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Diagnostic Challenges of Celiac Disease


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Marsh Classification

Slide 8

June 2010

Histology has long been considered the gold standard for the diagnosis of celiac disease and is a required part of the confirmation step for celiac disease diagnosis. However, there is a significant spectrum of damage that occurs in gluten-sensitive enteropathy.

In this illustration, we illustrate what has been termed the Marsh Classification of gluten-sensitive enteropathy lesions. While lesion number 3 is the classic lesion of celiac disease (where there is at least partial villous atrophy, crypt hyperplasia, and infiltration of the surface epithelium with lymphocytes characteristic for celiac disease) there is, however, a greater spectrum of disease.

Patients may have milder disease so called Marsh 1 or Marsh 2, where there are subtle changes in inflammation or slight degree of crypt hyperplasia but intact villi. These present greater challenges for diagnosis not only because they may not be recognized as part of the spectrum of gluten-sensitive enteropathy, but also have a broader differential diagnosis and frequently have other disorders that cause these changes.

Luckily, class 4 on the right, the hypoplastic lesion, is quite rare and often occurs in the context of very complicated celiac disease. There are a few patients who have been described who have Marsh 0 in the context of serologic positivity for celiac disease. This circumstance has been termed latent or potential celiac disease and patients who have positive serology, especially by tissue transglutaminase antibodies or endomysial antibodies, should be followed over time as they may be at increased risk of developing celiac disease in the future.

Marsh Classification


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