MASTERING THE COELIAC CONDITION FROM MEDICINE TO SOCIAL SCIENCES AND FOOD TECHNOLOGY FIRENZE 29 31 MARCH 2012 PITFALLS OF THE MORPHOLOGICAL EVALUATION THE POINT OF VIEW OF THE PATHOLOGIST
METHODOLOGY NUMBER OF BIOPSIES AND ORIENTATION CLASSIFICATIONS DIAGNOSTIC VARIABILITY
METHODOLOGY NUMBER OF BIOPSIES AND ORIENTATION
ORIENTATION LOCATION OF THE BIOPSIES TO CORRECTLY EVIDENCE THE DIFFERENT LAYERS OF THE BOWEL WALL
CLASSIFICATIONS
Type 1 Infiltrative Type 2 Hyperplastic Type 3 Destructive
CORAZZA VILLANACCI TYPE 1 TYPE2 GRADE A NON ATROPHIC TYPE 3 A TYPE 3 B GRADE B 1 PARTIAL ATROPHY TYPE 3 C GRADE B 2 TOTAL ATROPHY
DIAGNOSTIC VARIABILITY
A major pitfall in the diagnosis of coeliac disease is in pathological interpretation of intestinal biopsies. An adequate number of biopsies needs to be taken. A poorly oriented biopsy, as shown by crypts cut tangentially, will falsely reduce the crypt to villous ratio. Green P., Jabri B. THE LANCET 2003
Ecoendoscopy Enteroscopy N.B.I Video capsule Magnification Endomicroscopy
ESPGHAN (Coordinator: S. Husby; D. Branski, C. Catassi, S. Koletzko, I. Korponay Szabo, M. Maki, M.L. Mearin, R. Shamir, R. Troncone, A. Ventura, K.P. Zimmer) REVISION OF THE CRITERIA FOR THE DIAGNOSIS OF CD PROPOSAL: TO AVOID BIOPSY IN SYMPTOMATIC CHILDREN WITH HIGH VALUES OF TtG (>10 normal value) AND POSITIVITY FOR DQ2
AND NOW WE ARE.. WE WERE THE GOLD STANDARD
HOW TO CHANGE? TIME TO CHANGE! YOU ARE RIGHT!
The diagnosis and management of CD is a team process. High quality reporting of CD histology is very important as the whole team relies upon the skill of the pathologist. Failure to report key features can lead to undertreatment or overtreatment of the disease.
PATHOLOGIST GASTROENTEROLOGIST LABORATORIST ENDOSCOPIST GENETIST
Celiac disease: changing dogma on historical diagnosis V. Villanacci, C. Catassi, K. Rostami and U. Volta, 13 January 2010
WHERE AND HOW TO TAKE BIOPSIES
DUODENUM STOMACH 2 PART BULB PAPILLA OF VATER
BIOPSY HANDLING AND ORIENTATION
NOT ORIENTED ORIENTED
NORMAL MUCOSA VILLOUS / CRYPT RATIO = 3/1
Intraepithelial Lymphocytes Quantitation of intraepithelial lymphocytes in human duodenum:what is normal? M.Hayat, A. Cairns, M.F. Dixon, S.O Mahony J. Clin. Pathol 2002 Duodenal intraepithelial Lymphocyte. Count revisited Veress B, Franzen L,Bodin & Kork K Scand J Gastroenterol 2004 25 IELs/100 epithelial cells should be taken as the upper limit of the normal range for duodenal mucosa when counting profile densities in standard histological sections 40 IELs/100 epithelial cells is used as the upper limit of the normal range, a figure derived from jejunal biopsies over 30 years ago
Normal T LYMPHOCYTES < 25/100
Pathological T LYMPHOCYTES > 25/100
Intraepithelial Most european lymphocytosis pathologists do not in an otherwise routinely Increased count normal the intraepithelial small bowel biopsy lymphocytes is somewhat ( IEL) in ( I.E.L. duodenal nonspecific, is the first and most sensitive marker biopsies. of the Minor intestinal but in nearly 10% changes of cases compatible can be the initial effects of gluten on the small bowel mucosa; with CD are, therefore, overlooked presentation thus it is the major histological in many of GS. feature symptomatic Therefore of CD WHAT IS THE PROBLEM? cases Celiac and subsequently all patients with this Disease: A Progress Report labelled finding should IBS or be investigated functional for GS Donald A. Antonioli Kakar Rostami S. et K. Digestive and Liver Disease The American Journal of Modern2003 Gastroenterology Pathology 2003 2003
Counting of IELs is recommended in borderline cases where the histology is difficult to interpret. An increase, especially, in gamma delta positive cells strengthens the probability of CD Jarvinen T.T. et al. The American Journal of Gastroenterology 2003
Prof. Gino Roberto Corazza
Some considerations on the histological diagnosis of coeliac disease Gino Roberto Corazza and Vincenzo Villanacci Journal of Clinical Pathology CORAZZA VILLANACCI vol. 58 issue 6 2005
Intraepithelial lymphocytosis in architecturally preserved small intestinal mucosa. An increasing diagnostic problem with a wide differential diagnosis Brown I, Mino Kenudson M, Deshande V, Lauwers GY Arch Pathol Lab Med 2006
Helicobacter pylori infection in patients with coeliac disease Villanacci V., Bassotti G., Liserre B., Lanzini A., Lanzarotto F., Genta R. The American Journal of Gastroenterology 2006
Whole variation at second biopsy 11% 1% 3% Improvement No variation Restitutio ad integrum Worsening 85%
GIARDIA LAMBLIA
CD 3
CMV
APOPTOTIC BODIES APOPTOTIC BODIES
Treated celiac patients who do not respond clinically and histologically to treatment with a gluten free diet CD 3 CD 8
CD3 CD8 CD 3 CD 8
Ulcerative Jejunitis
THE PAST CD REFRACTORY CD ULCERATIVE JEJUNITIS LYMPHOMA THE PRESENT CD REFRACTORY CD ULCERATIVE JEJUNITIS LYMPHOMA CD 3
INTESTINAL BIOPSY: Is it yet the diagnostic essential Gold Standard? NO! but certainly still an important support to reach a correct diagnosis.
GASTROENTEROLOGIST MULTIDISCIPLINARY TEAM GOLD STANDARD
THANKS FOR COMPREHENSION!