Wahab P J, Crusius J B, Meijer J W, Mulder C J
Department of Gastroenterology and Hepatology, Rijnstate Hospital Arnhem, The Netherlands.
Am J Gastroenterol. 2001 May;96(5):1464-9. doi: 10.1111/j.1572-0241.2001.03812.x.
In patients with signs and symptoms of malabsorption, suggestive of gluten-sensitive enteropathy, small intestinal biopsies sometimes only reveal infiltration of lymphocytes into the mucosal epithelium. This infiltrative lesion (Marsh I) is not a definite proof for gluten-sensitive enteropathy. However, in the present study, we aimed to show that a subgroup of these patients could ultimately be identified as being gluten sensitive.
A total of 38 patients with a Marsh I lesion were subjected to a gluten challenge comprising 30 g of gluten added daily to a normal gluten-containing diet for 8 wk. Before and after the challenge, small intestinal biopsies were taken, and symptoms and signs of malabsorption were scored.
In 12 patients we demonstrated a significant change in mucosal histopathology, i.e., subtotal villous atrophy (Marsh IIIB, n = 1), partial villous atrophy (Marsh 3A, n = 6) or infiltrative-crypthyperplastic lesions (Marsh II, n = 5). In the other 26 patients, the small intestinal mucosa remained unchanged. After initiation of a gluten-free diet, follow-up small intestinal biopsies in 12 patients who initially had progressive mucosal pathology after gluten challenge showed normalization of mucosal pathology in seven cases, regression to a Marsh I lesion in four, and to a Marsh II lesion in one. Symptom relief was seen in all 12 patients. Ten of 26 patients without histological response to the gluten challenge were motivated to adhere to a gluten-free diet. Follow-up biopsies revealed unchanged Marsh I lesions in eight patients and normalization (Marsh 0) in two patients. Three patients had follow-up biopsies while on a normal diet. All had unchanged Marsh I lesions.
In the present study we demonstrated that a gluten challenge might be useful in identifying patients as being sensitive to gluten if initial small intestinal biopsies reveal only minor abnormalities.
对于有吸收不良体征和症状、提示麸质敏感性肠病的患者，小肠活检有时仅显示淋巴细胞浸润至黏膜上皮。这种浸润性病变（马什I型）并非麸质敏感性肠病的确切证据。然而，在本研究中，我们旨在表明这些患者中的一个亚组最终可被确定为对麸质敏感。
共有38例马什I型病变患者接受麸质激发试验，即在正常含麸质饮食中每日添加30克麸质，持续8周。激发试验前后进行小肠活检，并对吸收不良的症状和体征进行评分。
12例患者黏膜组织病理学出现显著变化，即全绒毛萎缩（马什IIIB型，n = 1）、部分绒毛萎缩（马什3A型，n = 6）或浸润性隐窝增生性病变（马什II型，n = 5）。其他26例患者小肠黏膜未发生变化。在麸质激发试验后最初有进行性黏膜病变的12例患者中，开始无麸质饮食后，7例患者的黏膜病变恢复正常，4例患者病变退回到马什I型，1例患者退回到马什II型。所有12例患者症状均缓解。26例对麸质激发试验无组织学反应的患者中有10例积极坚持无麸质饮食。随访活检显示，8例患者的马什I型病变未改变，2例患者病变恢复正常（马什0型）。3例患者在正常饮食期间进行了随访活检。所有患者的马什I型病变均未改变。
在本研究中，我们证明如果最初的小肠活检仅显示轻微异常，麸质激发试验可能有助于识别对麸质敏感的患者。
