Role of biopsy in diagnosis and treatment of adult celiac disease

Celiac disease (CD) is an immune-mediated enteropathy that characteristically responds to treatment with a gluten-free diet. In most, clinical features improve with resolution of diarrhea and weight loss. Serological studies also tend to normalize. Small intestinal biopsies from the duodenum reveal a severe to moderately severe architectural disturbance showing crypt epithelial hyperplasia with increased numbers of epithelial cell mitotic figures along with villous “flattening”, increased numbers of lamina propria plasma cells and lymphocytes and increased numbers of intra-epithelial lymphocytes in untreated disease. With a gluten-free diet, these changes can be expected to resolve to normal. In some patients, this mucosal inflammatory process may persist, especially in the proximal small intestine for variable periods of time. In CD, resolution of histopathological changes can occur within 6 months, but often, more than a year is required, and sometimes, 2 years or more. Changes are not only time-dependent, but appear to be gender-dependent with resolution more readily achieved in females compared to males, and age-dependent with more persistence of the inflammatory process in the elderly compared to younger patients. Future studies need to take into account the individual nature of the normal mucosal healing process in CD treated with a gluten-free diet.