Mucosal lesions of the gastric mucosa in adult patients with coeliac disease

Introduction

Coeliac disease (gluten enteropathy) is a chronic inflammatory disease of the gastrointestinal (GI) tract of autoimmune aetiology, occurring in genetically predisposed persons. Hallmarks of coeliac enteropathy include an early rise of intestinal intraepithelial lymphocytes (IEL), followed by crypt hyperplasia and villous atrophy, in response to oral gluten intake [1].

Inflammatory lesions in the GI tract of coeliac patients seem not to be confined to the small intestine. Gluten enteropathy may be a risk factor of development of lymphocytic gastritis (LG) [2]. The diagnostic threshold for LG is usually taken as greater than 25 IEL per 100 gastric columnar epithelial cells [3]. The significance of mucosal gastric lesions in coeliac patients and their influence on clinical course remain unexplained.

Aim

The aim of the studies was to evaluate the frequency of histological lesions in the gastric mucosa in coeliac patients, including the presence of CD3+ lymphocytes and their influence on the clinical picture of gluten enteropathy.

Material and methods

Patients from the Outpatient Clinic of the Department of Gastroenterology and Hepatology Jagiellonian University in Krakow, suffering from symptoms indicating malabsorption syndrome or dyspeptic symptoms, as well as patients with previously diagnosed coeliac disease, were included in the study.

They were informed about the subject of the above studies and expressed written consent to the studies. Clinical investigation comprised history of disease, including present complaints indicating coeliac disease, such as diarrhoea, microcytic anaemia, as well as dyspeptic symptoms including epigastric discomfort, early satiety, belching or nausea and physical examination.

Venous blood probes were taken for evaluation of the blood count, iron level and the titre of anti-transglutaminase (tTG) IgA antibodies in the serum.

Upper GI tract endoscopy was performed for the evaluation of macroscopic lesions in the mucosa as well as for taking mucosal biopsies from the body and antral part of the stomach and the distal part of the duodenum. Also the urease test for Helicobacter pylori bacteria presence in the gastric mucosa was performed.

The diagnosis of coeliac disease was based on the clinical symptoms, evaluation of tTG IgA in the serum and histological assessment of the distal part of the duodenal mucosa. Patients with infections of the GI tract, treated with non-steroidal anti-inflammatory drugs (NSAID) or glucocorticoids were excluded from the study.

Finally 90 patients, aged 18-72 years (average: 30.8 ±4.5 years), including 35 coeliac patients (n = 24, patients with recent diagnosis of CD, n = 11, patients with earlier diagnosis of CD) and 55 patients presenting dyspeptic symptoms (n = 48, patients without significant lesions in the gastric and duodenal mucosa, n = 7 with duodenal ulcers) as the control group were included. Additionally, in 6 coeliac patients and 1 in the control group, coexistence of autoimmune disorders was detected. Characteristics of examined groups are presented in Table I.

In the coeliac patients, a strict gluten-free diet was recommended. In patients with dyspeptic symptoms, a standard dose of proton pump inhibitor (PPI) was

initiated.

Coeliac patients with LG underwent upper GI endo­scopy after 6 months of gluten-free diet therapy, with biopsies being taken from the stomach and distal part of the duodenum for evaluation of the intensity of mucosal lymphocytic infiltrates.



Histological evaluation



Histological evaluation of mucosal lesions in the gastric mucosa stained with haematoxylin-eosin was performed according to the Sydney system, including normal appearance of gastric mucosa, chronic superficial gastritis (activity 0-3), follicular gastritis and atrophic gastritis [2].

The presence of H. pylori in the gastric mucosa was evaluated in the gastric mucosa biopsies, stained with haematoxylin-eosin and modified Giemsa method.

Histology of the mucosa of the distal part of the duodenum was expressed according to the Marsh classification, including: normal mucosa, type I: infiltrative lesions with more than 30 lymphocytes/100 epithelial cells, type II: infiltrative/hyperplastic lesions, type III: subdivided into partial (IIIA), subtotal (IIIB) and total (IIIC) villous atrophy [2, 4]. Type III is considered as the most characteristic for coeliac disease

[4, 5].

Evaluation of the number of IEL in the biopsies from the body, antral part of the gastric mucosa and distal part of the duodenum stained with haematoxylin-eosin was performed. Fife hundred consecutive epithelial cells were examined. The number of lymphocytes per 100 epithelial cells was counted. Lymphocytic gastritis was said to be present when the number of mature intra­epithelial lymphocytes was more than 25/100 gastric columnar epithelial cells [3].

For the identification of lymphocytes forming infiltrates in the gastric mucosa and the distal part of the duodenum, immunostaining was performed. Anti-CD3+ monoclonal antibodies (pan T cell marker) (Dako, High Wycombe, UK) at 1 in 50 dilution were used according to the method described by the producer.



Statistical analysis



Statistical analysis was performed using the program Statistica 8.0 (UJ license). Results were expressed as means ± SEM. Statistical differences between examined groups were evaluated with the 2 test. Differences at the level of p < 0.05 were considered significant.

Results

Clinical picture of patients with gluten enteropathy



Among dyspeptic symptoms observed in the coeliac patients, early satiety in the epigastrium was observed more frequently in comparison with the control group, but the differences were not statistically significant (Table II).

In patients diagnosed with endoscopy because of dyspeptic complaints, symptoms indicating coeliac disease, such as diarrhoea (45% of cases), microcytic ana­emia (35% of cases), osteoporosis (9% of cases), loss of weight (20% of cases), as well as depression (4% of cases) were reported (Figure 1).



Endoscopic picture of gastric mucosa in patients with gluten enteropathy



Gastric mucosa in the coeliac patients as well as in the control group showed focal reddening and erosions in the antral part and in the distal part of the duodenum.



Lymphocytic gastritis



In the coeliac patients, both treated and not treated with a gluten-free diet, increase of the number of IEL was observed in the gastric mucosa. The mean IEL number in the gastric mucosa of patients not treated with the gluten-free diet was 9.2 ±0.5 and it was significantly higher than the IEL number in the control group

(4.2 ±0.4) (p < 0.05) (Table III).

Three coeliac patients (8.6% of cases) and one in the control group fulfilled criteria of LG, which means that the IEL number exceeded 25 per 100 epithelial cells (Table III).

In all these cases, coeliac disease was diagnosed for the first time. Patients with gluten enteropathy and diagnosed LG suffered from intensive dyspeptic symptoms, mainly epigastric pain or discomfort, nausea, and pyrosis. Also, symptoms indicating malabsorption, such as microcytic anaemia, loss of weight or diarrhoea, were observed (Table IV). Endoscopic evaluation revealed focal reddening and mosaic structure in the body or antral part of the gastric mucosa (Figures 2 A, B). Thinning of the circular folds and mosaic surface of the distal part of the duodenum was also observed (Figure 2 C).

Haematoxylin-eosin staining revealed lymphocytes in the superficial epithelium and in the gastric foveolae of the body and antral part of the stomach, proportion

from 1 : 3 to 1 : 2, focal 1 : 1 (Figures 3 A, 4 A).

Lymphocytic gastritis in the coeliac patients coexisted with partial (1 patient) or total villous atrophy (2 pa­tients) in the distal part of the duodenum, according to grade III B and III C of the Marsh scale respectively (Figures 5 A, 6 A).

Helicobacter pylori infection was detected in one patient in this group. In addition, gastric mucosal lesions corresponding with LG were found in one patient presenting dyspeptic symptoms from the control group, with previously diagnosed ulcerative colitis.

Immunohistology showed in patients with LG the presence of CD3+ T lymphocytes, both in the gastric mucosa and in the distal part of the duodenum mucosal biopsies, giving evidence for the connection of lesions observed in the stomach and the duodenum in coeliac disease (Figures 3 B, 4 B, 5 B, 6 B).

Application of the gluten-free diet in the coeliac patients with LG caused the disappearance of dyspeptic symptoms, not responding to the previous PPI treatment. In 2 cases a decrease of IEL number in the gastric mucosa in the control histological evaluation after 6 months was observed.

Discussion

Association of coeliac disease with histological lesions in the gastric mucosa has not been fully explained. The results of our studies revealed the presence of LG in 8.6% of coeliac patients.

All coeliac patients with LG were not treated with the gluten-free diet previously and presented symptoms of malabsorption as well as dyspeptic complaints, making the main indication for the diagnosis of the upper GI tract. The results of our studies are similar to the data of 10% frequency of LG in coeliac patients, reported by Fee­ley et al. [3]. The results of other authors were divergent

and ranged from 4% to 38% frequency of LG in coeliac patients [6, 7]. Dyspeptic symptoms were also reported by Usai et al. [8]. They could originate from formation of

lymphocytic infiltrates, followed by impairment of the gastric mucosal barrier and gastric functional disorder.

Clinical symptoms were accompanied by non-specific endoscopic lesions in the gastric mucosa, such as

reddening, mosaic surface or erosions. Mucosal lesions typical for LG, such as gastritis varioliformis, including aphthoid erosions, papular lesions or thickening of mucosal folds, described by other authors, were not observed in our patients [3].

In all examined coeliac patients, an increased number of IEL was observed, but did not fulfil the criterion of LG with the exception of 3 cases. The increased number of IEL could be the result of the autoimmune reaction in the course of coeliac disease or the direct contact of gluten with the mucosal barrier in the stomach in

persons with hypersensitivity to this antigen [3, 6]. Im­munohistology of the gastric and duodenal mucosa biopsies revealed that lymphocytic infiltrates in both regions were formed by CD3+ T lymphocytes, suggesting that coeliac disease is an example of diffuse T lymphocyte gastroenteropathy.

As previous results revealed, LG could be the manifestation of H. pylori infection [9]. The results of our studies showed the frequency of H. pylori in the gastric mucosa of coeliac patients and in the control group

as 20% and 55% respectively, which was lower than the results reported by other authors, 82% and 97% res­pectively [2].

The explanation for lower H. pylori frequency in the examined group could be successful eradication therapy performed in patients with relapsing dyspeptic symptoms.

The above study showed the presence of LG in the coeliac patients, with or without H. pylori infection, which may suggest that these bacteria and the gluten enteropathy are independent factors inducing the rise of IEL number in the gastric mucosa. Application of the gluten-free diet caused regression of dyspeptic symptoms, accompanied by a fall of the IEL number in the gastric mucosa, in the control histological evaluation after 6 months. It suggests the significant role of lymphocytic infiltrates in the gastric mucosa in inducing dyspeptic symptoms in the coeliac patients.

In one dyspeptic patient from the control group, fulfilling the criterion of LG, ulcerative colitis was diagnosed previously. The association between LG and ulcerative colitis could be explained by the involvement of Th2 lymphocytes in the immunological response with the subsequent IL-5 and IL-10 cytokine mucosal expression [10].

A full explanation of the role of histological lesions in the gastric mucosa needs further studies in a more numerous group of patients.

Conclusions

Lymphocytic gastritis including CD3+ T lymphocytes in the gastric and the distal part of duodenal mucosa belongs to the picture of gluten enteropathy. Dyspeptic symptoms, observed in some of the coeliac patients, besides typical symptoms indicating malabsorption

syndrome, may have an association with intraepithelial lymphocytosis. Taking biopsies from the distal part of the duodenum, from patients presenting dyspeptic symptoms, during gastroscopy, may contribute to the diagnosis of coeliac disease in some of them.

Acknowledgments

The research was financed from a grant: K/ZDS/ 001599.

References

 1. Leon F, Sanchez L, Camarero C, et al. Cytokine production by intestinal intraepithelial lymphocyte subsets in celiac disease. Dig Dis Sci 2005; 50: 593-600.

 2. Santarelli L, Gabrielli M, Santoliquido A, et al. Interaction between Helicobacter pylori infection and untreated coeliac disease on gastric histological pattern. Scand J Gastroenterol 2006; 41: 532-5.

 3. Feeley KM, Heneghan MA, Stevens FM, et al. Lymphocytic gastritis and celiac disease: evidence of positive association.

J Clin Pathol 1998; 51: 207-10.

 4. Marsh MN. Studies of intestinal lymphoid tissue. The immunopathology of cell-mediated reactions in gluten sensitivity and other enteropaties. Scanning Microsc 1988; 2: 1663-84.

 5. Sanders DS, Hurlstone DP, Brown S. Does celiac disease affect colorectal practice? Int J Colorectal Dis 2007; 22: 565-70.

 6. Stancu M, De Petris G, Palumbo TP, et al. Collagenous gastritis associated with lymphocytic gastritis and celiac disease. Arch Pathol Med 2001; 125: 1579-84.

 7. Leung ST, Chandan VS, Murray JA, et al. The collagenous gastritis. Histopathologic features and association with other gastrointestinal diseases. Am J Surg Pathol 2009; 33: 788-98.

 8. Usai P, Satta P, Lai M, et al. Autonomic dysfunction and upper digestive functional disorders in untreated adult celiac disease. Eur J Clin Invest 1997; 27: 1009-15.

 9. Lynch DAF, Sobala GM, Dixon MF, et al. Lymphocytic gastritis and associated small bowel disease: a diffuse lymphocytic gastroenteropathy? J Clin Pathol 1995; 45: 939-45.

10. Bouma G, Strober W. The immunological and genetic basis of inflammatory bowel disease. Nat Rev Immunol 2003; 3:

521-33.