Celiac Disease, Liver Cirrhosis and the Small Bowel

Abstract

Purpose: The most reliable marker for celiac disease CD is the presence of abnormal small bowel SB mucosa defined by Marsh criteria. CD may be associated with liver disease and cirrhosis. Studies have shown that cirrhosis may cause lymphocytic infiltration of SB mucosa, decreased villous/crypt ratio, and reduced total absorptive surface. None of the studies described SB mucosal changes according to Marsh criteria. Verification that cirrhosis does not cause SB mucosal changes that fit Marsh criteria for CD is required if biopsy findings are to be used to establish a diagnosis of CD in cirrhotic patients. We aim to study the SB mucosa on biopsy in cirrhotics and non-cirrhotics and grade findings according to Marsh criteria. Methods: We obtained multiple SB biopsies from 25 cirrhotics undergoing upper endoscopy EGD to screen for esophageal varices, and from 26 non-cirrhotics receiving EGD for reasons other than weight loss, malabsorption or iron deficiency. At enrollment, none of the subjects had a history of CD and all had normal celiac serology for EMA, hTTG and AGA. Pathologist was unaware of diagnosis and graded findings according to Marsh criteria. We tested a null hypothesis stating that the Marsh grade between both groups was NOT equivalent using a Mann-Whitney test for equivalence. Results: There was no significant difference in age or gender between the two groups (p > 0.10) (table). There was no statistical difference in the SB mucosa between cirrhotics and non-cirrhotics. Mucosa was normal (Marsh grade 0) in 96% of each group, and (Marsh grade1) in one subject in each group (figure). Thus, SB architecture was equivalent between cirrhotics and non-cirrhotics (p < 0.001, H0: groups are NOT equivalent).Figure: P-value corresponds to Mann-Whitney test for EQUIVALENCE.TableConclusions: Liver cirrhosis does not cause small bowel mucosal changes of celiac disease. This implies that small bowel biopsy should be as accurate in patients with liver disease as in patients without liver disease in the diagnosis of celiac disease.