If you’re being tested for celiac disease, your healthcare provider will likely perform an endoscopy and biopsy to see whether your small intestine has been damaged by gluten, a protein found in wheat, barley, and rye. Your practitioner will use a medical instrument, called an endoscope, with a tiny camera to look directly at your upper digestive system, and will take very small samples of tissue from the lining of your small intestine.
Following your endoscopy, a pathologist will look at your tissue samples to see if there’s gluten-related damage. That pathologist will rate the condition of these samples based on a rating system called the Marsh Score.
Celiac disease is not the only condition that can cause some of these changes. That’s why a biopsy is only one of the diagnostic tests recommended for celiac disease. Although a biopsy is considered “the gold standard” for celiac diagnosis, the results of celiac disease blood tests and the person’s ultimate response to the gluten-free diet also can assist in getting the right diagnosis.
In this case, the biopsy sample would be classified as Marsh Stage 0, also known as the “pre-infiltrative stage.” It’s called “pre-infiltrative” because lymphocytes (a type of white blood cell) have not yet started move into, or “infiltrate,” the intestinal lining.
In a normal small intestine, there should be no more than 30 lymphocytes per 100 epithelial cells, but in cases deemed stage 1, there are more than that. If you have stage 1, your pathology report will likely read “increased intraepithelial lymphocytes.“
Celiac disease isn’t the only condition that can cause an increase in disease-fighting lymphocytes. You may have more lymphocytes if you have inflammatory bowel disease, Sjogren’s syndrome, and other food intolerances. Infections with a bacteria called Helicobacter pylori (which is linked to ulcers), and use of over-the-counter pain killers such as aspirin and ibuprofen, also can cause this.
People with celiac disease who are following the gluten-free diet, close family members of people with celiac disease, and people with dermatitis herpetiformis, an extremely itchy rash that’s considered to be the skin manifestation of celiac disease, may also have a stage 1 Marsh score.
With stage 2, you see more lymphocytes than normal as well as bigger depressions than normal between the intestinal villi. These depressions are called “crypts,” and larger-than-normal crypts are called “hyperplastic,” so if your pathology report following your biopsy says you have “hyperplastic crypts” or “crypt hyperplasia,” it means the depressions seen in your biopsy are bigger than they would be in a normal intestinal lining.
Stage 3 has three substages:
Partial villous atrophy (Stage 3a): Your intestinal villi are still there, but are smallerSubtotal villous atrophy (Stage 3b): Your intestinal villi have shrunken significantlyTotal villous atrophy (Stage 3c): Your intestinal lining is basically flat with no intestinal villi left
Stage 4 is most common amongst older people with celiac disease. If your Marsh score is a stage 4, you may have a higher risk for celiac disease complications, including lymphoma.
A Word from Verywell
Gastroenterologists use Marsh scores to quantify the damage to your small intestinal lining from celiac disease. Your Marsh score will determine whether you have celiac disease, and how much it has damaged your intestinal villi.
This guide to Marsh score levels can help you interpret the report from your intestinal biopsy. However, if you’re having trouble understanding it, don’t be afraid to talk to your healthcare provider about what it means. And remember: once you start the gluten-free diet, even bad intestinal damage should begin to heal.
