| INCREASED SPECIAL WHITE BLOOD CELLS IN | | | | definitively diagnosed by the combination positive |
| INTESTINE IS THE EARLIES SIGN OF GLUTEN | | | | results for specific blood antibodies for CD, either |
| INTOLERANCE AND CELIAC DISEASE | | | | endomysial (EMA) or tissue transglutaminase |
| Specialized white blood cells known as | | | | (tTG); a characteristic small intestine biopsy; and |
| lymphocytes are present in the tips of the villi of | | | | response to a gluten-free diet (GFD). Classically, |
| small intestine. They are believed to be important | | | | flattening of the intestinal villi, known as villous |
| in surveying the digestive tract for potential | | | | atrophy, has been the gold standard for diagnosis. |
| invaders or attacks from viruses, bacteria and | | | | Positive EMA or tTG tests without villous atrophy |
| parasites. In the context of leaky gut that can | | | | on biopsy but increased IEL's is accepted as |
| occur from eating gluten containing grains and | | | | diagnostic in the context of response to GFD, |
| flour, these lymphocytes can increase in numbers | | | | especially when an individual is positive for one of |
| at the tips of the intestinal villi. This change is | | | | the two predisposing genes, DQ2 or DQ8. |
| critical in the development of celiac disease (CD). | | | | WHAT DID THIS RECENT STUDY FIND |
| INCREASES IN INTESTINAL LYMPHOCYTES CAN | | | | REGARDING THE NUMBERS OF LYMPHOCYTES |
| BE SEEN UNDER THE MICROSCOPE BEFORE | | | | IN THE DIGESTIVE LINING? |
| DAMAGE OF THE INTESTINE LINING IS SEEN | | | | A recent study of biopsies of the esophagus, |
| Though not specific for CD, increased | | | | stomach, and duodenum of 46 people without |
| lymphocytes in the tips of the villi, also known as | | | | Celiac disease reached several conclusions. Though |
| increased intraepithelial lymphocytosis, is accepted | | | | there may be a slight increase in lymphocytes in |
| as the earliest sign of gluten intolerance in the gut. | | | | esophagitis and gastritis, the difference in |
| This increase when significant is obvious to most | | | | lymphocyte numbers is not significantly different |
| pathologists reviewing biopsy slides from tissue | | | | in normal biopsies of the esophagus and stomach. |
| obtained from the intestine during a scope | | | | Though general ranges of duodenal lymphocytes |
| examination. However, this may not be obvious | | | | found in active esophagitis (2-13, average 8.8), |
| without an objective count of the number | | | | active gastritis with Helicobacter pylori infection |
| lymphocytes in the tips of the intestinal villi. | | | | (2-13, average 7.2) and chronic gastritis without H. |
| HOW DO THE PATHOLOGISTS COUNT THE | | | | pylori infection (4-20, average 10.2) was very |
| NUMBER OF LYMPHOCYTES IN THE INTESTINAL | | | | similar to those with negative esophagus, stomach |
| LINING AND WHAT IS NORMAL? | | | | and duodenal biopsies (2-18, average 6.7) the |
| Most pathologists either report the number of | | | | average number of lymphocytes was slightly |
| IEL's per 20 intestinal lining cells (enterocytes) or | | | | higher, though not statistically significant. |
| per 100 enterocytes. Generally there are only 1-4 | | | | WHAT MIGHT THIS TELL US ABOUT |
| lymphocytes in the tips of each villous where | | | | LYMPHOCYTE NUMBERS IN THE INTESTINE? |
| there are typically 20 intestinal cells. When the | | | | In my opinion, I believe this study showed that |
| pathologist or a computerized counting microscope | | | | the numbers of lymphocytes in people with |
| reports or counts the lymphocytes per 100 | | | | normal biopsies, esophagitis and gastritis were |
| intestinal cells there are usually no more than | | | | significantly lower than those reported in people |
| 12-15 per 100 intestinal lining cells. In the past, 40 | | | | with Celiac disease (>30/100 ) and early gluten |
| lymphocytes per 100 intestinal cells (or about 8 | | | | injury (20-25/100 enterocytes) but not meeting |
| per villous tip) was considered the cut off for | | | | diagnostic criteria for Celiac disease. I believe this |
| abnormal. More recently that number has been | | | | study is helpful because it argues against |
| lowered to 30 lymphocytes per 100 intestinal or | | | | attributing more than 20-25 lymphocytes/ 100 |
| epithelial cells (about 6 per villous tip). There are | | | | enterocytes to other inflammatory processes in |
| some researchers who believe the number should | | | | the esophagus or stomach. It also supports the |
| be lowered to 25 per 100 (or about 5 per villous | | | | findings of other studies that have found that |
| tip). | | | | >20-25 /100 as an early sign of gluten |
| WHAT ARE CAUSES OF INCREASED WHITE | | | | sensitivity. |
| BLOOD CELLS OR LYMPHOCYTES IN THE | | | | WHAT ABOUT LYMPHOCYTE COUNTS LESS |
| INTESTINE? | | | | THAN 30 BUT 25 OR MORE? |
| Celiac disease is the most common but infection | | | | In the context of elevated gliadin antibody levels I |
| from the ulcer causing bacterium Helicobacter | | | | believe that intestinal lymphocyte counts in the villi |
| pylori or the parasite giardia can be a cause as | | | | of 25 or more likely indicates gluten sensitivity |
| well as recent viral infection. Cow's milk protein | | | | though it does not necessarliy mean Celiac |
| sensitivity and allergy is also a cause. Though not | | | | disease. Strict criteria for diagnosing of this |
| well established, it is believed that the number of | | | | disease require a positive specific blood test such |
| lymphocytes in conditions other than Celiac | | | | as endomysial antibody or tissue transglutaminase |
| disease or gluten intolerance may not be as high. | | | | antibody and >30 IEL's/100 enterocytes and |
| Inflammatory conditions in the esophagus, | | | | evidence of villous atrophy on small intestinal |
| stomach, distal small bowel or colon may be | | | | biopsy. |
| associated with increased IEL's in those areas but | | | | WHAT SHOULD I TAKE FROM THIS? |
| the number has not been well studied. There is a | | | | If you have had an intestinal biopsy but were told |
| concern that some pathologists may falsely | | | | you did not have signs of Celiac disease, I |
| attribute increased duodenal lymphocytes to | | | | recommend you consider asking that biopsy be |
| associated inflammation going on in either the | | | | reviewed by another pathologist who has |
| esophagus or stomach. Increased lympnocytes | | | | experience in Celiac disease and you ask them to |
| have been noted in the gut above the duodenum | | | | provide you with the number of lymphocytes in |
| (esophagus and stomach) and below the jejunum | | | | the villi. If they provided the number and you find |
| (ileum and colon) in both celiac and microscopic or | | | | there were 30 or more then that is clearly |
| collagenous colitis caused by gluten sensitivity. | | | | abnormal and can be diagnostic of Celiac disease if |
| WHAT IS CELIAC DISEASE? | | | | you have a positive specific blood test such as |
| Celiac disease is an autoimmune disease of gluten | | | | the endomysial or tissue transglutaminase |
| intolerance or sensitivity not a food allergy though | | | | antibodies, especially if you carry either the DQ2 |
| many people mistakenly refer to it as gluten | | | | and/or the DQ8 genetics. If you have less than |
| allergy or wheat allergy. Previously thought to be | | | | 30 lymphocytes per 100 enterocytes but 20 or |
| rare it is now known to be very common, | | | | more and have a gliadin antibody elevation I would |
| affecting 1/100 worldwide. | | | | recommend you get HLA DQ genetic testing and |
| Celiac Sprue, as CD is also commonly known, is | | | | try a gluten free diet. |