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Year : 2011  |  Volume : 54  |  Issue : 2  |  Page : 279-283
Comparative study of histopathological Marsh grading with clinical and serological parameters in celiac iceberg of north India

1 Department of Pathology, Army College of Medical Sciences, Delhi Cantt, India
2 Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India

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Date of Web Publication27-May-2011


Background: Celiac disease is an autoimmune disorder caused by the ingestion of wheat gluten and related proteins in genetically susceptible individuals. It is characterized by anti-tissue transglutaminase (anti-tTG) antibodies. Duodenal biopsy is the gold standard for diagnosis. Correlation of clinical, serologic, and histological features is essential for a definitive diagnosis. The ratio of diagnosed versus undiagnosed cases is quite high. Aims: This study aimed to correlate the degree of mucosal damage with anti-tTG levels, mean baseline hemoglobin and endoscopic findings. Setting and Design: Two hundred twenty six adults suspected to have celiac disease were studied. Marsh grades were compared with anti-tTG levels, hemoglobin, endoscopy, and clinical presentations. Materials and Methods: Esophagogastroduodenoscopy, serum levels of anti-tTG, complete hematologic work-up, and duodenal biopsy were performed in all 226 cases (including three siblings of confirmed patients) with well-defined symptom groups. Histopathological grading was done as per modified Marsh system. Correlation of all the parameters was performed with Marsh grades. Statistical Analysis : Performed on SPSS version 15.0. Tests applied include one way ANOVA, Chi-square test, repeated measure analysis, and Bonferroni's method for comparison. Results were considered significant when P<0.05. Results and Conclusions: Anti-tTG levels, mean baseline hemoglobin, and endoscopic findings were found to correlate with increasing severity of mucosal damage with P<0.001 for all. Anti-tTG levels of grades 1+2 and those of grade 3a were significantly different from levels of grades 3b and 3c+4 with P<0.001 for each. Varied clinical presentations of celiac disease were seen in the adult wheat eaters of North India.

Keywords: Adult celiac disease, Marsh grading, anti-tTG

How to cite this article:
Kalhan S, Joseph P, Sharma S, Dubey S, Dudani S, Dixit M. Comparative study of histopathological Marsh grading with clinical and serological parameters in celiac iceberg of north India. Indian J Pathol Microbiol 2011;54:279-83

How to cite this URL:
Kalhan S, Joseph P, Sharma S, Dubey S, Dudani S, Dixit M. Comparative study of histopathological Marsh grading with clinical and serological parameters in celiac iceberg of north India. Indian J Pathol Microbiol [serial online] 2011 [cited 2021 Sep 22];54:279-83. Available from: https://www.ijpmonline.org/text.asp?2011/54/2/279/81593

   Introduction Top

Celiac disease (CD), also known as gluten-sensitive enteropathy, nontropical sprue, and endemic sprue, is an autoimmune disorder triggered by the ingestion of wheat gluten and related proteins of rye and barley in genetically susceptible individuals. [1] Well identified haplotypes in the human leukocyte antigen (HLA) class II region confer genetic susceptibility. [2] Duodenal biopsy remains the gold standard for diagnosis of CD, even though there are very specific serologic tests like anti-gluten and anti-tissue transglutaminase (anti-tTG) antibodies. Correlation of clinical, serologic, and histological features is essential for definitive diagnosis. [3] Different patterns of presentation of CD are recognized. [2]

We correlated serum levels of anti-tTG of immunoglobulin A (IgA) with degree of mucosal damage (typified by Marsh grade) in adult CD patients. Duodenal histopathology was additionally compared with clinical presentation, endoscopic findings, and hemoglobin levels.

   Materials and Methods Top

This was a prospective study including 226 adult patients (above 14 years of age) with the following symptom groups: gastrointestinal (GI) symptoms (diarrhea, vomiting, pain abdomen, and abdominal distension), easy fatigability and others (mouth ulcers, pubertal delay, bad obstetric history, dermatitis herpetiformis, infertility, and Type I diabetes mellitus). Three siblings of confirmed patients were also screened. Complete history and clinical examination (including upper and lower gastrointestinal endoscopy) were done to rule out chronic blood loss.

Esophagogastroduodenoscopy and serum anti-IgA tissue transglutaminase (anti-tTG) were performed in adults suspected to have CD. The following duodenal endoscopic markers were looked for: scalloping of folds, grooving, and nodular mucosa. Three duodenal biopsies were performed from the second part of duodenum and histological grading was performed as per modified Marsh system [Table 1]. [4]
Table 1: Marsh grading

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Anti-tTG levels were performed by enzyme-linked immunosorbent assay (ELISA). Patients with anti-tTG>15 U/ml were considered to be at risk. Complete hematologic work-up including hemoglobin, RBC indices, and peripheral blood smear examination was performed. Cut-off hemoglobin for diagnosis of anemia in males was taken as 13 g/dl and in females as 12 g/dl. Serum iron studies could not be performed due to financial constraints. Chronic blood loss and thalassemia were ruled out by clinical and hematologic evaluation.

The patients were classified into the following classes: (i) typical, with gastrointestinal signs and symptoms; (ii) atypical or extra intestinal, with minimal or absent gastrointestinal signs/symptoms but with other manifestations; (iii) silent, asymptomatic patients with biopsy evidence of small intestinal mucosal damage and positive CD autoimmunity on serology; and, (iv) latent, where individuals may show positive autoimmune serology, have a normal mucosal morphology, and may or may not be symptomatic.

All patients with anti-tTG > 15 U/ml and/or positive histopathology were started on gluten-free diet (GFD) with exclusion of wheat, barley, and rye from diet, along with hematinics. Celiac status of a patient was confirmed by clinical response to GFD, defined as amelioration of symptoms, weight gain, and increase in hemoglobin concentration at 8, 12, and 24 weeks. For statistical analyses, data at presentation, 8 and 24 weeks were considered.

Statistical analysis was done on SPSS version 15.0. The comparison among different groups was made by one-way ANOVA for continuous data. The quantitative data was compared by Chi-square test. The change over a period of time was seen by application of repeated measure analysis. The post hoc (multiple tests) comparison was made by Bonferroni's method. Log transformation was applied to make the data normalized wherever applicable. Results were considered significant when P<0.05.

We had two cases in the latent category and one with normal anti-tTG, who were excluded from statistical analyses, owing to which 223 cases were considered. Additionally, sample size for grades 1 (n = 5), 2 (n = 4), and 4 (n = 1) being small, these cases were clubbed for statistical analyses (1 with 2 and 4 with 3c). Patients with poor/no follow-up and overlapping histological grades were excluded from the study.

   Results Top

The study included 226 patients with 150 (67.3%) patients presenting with typical gastrointestinal (GI) symptoms, 70 (31.4%) with atypical presentations, 3 (1.3%) silent, and 2 with latent presentation. There was a single patient with normal anti-tTG level but with clinical and biopsy evidence of CD.

The mean age of presentation of all the grades combined together revealed mean age of 26.5 ± 10.3 years. There were 106 (46.9%) males and 120 (53.1%) females in the study group. The predominance of females seen in all grades except 3b was not significant (P = 0.16). GI symptoms predominated in 150 (67.3%) cases with a linear progression seen from grades 1 and 2 (n = 5; 55.6%) to grades 3c and 4 (n = 99; 71.7%). Easy fatigability was seen in 64 (28.7%) patients (P = 0.21) [Table 2].
Table 2: Clinicopathological parameters versus Marsh grades

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Mouth ulcers were present in 7 (3.1%) of all patients. Dermatitis herpetiformis, also known as the cutaneous manifestation of CD, infertility, and pubertal delay were seen in three patients (1.3%) each. Two patients (0.9%) presented with bad obstetric history. One patient (0.4%) each had osteoporosis, type I diabetes, peripheral neuropathy, and ileocecal tuberculosis.

Esophagogastroduodenoscopy findings were recorded as grooving (G), nodularity (N), scalloping (S), and normal. Additionally, patients with overlapping endoscopic findings were grouped as grooving + fine nodularity (G+FN), grooving + nodularity (G+N), grooving + scalloping (G+S). Overall, 172 (77.1%) patients had grooving, 5 (2.2%) had G+FN, 20 (9%) G+N, 18 (8.1%) G+S, 4 (1.8%) N, 3 (1.3%) S, and one patient (0.4%) with normal endoscopy. The patient with normal endoscopy was found to have Marsh grade 1 on biopsy. All the grades had predominance of grooving as the endoscopic finding, ranging from 66.7% in grades 1 and 2 to 76.7% (3a), 89.1% (3b), and 73.9% (3c+4). Additionally, the two patients in the latent category had normal endoscopy and normal histopathology. All the three patients in the silent category had grooving on endoscopy. On histopathology, these patients were distributed in grades 3a (n=1) and 3b (n=2). Correlation of endoscopic findings with Marsh grades on histopathology was statistically significant (P<0.001).

Anti-tTG levels of all (but one) cases were raised [Table 2]. Patients in the latent category also had increased anti-tTG levels. The single patient with normal anti-tTG level showed typical biopsy features (3c) and response to GFD. Comparison of log anti-tTG against Marsh grades was statistically significant for grades 3b and 3c (inclusive of grade 4) as compared against grades 1 (along with 2) and 3a with P<0.001 for both.

Analysis of biopsy findings revealed maximum cases of grade 3c (n = 137) [Figure 1], followed by those of 3b (n = 46) and 3a (n = 30). Grades 1 [Figure 2] and 2 had 5 and 4 cases, respectively, and grade 4 had 1 case. The two latent cases had normal histology and the single case with normal anti-tTG was Marsh 3c.
Figure 1: Marsh grade 3c showing total villous atrophy (H and E, ×100)

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Figure 2: Marsh grade 1 showing increased intraepithelial lymphocytes (>40/100 enterocytes) (H and E, ×400)

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Anemia was seen in majority of patients (87.4%) spanning all the grades. On detailed hematologic analysis, including automated RBC parameters and peripheral blood smear examination, all the cases were found to have microcytic hypochromic anemia, except one case where the anemia was dimorphic. The anemia was labeled as iron deficiency on exclusion of chronic blood loss and thalassemia on complete clinical and hematologic evaluation. There was a significant linear progression in both percentage of patients with iron deficiency anemia and the mean baseline hemoglobin levels from grades 1 and 2 to 3c and 4 (P<0.001) [Table 2].

Patients in all the histological and clinical groups responded to GFD. This improvement was reviewed objectively by plotting the progressive increase in mean hemoglobin levels [Figure 3] and weights [Figure 4] against time in each of the categories. There were two patients in grade 3c who reported partial noncompliance to GFD at the first follow-up visit and recorded an initial weight loss. On counseling, these patients adhered to strict GFD subsequently and improved clinically, symptomatically and recorded weight gain.
Figure 3: Mean Hb at 0, 8, and 24 weeks

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Figure 4: Mean weight at 0, 8, and 24 weeks

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   Discussion Top

Celiac disease is an under-diagnosed gluten-sensitive enteropathy, often presenting with atypical/extraintestinal features and even as a latent or silent disease, thereby contributing to the 'celiac iceberg'. The ratio of diagnosed versus undiagnosed cases is as high as 1 : 7. [5] The prevalence among schoolchildren in India is 1%. [6] Though population-based studies among adults in India are not available, CD is one of the most common causes of small bowel diarrhea. [7] An apparent regional variation of occurrence in India has been seen, possibly due to differences in genetic predisposition, differences in consumption of wheat or both. [8]

Our study had the maximum number of patients presenting in the typical fashion (n= 150, 67.3%). We had 70 (31.4%) patients with atypical features and 3 (1.8%) silent. There were two patients in the latent category. In the literature, while some studies have found atypical presentations in adults to predominate over typical GI symptoms and recognized silent forms of the disease, [9] others have found classic gastrointestinal symptoms to predominate. [10]

The mean age of presentation spanning all the grades in our study was 26.5 ± 10.3 years with a range of 15 to 65 years. We had 53.4% females and 46.6% males in our study with a majority of females in all the grades except 3b. This predominance, however, was not found to be significant on statistical analysis. Study of sex distribution in the other studies shows female predominance in some [9],[11] and males in others. [10]

Patients presenting with typical gastrointestinal symptoms showed a linear increase from grades 1 and 2 (n = 5; 55.6%) to 3c and 4 (n = 99; 71.7%). Sixty four (28.7%) patients in our study had easy fatigability with no distinct distribution pattern among the various grades. The other manifestations included mouth ulcers (7; 3.1%), dermatitis herpetiformis, infertility, pubertal delay (n = 3; 1.3% each); bad obstetric history (n = 2; 0.9%); osteoporosis and type I diabetes (n = 2; 0.4% each). Ileocecal tuberculosis was also seen in one of our patients. Typical gastrointestinal manifestations have been found to range from 26% to 68.8% in the literature [8],[9],[10],[11] with atypical presentations predominating in adults in some studies. [8],[9],[11]

Endoscopic findings were compared with the histological subgroups and the correlation thus obtained was statistically significant (P<0.001). Endoscopic features of CD have been compared in adults and increasing severity of endoscopic damage has been found to correlate with increasing Marsh grades and classical form of the disease. [9]

The mainstay of our study was a correlation between anti-tTG levels and Marsh grades in adult celiacs. Anti-tTG levels of all (but one) cases were raised [Table 2]. We found a statistically significant increase in anti-tTG values from histologically milder forms of the disease to more severe forms (P<0.001). Anti-tTG values in grades 3c+4 were highest amongst all (354.66 ± 111.43 U/ml). Patients in latent category were diagnosed on the basis of increased anti-tTG levels. We had one case with anti-tTG level of 11 U/ml, who presented with classic gastrointestinal symptoms with iron deficiency anemia and had Marsh grade 3c on biopsy. He responded to GFD, supplemented with hematinics. Due to financial limitations, this patient could not be tested for IgA deficiency.

Multiple comparisons of log anti-tTG by Bonferroni's method demonstrated significantly different levels between grades 1+2 vs. both grades 3b and 3c+4 (p<0.001). Similarly, anti-tTG values of grade 3a were significantly different from those of grades 3b and 3c+4 with p<0.001. However, levels of grades 1+2 vs. 3a, as also 3b vs. 3c+4 were not significantly different (P=1 in both). Correlation of anti-tTG with Marsh grades has also been done in other studies and grade 3 lesions have been found to correlate with raised levels. [12],[13],[14] Other antibodies available for screening for CD include anti-endomysial antibody (anti-EMA), antigliadin IgG and antigliadin IgA. Anti-EMA has a sensitivity and specificity of 97% and 98%, respectively, and anti-tTG has a sensitivity and specificity of 100% and 98%, respectively, to diagnose CD. [15] Anti-EMA, however is more operator dependent, liable to errors, and based on indirect immunofluorescence. [8],[16] Antigliadin antibodies have a sensitivity and specificity of 85% and 97% (IgA) and 97% and 92% (IgG), respectively. [15],[16] Anti-tTG is, therefore preferred for screening for CD. IgA-deficient celiac sufferers (2.8-8%), however, are known to exist. [5]

Anemia was seen in majority of patients (87.4%). On detailed hematologic analysis, all patients had microcytic hypochromic anemia, except one case of dimorphic anemia. The anemia was labeled as iron deficiency after exclusion of chronic blood loss and thalassemia. Linear progression was seen from grades 1+2 to 3c+4, which was statistically significant (P<0.001). In the limited studies available on CD in adults, refractory anemia due to iron deficiency has been the most dominant presentation. [8],[11] Occult CD has been reported in up to 2.8% of patients presenting with iron deficiency anemia. [17] Our patients showed statistically significant fall in mean baseline hemoglobin from grades 1+2 to grades 3c+4 (P<0.001), thereby indicating increasing severity of anemia with progressive destruction of mucosal epithelium. Correlation of hemoglobin levels with Marsh grades is underreported in adult celiacs, though baseline hemoglobin of 7.3 ± 2.3 g/dl has been reported. [11]

Patients in all histological and clinical groups responded to GFD. Weight gain has been recorded in the other studies on adult CD and ranges from 47.6 ± 18.2 to 54.9 ± 5.1 kg at one year. [11] The mean increase in hemoglobin in adult celiacs on GFD and hematinics has been reported to be from 8.6 ± 1.5 to 9.8 ± 1.0 g/dl at 3-4 months. [4]

There were two patients in grade 3c who reported partial compliance to GFD at the first follow-up visit with initial weight loss. Of these, one had anemia. On counseling, these patients adhered to strict GFD subsequently and improved clinically, symptomatically and recorded weight gain. The anemic patient did not record significant increase in hemoglobin at first follow-up visit (baseline: 9.8 g/dl, 10 g/dl at 8 weeks) but did so subsequently (11.5 g/dl at 24 weeks).

   Conclusions Top

This study draws attention to the adult CD in the wheat eaters of North India. It has varied clinical presentations ranging from typical to atypical, silent and latent forms. Anti-tTG levels, mean baseline hemoglobin and endoscopic findings have conclusively been proven to correlate with increasing severity of mucosal damage. Increased awareness among clinicians and pathologists about adult CD, especially in its atypical forms will aid in diagnosing more cases from the "celiac iceberg". This will relieve a distinct subset of population of distressing symptoms and associated complications by lifestyle modifications.

   Acknowledgements Top

We thank Dr Gursewak Singh for providing clinical material.

   References Top

1.Briani C, Samaroo D, Alaedini A. Celiac disease: From gluten to autoimmunity. Autoimmun Rev 2008;7:644-50.   Back to cited text no. 1
2.Setty M, Hormaza L, Guandalini S. Celiac disease: Risk assessment, diagnosis, and monitoring. Mol Diagn Ther 2008;12:289-98.  Back to cited text no. 2
3.Heredia PC, Castro PF, Palma HJ. Adult celiac disease. Rev Med Chil 2007;135:1186-94.  Back to cited text no. 3
4.Oberhuber G, Granditsch G, Vogelsang H. The histopathology of coeliac disease: time for a standardized report scheme for pathologists. Eur J Gastroenterol Hepatol 1999;11:1185-94  Back to cited text no. 4
5.Tommasini A, Not T, Kiren V, Baldas V, Santon D, Trevisiol C, et al. Mass screening for coeliac disease using antihuman transglutaminase antibody assay. Arch Dis Child 2004;89:512-5.  Back to cited text no. 5
6.Bhattacharya M, Dubey AP, Mathur NB. Prevalence of celiac disease in north Indian children. Indian Pediatr 2009;46:415-7.   Back to cited text no. 6
7.Thakur B, Mishra P, Desai N, Thakur S, Alexander J, Sawant P. Profile of chronic small-bowel diarrhea in adults in Western India: A hospital-based study. Trop Gastroenterol 2006;27:84-6.  Back to cited text no. 7
8.Yachha SK, Poddar U. Celiac disease in India. Indian J Gastroenterol 2007;26:230-7.  Back to cited text no. 8
9.Tursi A, Brandimarte G, Giorgetti GM, Gigliobianco A. Endoscopic features of celiac disease in adults and their correlation with age, histological damage, and clinical form of the disease. Endoscopy 2002;34:787-92.  Back to cited text no. 9
10.Sood A, Midha V, Sood N, Malhotra V. Adult celiac disease in northern India. Indian J Gastroenterol 2003;22:124-6.  Back to cited text no. 10
11.Agarwal N, Puri AS, Grover R. Non-diarrheal celiac disease: A report of 31 cases from northern India. Indian J Gastroenterol 2007;26:122-6.  Back to cited text no. 11
12.Donaldson MR, Book LS, Leiferman KM, Zone JJ, Neuhausen SL. Strongly positive tissue transglutaminase antibodies are associated with Marsh 3 histopathology in adult and pediatric celiac disease. J Clin Gastroenterol 2008;42:256-60.  Back to cited text no. 12
13.Donaldson MR, Firth SD, Wimpee H, Leiferman KM, Zone JJ, Horsley W, et al. Correlation of duodenal histology with tissue transglutaminase and endomysial antibody levels in pediatric celiac disease. Clin Gastroenterol Hepatol 2007;5:567-73.   Back to cited text no. 13
14.Diamanti A, Colistro F, Calce A, Devito R, Ferretti F, Minozzi A, et al. Clinical value of immunoglobulin A antitransglutaminase assay in the diagnosis of celiac disease. Pediatrics 2006;118:1696-700.   Back to cited text no. 14
15.Fernández ML, Vivas S, Ruiz de Morales JM, Marugan JM. Usefulness of anti-transglutaminase antibodies in the diagnosis of celiac disease. Gastroenterol Hepatol 2005;28:437-40.  Back to cited text no. 15
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Correspondence Address:
Shivani Kalhan
B 44, Sector 36, Noida, Dist - Gautambudh Nagar, Uttar Pradesh - 201 303
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.81593

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]

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