Kakar Sanjay, Nehra Vandana, Murray Joseph A, Dayharsh Gerald A, Burgart Lawrence J
Department of Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Am J Gastroenterol. 2003 Sep;98(9):2027-33. doi: 10.1111/j.1572-0241.2003.07631.x.
The aim of this study was to determine the specificity of increase in intraepithelial lymphocytes (IELs) with normal villous architecture in small bowel biopsy samples for diagnosis of gluten sensitivity (GS) and its significance in the absence of GS.
Small bowel biopsy samples from 43 patients with increased IELs and no other pathology were reviewed. Patients with prior diagnosis of GS were excluded. A group of 46 patients with normal duodenal biopsy during the same period served as controls. The clinical records of patients and controls were examined for presenting symptoms, laboratory tests, and final clinicopathological diagnosis. Immunohistochemical characterization of IELs was performed in 13 cases.
Four (9.3%) patients had GS based on positive IgA antiendomysial antibodies (n = 3) and favorable response to gluten-free diet (n = 4). One patient (2.2%) had partially treated tropical sprue; six patients (14%) had disorders of immune regulation including Hashimoto's thyroiditis (n = 2) and one case each of Graves' disease, rheumatoid arthritis, psoriasis, and multiple sclerosis; and six patients (14%) were on nonsteroidal anti-inflammatory drugs (NSAIDs). In contrast, none of the control subjects had GS (p = 0.05), tropical sprue, or immunoregulatory disorders (p = 0.011), and one (2.2%) was on NSAIDs (p = 0.04). Increased IELs were also observed in Crohn's disease, lymphocytic/collagenous colitis, and bacterial overgrowth, but the association did not reach statistical significance. Histological features (number and distribution of IELs, crypt mitoses) and immunophenotypic analysis of IELs did not reliably distinguish GS-related from non-GS-related causes of increased IELs.
Intraepithelial lymphocytosis in an otherwise normal small bowel biopsy is somewhat nonspecific, but in nearly 10% of cases can be the initial presentation of GS. Therefore all patients with this finding should be investigated for GS. Increased IELs may also be associated with autoimmune disorders and NSAIDs.
本研究旨在确定小肠活检样本中上皮内淋巴细胞（IELs）增多且绒毛结构正常对于诊断麸质敏感性（GS）的特异性及其在无GS情况下的意义。
回顾了43例IELs增多且无其他病理改变患者的小肠活检样本。排除先前诊断为GS的患者。同期46例十二指肠活检正常的患者作为对照组。检查患者和对照组的临床记录，包括出现的症状、实验室检查及最终临床病理诊断。对13例患者进行了IELs的免疫组织化学特征分析。
4例（9.3%）患者基于IgA抗肌内膜抗体阳性（n = 3）及对无麸质饮食有良好反应（n = 4）而诊断为GS。1例（2.2%）患者患有部分治疗的热带口炎性腹泻；6例（14%）患者有免疫调节紊乱，包括桥本甲状腺炎（n = 2），格雷夫斯病、类风湿关节炎、银屑病和多发性硬化各1例；6例（14%）患者正在服用非甾体抗炎药（NSAIDs）。相比之下，对照组中无患者患有GS（p = 0.05）、热带口炎性腹泻或免疫调节紊乱（p = 0.011），1例（2.2%）正在服用NSAIDs（p = 0.04）。在克罗恩病、淋巴细胞性/胶原性结肠炎和细菌过度生长中也观察到IELs增多，但这种关联未达到统计学意义。IELs的组织学特征（IELs的数量和分布、隐窝有丝分裂）和免疫表型分析不能可靠地区分IELs增多与GS相关或非GS相关的原因。
在其他方面正常的小肠活检中出现上皮内淋巴细胞增多有一定非特异性，但在近10%的病例中可能是GS的初始表现。因此，所有有此发现的患者均应进行GS检查。IELs增多也可能与自身免疫性疾病和NSAIDs有关。
