Minimal Lesions of the Small Intestinal Mucosa: More than Morphology
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CURRENT CLINICAL CONTROVERSY
Minimal Lesions of the Small Intestinal Mucosa: More than Morphology Umberto Volta1 · Giacomo Caio2,3 · Caterina Ghirardi2 · Lisa Lungaro2 · Pasquale Mansueto4 · Antonio Carroccio5 · Roberto De Giorgio2
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Minimal lesions of the small bowel are mucosal changes characterized by an increased number of intraepithelial lymphocytes (with or without crypt hyperplasia) and normal villous architecture. Such changes are associated with a wide spectrum of conditions, ranging from food intolerances to infections, and from drugs to immune diseases, with different clinical profiles and manifestations, which complicates the formulation of a differential diagnosis. Patient history, symptom evaluation, and histopathology are the diagnostic features needed to establish a correct diagnosis. Physicians should assist pathologists in formulating a precise morphological evaluation by taking well-oriented small intestinal biopsies and collecting informative clinical findings that inform histopathology. In this current clinical controversy, the authors provide the reader with an appraisal of the small intestine minimal lesions through a careful analysis of the major conditions (e.g., celiac disease and other non-celiac disorders) responsible for such changes and their differential diagnosis. Also, we acknowledge that some of the diseases detailed in this article may progress from an early minimal lesion to overt mucosal atrophy. Thus, the timing of the diagnosis is of paramount importance. Keywords Celiac disease · Immunoglobulin A-tranglutaminase 2 depositis · Intra-epithelial lymphocytes · Mucosal enteropathies · Non-celiac gluten/wheat sensitivity · Potential celiac disease
Introduction Umberto Volta and Giacomo Caio contributed equally to this work. * Roberto De Giorgio [email protected] 1
Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
2
Department of Morphology, Surgery and Experimental Medicine, St. Anna University Hospital, University of Ferrara, Ferrara, Italy
3
Celiac Center and Mucosal Immunology and Biology Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
4
Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
5
Unit of Internal Medicine, “V. Cervello” Hospital, Ospedali Riuniti “Villa Sofia‑Cervello”, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
Patients with gastrointestinal symptoms, such as those attributable to dyspepsia and/or other functional syndromes, including irritable bowel syndrome (IBS), are commonly encountered in daily practice [1]. These patients, who have negative laboratory, radiologic, and endoscopic exams, become puzzling when their upper intestinal mucosal histopathology shows mild changes, refer
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