Spectrum of expression of intestinal cellular immunity: proposal for a change in diagnostic criteria of celiac disease.

The clinical heterogeneity of celiac disease is well recognized, with great variability in malabsorption and in gastrointestinal symptoms of patients with active celiac disease, and the fairly common occurrence of silent celiac disease (ie, an apparently healthy individual with a flat small bowel mucosa). Research in experimental animals has shown that expression of cell-mediated immunity in the gut mucosa occurs in a spectrum of pathologies ranging from minimal enteropathy with a high count of intra-epithelial lymphocytes to the celiac-like lesion with short villi and long crypts. A similar range of pathology is seen in celiac patients in some circumstances, with low grade enteropathy occurring in the early stages of gluten challenge, in patients taking a low gluten diet, and also in some patients with dermatitis herpetiformis. In so-called latent celiac disease, sophisticated immunologic studies may reveal a high intra-epithelial lymphocyte count, an increased gamma delta intra-epithelial lymphocyte count, and a celiac-like intestinal antibody abnormality with overexpression of mucosal IgM responses. If further work confirms that one or more of these features may be the only manifestation of gluten-sensitive disease in some newly presenting patients, the current definition of celiac disease (a flat mucosa, gluten-sensitive) will need to be revised.