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Difficulty: EasyPathology and Biopsy Interpretation

An evaluation is requested for a 32-year-old woman who reports a 6-month history of profound fatigue, abdominal bloating, and loose, malodorous stools. Initial workup reveals a microcytic anemia with a hemoglobin level of 10.2 g/dL10.2 \text{ g/dL}, and serologic testing is markedly positive for IgA anti-tissue transglutaminase antibodies. The patient subsequently undergoes an esophagogastroduodenoscopy with mucosal sampling of the distal duodenum. Which of the following histopathologic features are expected to be present on microscopic examination of this patient's biopsy specimens? (Select all that apply)

  1. Villous blunting and atrophyAnswer
  2. Increased intraepithelial lymphocytesAnswer
  3. Crypt hyperplasiaAnswer
  4. D
    Thickened subepithelial collagen band
  5. E
    Periodic acid-Schiff (PAS)-positive macrophages in the lamina propria

Answer

The expected histopathologic features are villous blunting and atrophy, increased intraepithelial lymphocytes, and crypt hyperplasia.
The patient's clinical presentation (malabsorption, microcytic anemia) combined with a positive IgA anti-tissue transglutaminase antibody strongly supports a diagnosis of celiac disease. The confirmatory diagnostic test is an upper endoscopy with duodenal biopsy. The classic, pathognomonic histopathologic triad of celiac disease consists of villous blunting or complete atrophy, compensatory crypt hyperplasia, and a marked increase in intraepithelial lymphocytes (predominantly CD8+ T cells) due to the gluten-induced inflammatory response.

Step-by-Step Solution

1
Analyze the clinical presentation and laboratory data.
The patient has symptoms of malabsorption (bloating, malodorous stools), iron deficiency anemia, and highly specific autoantibodies (anti-tTG IgA), firmly pointing to a diagnosis of celiac disease.
Establishing the clinical diagnosis sets the expectation for the histopathologic findings on the duodenal biopsy.
2
Identify the classic histopathologic triad of celiac disease.
The classic biopsy findings in the duodenum include villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis.
These three features represent the spectrum of gluten-induced, T-cell-mediated mucosal damage and attempted regeneration.
3
Differentiate from other causes of chronic diarrhea.
Rule out conditions like microscopic colitis (thickened collagen band) and Whipple disease (PAS-positive macrophages) based on the specific clinical and serologic context.
Distractors represent classic biopsy findings for other gastrointestinal diseases that do not fit this specific clinical picture.

Key Concept

The classic histopathologic triad of celiac disease on duodenal biopsy includes villous atrophy, crypt hyperplasia, and an increase in intraepithelial lymphocytes.
Estimated Time:1m 0s
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Topics

Pathology and Biopsy Interpretation

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