A patient with coeliac disease is identified based on positive serum IgA anti-tissue transglutaminase antibody (anti-tTG IgA >10× upper limit of normal) and total IgA level is normal. HLA-DQ2 positive. Duodenal biopsy is performed. Marsh classification of coeliac disease histology — which Marsh grade shows villous atrophy (subtotal or total) with crypt hyperplasia and increased IELs?
- A Marsh 1 (infiltrative lesion only)
- B Marsh 3 (destructive lesion: 3a partial, 3b subtotal, 3c total villous atrophy) ✓
- C Marsh 2 (infiltrative-hyperplastic lesion)
- D Marsh 4 (hypoplastic lesion with atrophic mucosa)
Explanation
The Marsh classification of coeliac disease histology: Marsh 1 shows increased IELs (>25 per 100 epithelial cells) only with normal villous architecture; Marsh 2 adds crypt hyperplasia to increased IELs; Marsh 3 (most important clinically) shows villous atrophy — partial (3a), subtotal (3b), or total (3c) — with crypt hyperplasia and increased IELs. Marsh 3c (total villous atrophy) represents the classic 'flat biopsy' of coeliac disease. Marsh 4 (total atrophy without inflammation) is seen in refractory coeliac disease or enteropathy-associated T-cell lymphoma. HLA-DQ2 (95%) or HLA-DQ8 (5%) is found in nearly all coeliac patients.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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