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Open Access 
F u l l  L e n g t h  A r t i c l e  

 Clinical and Morphological Aspects of Celiac Disease 
 

Anum Usman, Noor Khan Lakhanna, Mudassira Zahid, Humaira Zafar 
1,3 Assistant Professor, 2 Professor/Head of Department, 4 Associate Professor 

Department of Pathology, Al-Nafees Medical College and Hospital Islamabad 
 

A B S T R A C T  

Objective: To assess the clinical and morphological aspects of celiac disease. 

Patients and Methods: This cross sectional study was conducted at Department of Pathology, Al Nafees Medical 

College & Hospital for a period of 8 months. After taking approval from Institutional review board, a written informed 

consent was taken from all the enrolled patients depending upon inclusion and exclusion criteria. Clinical data including 

the symptoms and signs and their severity was collected and entered on a specially designed proforma. Morphological 

data was collected with the help of patient’s endoscopic biopsy. Histopathological biopsies were graded according to 

modified Marsch grading system. For qualitative variables frequencies and percentages were calculated. Quantitative 

variables were measured in terms of mean and standard deviation. 

Results: There were 77 patients with suspicion of celiac disease whose endoscopic biopsy was done. Among these 

42% were males and 58 % were females. Maximum number of patients were in the age group of 13-30 years. Among 

symptoms, diarrhea was present in 83.11% (n=64) patients, abdominal distention and pain was present in 53% and 

63.6% patients respectively. Lesser frequent symptoms including vomiting and weight loss was significant in only 16.9% 

patients and constipation in 14.3% patients. According to modified Marsch grades, maximum celiac patients were 

graded in Marsch-3a (15.6%) and Marsch-3b (19.5%). 

Conclusion: Majority of patients with Celiac disease presented with typical gastrointestinal signs and symptoms in 

which diarrhea was the commonest complaint. The disease is more common in adults with female predominance. 

Majority of patients belong to the 3a and 3b type lesion of the modified Marsch grading system. 

Key words: Celiac disease, Malabsorption, Morphology, Modified Marsch grades. 

Author`s Contribution 
1
 Conception, synthesis, planning of research 

and manuscript writing Interpretation and 
discussion 
2 3 

Data analysis, interpretation and 
manuscript writing, 

4 
Active participation in 

data collection. 

Address of Correspondence 
Mudassira Zahid 
Email: Mudassirazahid@gmail.com 

Article info. 
Received:  May 17, 2018 
Accepted:  August 22, 2018 

Cite this article. Usman A, Lakhana NK, Zahid M, Zafar H. Clinical and Morphological Aspect 
of Celiac Disease. JIMDC.2018; 7(3):165-168 
 

Funding Source: Nil 
Conflict of Interest: Nil 

I n t r o d u c t i o n  
 

Celiac disease (CD) is a chronic disease of the small 

intestine in which intake of gluten found in rye, wheat and 

barley determines the injury of the intestinal mucosa in 

genetically susceptible individuals.1 It is an inflammatory 

process which mainly involves the mucosa of small 

intestine resulting in atrophy of intestinal villi along with 

clinical manifestations. Gluten proteins are resistant to 

digestive enzymes resulting in peptide derivatives leading 

to immunogenic response in CD patients.2 Celiac disease 

affects 0.6-1.0% people worldwide and different studies 

showed the prevalence of 0.3% in Germany and 2.4% in 

Finland.3-5 Celiac disease affects around 1% of the 

general population with increasing prevalence over time 

as reported in the United States and Europe.6-8 Diagnosis 

of Celiac disease is based on clinical manifestations, 

laboratory tests, histological aspects of small intestine 

O R I G I N A L  A R T I C L E  



 

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mucosa and serological markers.9-10 Patients suffering 

from celiac disease usually present with features of 

malabsorption represented by diarrhea, steatorrhea, 

weight loss or failure to thrive. CD patients can also 

present with variety of extraintestinal symptoms and signs 

including anemia, vague abdominal symptoms, ataxia, 

neuropathy, depression, short stature, osteoporosis, 

osteomalacia, liver diseases and lymphoma.11-15 

Characteristic histopathological changes in the mucosa of 

small intestine are taken as the standard criteria for 

diagnosis of celiac disease. According to the modified 

Marsch grading system, histopathological changes are 

categorized as 0-4.16 The severity of mucosal changes in 

celiac disease is variable ranging from almost normal to 

total atrophic villi.17 Marsh proposed histopathological 

classification system which was later modified by 

Oberhuber. Marsh-Oberhuber grading system includes 

five grades of lesions as type 0 with normal histology, 

type 1 with increased Intraepithelial lymphocytes (IEL) 

only; type 2 with increased IEL and crypt hyperplasia, 

type 3 with increased IEL, crypt hyperplasia and villous 

atrophy which is further classified as 3a, 3b and 3c for 

mild, marked and total villous atrophy and type 4 lesion 

with flat atrophic villi.18 

The current study is aimed at determining how patients 

with celiac disease present to the physicians and what are 

the morphological attributes in these patients. This study 

will help identify the current trends of presentation of 

celiac disease patients in our settings. 

P a t i e n t s  a n d  M e t h o d s  

This cross sectional study was conducted over a period of 

eight months from May 2015 to December 2015 in 

department of Pathology, Al Nafees Medical College and 

Hospital. Both males and females from all age groups, 

having symptoms of malabsorption and later labeled as 

celiac disease patients on intestinal biopsy were included 

in the study. Patients diagnosed with other causes of 

malabsorption, improperly processed samples and 

improperly stained slides were not included in the study. 

Written and informed consent was taken from all patients. 

Data regarding procedure performed and history of 

patient was collected along with each specimen. Proforma 

was filled. Surgically removed endoscopic duodenal 

biopsy specimens, placed immediately in 10% buffered 

formalin, were received in the pathology lab. After fixation 

the gross examination of biopsy was carried out. These 

gross specimens were sent for processing and 

Hematoxylin & Eosin staining. The stained sections of the 

specimen were examined microscopically at low power 

(4x, 10x objective), medium power (20x objective) and 

high power (40x objective). The microscopic details were 

analyzed by using modified Marsch grading system. Data 

was computed using SPSS version 20. Qualitative 

variables were analyzed in terms of frequencies and 

percentages. For quantitative variables mean and 

standard deviation was calculated.  

R e s u l t s  

Total 77 patients were enrolled in the study. Among them, 

39% were male and 61% were female. The stratification 

of patient data according to patient age group is shown in 

Table-1. Maximum number of patients were between 

ages 13 to 30 years. Among all symptoms, diarrhea was 

the commonest in both male and female (Figure 1), noted 

in 83.11% (n=64) patients. Abdominal distention and pain 

were present in 67.53 % (n=52) and 63.6% (n=49) 

patients respectively. Vomiting was noted in 16.9% (n=13) 

patients and constipation was present in 14.3% (n=11) 

patients. 

Endoscopic duodenal biopsy findings of all patients were 

recorded and grouped into different grades as per 

Modified Marsch grading system. Marsch-0 included 

28.6% (n=22) patients, Marsch-1 consisted of 9.1%(n=7) 

patients and Marsch-2 included 13%(n=10) patients. 

Whereas, Marsch-3a, Marsch-3b and Marsch-3c 

comprised of 15.6% (n=12), 19.5% (n=15) and 14.3% 

(n=11) patients respectively as shown in Graph-2. 
 

 
Figure1: Percentage distribution of patients 

according to symptoms 



 

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Figure 2: Gender distribution according to Marsch 

Grades 

D i s c u s s i o n  

Celiac disease is known as one of the most important 

gastrointestinal diseases. Diagnosis of celiac disease is 

difficult because of the unusual presentation of large 

number of patients with intestinal and extraintestinal signs 

and symptoms.19 In the current study, findings about 

distribution of patients according to age shows that 

maximum number of patients lie in the age group of 13 to 

30 years while pediatric (n=6) and old (n=5) age group 

has lesser number of patients. In contrast a study 

conducted by Rashtak S et al showed that median age of 

patients at the time of diagnosis was under the age of 50 

while one third of patients were diagnosed above the age 

of 65.20 Another study carried out by Marine M et al 

reported that the prevalence of celiac disease in the 

pediatric  age group had increased fivefold as compared 

to the adult age group.21 The current study reveals  that 

female adults are more commonly affected by celiac 

disease as compared to males. These findings are in 

favor of other study conducted by Makharia G which 

revealed that celiac disease is more frequent in adult 

women than in men with a ratio of 4:1.22 In another study 

done by Thomas H also showed similar results that the 

prevalence of celiac disease was high in women to that in 

men.23 In current study, amongst all symptoms, diarrhea, 

abdominal pain and abdominal distention are maximally 

present in the patients and also in the same group of 13 

to 30 years. A study conducted by Santiago V et al 

reported that diarrhea, malnutrition, bloating and vomiting  

Table-1: Distribution of Patients According To 
Age Groups 

Gender Males Females Total 

Age n(%) n(%) n 

<13 years 2(6.7) 4(8.5) 6 

13-30 years 15(50.0) 24(51.1) 39 

30-50 years 10(33.3) 17(36.2) 27 

>50 years 3(10.0) 2(4.3) 5 

Total 30(100) 47(100) 77 

 

were more prevalent in children less than 2 years while 

dyspepsia, iron deficiency anemia and constipation were 

maximally present in adult age group.24 Another study 

conducted by Kivela L revealed that the clinical 

presentation of celiac disease in children were minor 

especially in the 1990s while most of these changes had 

reached a peak in recent years.25 Histopathological 

findings graded by modified Marsch revealed that 

maximum number of both male and female patients 

suffered from 3a and 3b type lesion of the celiac disease 

among all Marsch categories. Study conducted by 

Parveen malothra et al in 2015 also had similar findings, 

which revealed that maximum number of patients 

belonged to grade 3a of modified Marsch grading 

system.26 

C o n c l u s i o n  

Majority of patients with celiac disease present with 

typical gastrointestinal signs and symptoms in which 

diarrhea is the commonest finding. Majority of patients 

were adults with female predominance. Histopathological 

findings showed that 3a and 3b type lesion of the 

modified Marsch grading system were the commonest. 

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