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Abstract
Most absorption of nutrients takes place in the proximal small intestine, and the
most common disorders leading to malabsorption are associated with a morphological
abnormality in the duodenal mucosa that is appreciable in histological sections of
biopsy specimens. Coeliac disease is the most well-known example, causing intraepithelial
lymphocytosis, inflammation and villous atrophy in the duodenum. Remarkably similar
inflammatory changes can be induced by other processes, including medications, e.g.
angiotensin II receptor blockers and immune checkpoint inhibitors, immune dysregulation
disorders, e.g. common variable immunodeficiency and autoimmune enteropathy, infections,
collagenous sprue, and tropical sprue. However, there are often subtle histological
differences from coeliac disease in the type of inflammatory infiltrate, the presence
of crypt apoptosis, and the extent and type of inflammation beyond the duodenum. The
clinical setting and serological investigation usually allow diagnostic separation,
but some cases remain challenging. Histopathology is also important in assessing the
response to treatment, such as the change in villous architecture caused by a gluten-free
diet, or the response to cessation of a potentially causative medication. This review
examines the practical role that histopathology of duodenal biopsy specimens plays
in the assessment and management of inflammatory malabsorptive processes of the proximal
small intestine, with a particular emphasis on coeliac disease.