MORPHOLOGICAL SPECTRUM OF MUCOSAL LESIONS

IN CLINICALLY SUSPECTED CELIAC DISEASE AND

COMPARISON WITH SEROLOGY

Dr. Nusrat Zahra

MBBS

Supervisor:
Professor Dr. Anwar-ul-Haque
Diplomat American Board of Pathology
Fellow College of American Pathologists

Pathology Department
Pakistan Institute of Medical Sciences
Date: 22-02-10

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SUPERVISORS CERTIFICATE

I, hereby certify that Dr. Nusrat Zahra

Having enrolment number: F-03-24803
And RTMC Registration number: HSP-2005-042-208
Has been working under my direct supervision with effect from: 01.03.06 to date.
In the department of Pathology
Of Training Institution: Pakistan Institute of Medical Sciences
In the City of: Islamabad
The dissertation titled, Morphological Spectrum of Mucosal Lesions in Clinically
Suspected Celiac Disease and Comparison with Serology, was prepared according to the
FCPS Dissertation Guidelines under my direct supervision. I have read the
Dissertation and have found it satisfactory for FCPS part II examination in the subject of
Pathology.

Signature of Supervisor:
Professor Dr: Anwar-ul-Haque
Official stamp:
Date: 22 -02-10

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I am indebted to Professor Anwar-ul-Haque who motivated and guided me

through every step of the way. I would also like to thank the technical staff without whose
help; the assignment would not have been possible. I have deep regards for the
gastroenterology department who cooperated with me fully during my study.

I would also like to take this opportunity to thank my parents who have
encouraged and believed in me throughout my life.

And most importantly, I would like to thank Allah Almighty, without whose will
no vision can ever become a reality.

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TABLE OF CONTENTS

CONTENTS

PAGE NO.

PART I
Acknowledgement
List of Tables
List of Figures
List of Abbreviations
PART II
Abstract
Introduction
Review of Literature
Objective
Operational definitions
Material and Methods
Results
Discussion
Conclusion
References
Annexes

iii
v
vi
vii
1
3
7
30
31
32
37
54
65
66
86

LIST OF TABLES
Serial No.
i.
ii.

Table 1
Table 2

The Modified Marsh Classification

Frequencies of Comorbid Disease, and Symptoms for

Page No.
36
40

iii.

Table 3

various Marsh grades

Patient age and frequencies of gender for various Marsh

41

iv.

Table 4

grades
Frequencies of positive and negative tTGA (IgA/M)

42

v.

Table 5

serology for various Marsh grades

Frequencies of positive and negative AGA (IgA)

vi.

Table 6

serology for various Marsh grades

Patient characteristics and Marsh grading in cases with

43
44

High grade Marsh lesions and positive tTGA (IgA/M)

vii.

Table 7

serology
Patients with discordant Serology and Histology

45

LIST OF FIGURES

Serial No.
i.
Figure 1
ii.
Figure 2
iii.
Figure 3
iv.
v.
vi.

Age- Distribution of Male Patients

Age Distribution of Female Patients
Gender distribution of clinical symptoms in patients

Page No.
46
47
48

Figure 4

clinically suspected of Celiac disease

Duodenal Biopsy showing Modified Marsh Type 1

49

Figure 5

lesion
Duodenal Biopsy showing Modified Marsh Type 3a

50

Figure 6

Lesion
Duodenal Biopsy showing Modified Marsh Type 3b

51

Lesion

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vii.
viii.

Figure 7

Duodenal Biopsy showing Modified Marsh Type 3c

52

Figure 8

lesion
Duodenal biopsy showing Modified Marsh Type 3c

53

Lesion

LIST OF ABBREVIATIONS
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
xii.
xiii.
xiv.
xv.
xvi.
xvii.
xviii.
xix.
xx.
xxi.
xxii.
xxiii.
xxiv.

AGA
AGA
ARA
CD
CT
DH
EATL
EGD
ELISA
EMA
ESPGHAN

Antigliadin antibody
American Gastroenterological Association
Antireticulin antibodies
Celiac disease
Computerized tomography
Dermatitis herpetiformis
Enteropathy-associated T-cell lymphoma
Esophagogastroduodenoscopy
Enzyme-linked immunosorbent assay
Endomysial antibody
European Society for Pediatric Gastroenterology, Hepatology

GFD
GI
GS
H&E
HLA
IBS
IDA
IELs
IgA
IgG
IgM
NIH
NSAIDs

and Nutrition
Gluten-free diet
Gastrointestinal
Gluten-sensitivity
Hematoxylin and eosin
Human leukocyte antigen
Irritable bowel syndrome
Iron deficiency Anemia
Intraepithelial lymphocytes
Immunoglobulin A
Immunoglobulin G
Immunoglobulin M
National Institute of Health
Nonsteroidal anti-inflammatory drugs

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xxv.
xxvi.
xxvii.
xxviii.
xxix.
xxx.
xxxi.
xxxii.
xxxiii.

NK cells
PAS
PET
PIMS
SIBO
SPSS
TCR
tTG
tTGA

Natural killer cells

Periodic acid Schiff
Positron emission tomography
Pakistan Institute of Medical Sciences
small intestinal bacterial overgrowth
Statistical Package for Social Sciences
T cell receptor
Tissue transglutaminase
Tissue transglutaminase antibody