villous atrophy (fig 1) and prominent tectural changes and inflammatory infiltration intraepithelial lymphocytes, with focal gastric suggestive of coeliac disease but also con- metaplasia (less than 5% of surface entero- tained acute inflammation and surface epithe- cytes) (fig 2) and pronounced polymorphonu- lial gastric metaplasia. These three cases are clear leucocyte infiltrate in the lamina propria presented in detail below. A fourth example which extended into the surface epithelium. of gastric metaplasia and focal poly- This was interpreted as peptic duodenitis morphonuclear leucocyte exudate was rather than coeliac disease. Serum a gliadin encountered during 1992, and has been antibodies were positive at a titre of >32 added to the series (case 4). units/ml and serum endomysial antibodies (EMA) were positive. A gluten challenge was performed (50 g Case reports gluten a day for 10 weeks) and a biopsy speci- CASE 1 men of the second part of the duodenum was A 42 year old man presented with a history taken at the end of this. This again showed of persistent unexplained iron deficiency architectural features suggestive of coeliac anaemia (haemoglobin 114 g/l, mean cell vol- disease, but it also showed a noticeable poly- ume 74X5 fl). There was no history of diar- morphonuclear leucocyte infiltrate, raising rhoea, , weight loss, mouth ulcers or the possibility of non-specific duodenitis; a gliadin antibodies was again positive at a titre of >32 units/ml, and EMA were positive. The patient was started on a gluten free diet. After 6 months a duodenal biopsy was performed which showed that the mucosa had reverted to normal (fig 3).

CASE 2 A 13 year old girl who had not yet begun to menstruate presented with lassitude and fatigue and was found to have iron deficiency anaemia (haemoglobin 37 g/l, mean cell vol- http://jcp.bmj.com/ ume 67-6 fl). She was also folate deficient (1.2 mg/l normal 2-7 > 20 mg/l). She had no gastrointestinal symptoms. There was no family history of coeliac disease. At endoscopy the oesophagus and stomach appeared normal and the duodenum appeared atrophic. A mucosal biopsy speci- on September 26, 2021 by guest. Protected copyright. PIT;, ;i;'.£P ^. men from the second part of the duodenum Figure I Case 1: duodenal mucosa with vilous atrophy and severe inflammmation showed villous atrophy, mixed chronic (haematoxylin and eosin.) inflammatory infiltrate of the lamina propria, increased intraepithelial lymphocytes, and a polymorphonuclear leucocyte infiltrate of lamina propria, crypt, and surface epithelium (fig 4), and focal gastric metaplasia of surface epithelium. Serum a gliadin antibodies were positive, at a titre of 30 units/ml; EMA were positive.

CASE 3 (. A 74 year old woman was admitted with weakness and dyspnoea. Other symptoms included heartburn, anorexia, and a weight loss of 5 lbs. A full blood count showed iron deficiency anaemia (haemoglobin 83 g/l, mean cell volume 82 fl). At endoscopy there was oesophagitis at 28 cm and the stomach and duodenum were macroscopically normal. A mucosal biopsy specimen of the oesopha- gus showed changes suggestive of reflux oesophagitis. A biopsy specimen of the sec- ond part of the duodenum showed subtotal Figure 2 Case 1: focal surface epithelial gastnic metaplasia (arrow) (periodic acid-Schiff. villous atrophy with crypt hyperplasia, epithe- 4224Jeffers, Hourihane

lial cell abnormalities, increased numbers of intraepithelial lymphocytes and a mixed chronic inflammatory cell infiltrate of the lamina propria, with, in addition, a polymor- phonuclear leucocyte infiltrate with extension J Clin Pathol: first published as 10.1136/jcp.46.5.420 on 1 May 1993. Downloaded from upwards into the surface epithelium which also showed focal gastric metaplasia. The patient was discharged with oral iron supple- ments. Three months later she still had per- sistent abdominal discomfort. Serum a gliadin antibodies were positive, at a titre of 11 units/ml, and she was started on a gluten free diet. Six months later her symptoms had improved. Haemoglobin and mean cell vol- ume were normal. At endoscopy there was C mS~~~~~~~~~~C mild oesophagitis. The stomach and duode- Figure 3 Case 1: duodenal biopsy specimen from patientfollowing glutenfree diet. num were macroscopically normal. Duodenal ViUous architecture is restored and surface epithelium is normal (haematoxylin and eosin). biopsy specimens were normal apart from minor architectural changes and a mild chronic inflammatory cell infiltrate. Serum a gliadin antibodies were positive at 10 units/ml.

CASE 4 A 63 year old man was anaemic (haemoglo- bin 99 g/l) on presentation for his regular donation of blood to the transfusion service. He had no family history of coeliac disease, no bowel symptoms, and no history of blood IFS..8 ik. loss. As part of investigation of an iron defi- -4~~~~~~~ ciency anaemia he had a gastroscopic exami- nation and a biopsy of the duodenum. The mucosa was flat with one focus of gas- INW~~ ~ ~ ~ ~ tric metaplasia (less than 5%) and several g. areas with prominent polymorphonuclear leu- *, 94t.....'b t 4 * X *,*.** * i . 41 g6 VA ~ ~ ~ cocytes in the lamina propria, extending 4 i >; *4; < 4 b<*!*Y @i t. locally into the surface epithelium (fig 5). http://jcp.bmj.com/ 2 t m g A!. S~ ; ~ ~ ~ ~A ~ * Intraepithelial lymphocytes were also promi- i w M .v* ....% :.x t nent. Serum a gliadin antibodies were posi- 41. tive, at a titre of 18 units/ml As intraepithelial lymphocytes were promi- *~~~~~~ nent in all four cases, counts were conducted Figure 4 Case 2: prominent neutro~phil (and plasma cell) infiltrate of lamina propria, on all four, and in 1 1 out of the 15 cases clas- on September 26, 2021 by guest. Protected copyright. with vacuolationzXof surface epithelium (haematoxCylin and eosin). = ..~~' sified as peptic ulcer (n 3) or peptic duo- denitis (n = 12). In four cases of peptic disease surface epithelium was either absent, was largely gastric, or was technically poorly preserved so that the counts were conducted The results are as follows: Peptic Coeliac ulcer disease IEL1300 (11 cases) (4 cases) surface epithelial cells 10(5-6 - range) 52(43-66 - range)

..A. .4 p = 0 0047 4~~~~~~~~4 on the remaining 11 cases. F *tA0

We Discussion 44~~~~~~~~~~~~~~~~4 With the widespread replacement of jejunal biopsy by endoscopic biopsy of the second part of the duodenum for the diagnosis of coeliac disease, histopathologists are increas- ingly faced with the problem of interpretation of duodenal mucosal biopsy specimens in attempting to establish the diagnosis. The and Figure Case 4: duodenal surface with prominent intraepithelial polymorphonucear original descriptions, most subse- leucocytes (arrows); intraepithelial lymphocytes also present (haematoxylin and eosins). quent research observations of coeliac dis- Coeliac disease with histologicalfeatures ofpeptic duodenitis 423

ease, refer to histological abnormalities in in both jejunal'0 and rectal"'mucosa is charac- jejunal mucosa. Duodenal mucosal specimens terised by an acute inflammatory response in pose certain problems of interpretation in the lamina propria with vascular dilatation, that the architecture shows shorter and thick- prominent polymorphonuclear leucocyte er villi compared with those found in the exudation, and mast cell degranulation. J Clin Pathol: first published as 10.1136/jcp.46.5.420 on 1 May 1993. Downloaded from , especially in areas overlying Secretion of neutrophil enzymes (such as Brunner's glands. Stromal inflammation is myeloperoxidase) into jejunal juice has also also common and may lead to progressive been shown to be increased following gluten shortening of villi, resulting ultimately in a challenge.12 The early mucosal acute inflam- flat mucosa. matory response to gluten challenge is fol- Peptic duodenitis, also termed "non-specif- lowed by increasing lymphocytic infiltration ic" duodenitis, is associated with acid injury of the lamina propria, migration of lympho- and leads to a spectrum of histological cytes into the surface epithelium, and reduc- mucosal changes from mild inflammation to a tion in the polymorphonuclear leucocyte flat mucosa which may be very difficult to population. A substantial increase in poly- distinguish from that seen in coeliac disease'. morphonuclear leucocytes has been reported Grading systems for duodenitis have been in jejunal mucosal biopsy specimens of proposed based on morphological changes patients with untreated coeliac disease using chiefly described in the duodenal cap or first ultrathin sections stained with toluidine part of the duodenum (Dl). Low grade duo- blue,"3 but in 4 gm paraffin wax embedded denitis is characterised by mild widening and routine sections stained with haematoxylin flattening of villi associated with mild chronic and eosin polymorphonuclear leucocytes are inflammation of the lamina propria. As the generally referred to as scanty or absent.'4 inflammation becomes more severe increasing Although substantial polymorphonuclear flattening of architecture is noted, combined leucocyte infiltrate and surface epithelial gas- with a mixed acute and chronic inflammatory tric metaplasia have been recommended as cell infiltrate of lamina propria, and with pointers strongly favouring peptic duodenitis extension of polymorphonuclear leucocytes over coeliac disease,'4 they are not specific to into the surface epithelium together with gas- acid induced injury and should not therefore tric metaplasia of the surface.23 be used as criteria to exclude the diagnosis of Our four cases had flattening, gastric meta- coeliac disease. We have shown here that plasia, and a polymorphonuclear leucocyte small foci of gastric epithelium and focal exu- exudate, but the metaplasia was never more dates of polymorphonuclear leucocytes may than 5% of the surface, and the polymor- be found in coeliac disease, and that assess- phonuclear leucocytes, although prominent, ment of intraepithelial lymphocytes is a were also in foci, while no erosions were seen. reliable morphological discriminant to distin- Some assessment of intraepithelial lympho- guish between coeliac disease and peptic duo- cytes is the best way to discriminate between denitis. It has been suggested that peptic http://jcp.bmj.com/ the two different causes of inflammation in duodenitis and coeliac disease may coexist in the duodenum. the same patient'5 and this could be invoked Gastric metaplasia in the duodenum has to explain the changes in the cases we report been considered a reparative or protective here. The symptomatic and morphological response to acid injury.4 Small groups of gas- improvement seen in our patients following tric type epithelial cells are commonly seen in gluten withdrawal without any treatment the mucosa of DI, but more extensive meta- aimed at the acid-peptic disease implies that on September 26, 2021 by guest. Protected copyright. plasia with extension to D2 is strongly associ- the structural changes were in fact due to ated with active duodenitis, low gastric pH, coeliac disease. and Hpylori infection.45 Gastric metaplasia of In patients with clinical features suggestive intestinal crypts is well recorded in chronic of coeliac disease, morphological abnormali- ulceration of the from any ties of duodenal mucosa should be interpret- cause such as Crohn's disease or potassium ed in conjunction with the clinical tablets.6 Ectopic gastric mucosa has been information with particular reference to recorded in the duodenum, jejunum, and dietary exclusion of gluten and immunologi- in coeliac disease,78 but gastric meta- cal confirmation using a gliadin and plasia of the surface epithelial cells is not gen- endomysial antibody titres. Definitive diagno- erally accepted as part of the spectrum of sis in cases where morphology is not typical coeliac disease. There is a strong correlation depends on consideration of all of these between gastric metaplasia, villous atrophy modalities rather than a reliance on individual and polymorphonuclear leucocyte infiltration9 morphological structural criteria. and, especially in the first part of the duode- We thank Ms Orla Shiels for photographic assistance and Ms num, polymorphonuclear leucocyte and gas- Truda McCullagh for typing the manuscript. tric metaplasia are the strongest histological correlates of endoscopic descriptions of inflammation. 1 Dobbins WO. Diagnostic pathology of the intestinal mucosa. Polymorphonuclear leucocytes have not New York: Springer-Verlag, 1990. 2 Whitehead R, Roca M, Meikle DD, Skinner J, Truelove been emphasised in the descriptions of SC. The histological classification of duodenitis in fibre- mucosal biopsy specimens in coeliac disease, optic biopsy specimens. Digestion 1975;13:129-31. 3 McCallum R W, Singh D, Wollam J. Endoscopic and his- although they seem to have some role in the tologic correlations of the duodenal bulb. Arch Pathol pathogenesis of mucosal injury in coeliac dis- Lab Med 1979;103:169-72. ease as the early response to gluten challenge 4 Wyatt SS, Rathbone BJ, Dixon MF, Heatley RV. 424 Jeffers, Hourihane

Campylobacter pyloridis and acid induced gastric meta- challenge with gluten in treated coeliac disease. Q Jf Med plasia in the pathogenesis of duodenitis. Clin Pathol 1981;197:83-94. 1987;40:841-8. 11 Loft DE, Marsh MN, Sandle GI, et al. Studies of intesti- 5 Wyatt JL, Rathbone BJ, Sobala GM, et al. Gastric epithe- nal lymphoid tissue XII. Epithelial lymphocyte and lium in the duodenum: its association with Helicobacter mucosal responses to rectal gluten challenge in celiac pylori and inflammation. Clin Pathol 1990;43:981-6. sprue. 1989;97:29-37. 6 Bayless TM, Kapelowitz RF, Shelley WM, Ballinger WF, 12 Hallgren R, Colambel JF, Dahl R, et al. Neutrophil and J Clin Pathol: first published as 10.1136/jcp.46.5.420 on 1 May 1993. Downloaded from Hendrix TR. Intestinal ulceration, a complication of eosinophil involvement of the small bowel in patients coeliac disease. NEngilMed 1967;276:996-1002. with celiac disease and Crohn's disease. Am Med 7 Trier JS, Moxey PC, Fordtran JS, MacDermott RP. 1989:86;56-64. Ectopic gastric mucosa in coeliac sprue. Gastroenterology 13 Dheshi I, Marsh M N, Kelly C, Crowe P. Morphometric 1973;65:712-17. analysis of small intestinal mucosa. (H). Determination 8 Thompson H. Necropsy studies on adult coeliac disease. of lamina propria volumes; plasma cell and neutrophil Jf Clin Pathol 1974;27:710-21. populations within control and coeliac disease mucosae. 9 Jenkins D, Goodall A, Gillet FR, Scott BB. Defining duo- Virchows Arch (Pathol Anat) 1984;403:173-80. denitis: quantitative histological study of mucosal 14 Day DW, Husain OAN. Biopsy pathology of the oesophagus, responses and their correlations. J' Clin Pathol 1985;38: stomach and duodenum. London: Chapman and Hall, 1119-26. 1986. 10 Anand BS, Piris J, Jerrome DW, Offord RE, Truelove SC. 15 Bayless TM, Jones B, Hamilton SR, Yardley JH. Nodular The timing of histological damage following a single duodenal bulb and peptic duodenitis is incompletely responsive "atypical" sprue. Gastroenterology 1982;82: 1014. http://jcp.bmj.com/ on September 26, 2021 by guest. Protected copyright.