Celiac diseaseis 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” forceliac diagnosis, the results ofceliac diseaseblood testsand the person’s ultimate response to the gluten-free diet also can assist in getting the right diagnosis.

Stage 0Science Picture Co. / Getty ImagesThis is a photograph taken during anendoscopy, showing a normal small intestine lined with healthyvilli. Since the intestinal lining appears normal, it’s unlikely that the person has celiac disease.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 to move into (infiltrate) the intestinal lining.

Stage 0

Science Picture Co. / Getty Images

normal intestinal lining

This is a photograph taken during anendoscopy, showing a normal small intestine lined with healthyvilli. Since the intestinal lining appears normal, it’s unlikely that the person has celiac disease.

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 to move into (infiltrate) the intestinal lining.

Stage 1© Ludvigsson et al, 2009Stage 1 celiac disease is when the cells on the surface of the intestinal lining, known as the epithelial cells, have more lymphocytes among them than normal. The presence of too many lymphocytes indicates inflammation and the potential for damage.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 “increasedintraepitheliallymphocytes.“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,Sjögren’sdisease, and other food intolerances. Infections with a bacteria calledHelicobacter pylori(which is linked to ulcers), and the use of over-the-counter painkillers 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 withdermatitis herpetiformis, an extremely itchy rash that’s considered to be the skin manifestation of celiac disease, may also have a stage 1 Marsh score.

Stage 1

© Ludvigsson et al, 2009

celiac disease Marsh Score 1 intestinal lining

Stage 1 celiac disease is when the cells on the surface of the intestinal lining, known as the epithelial cells, have more lymphocytes among them than normal. The presence of too many lymphocytes indicates inflammation and the potential for damage.

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 “increasedintraepitheliallymphocytes.”

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,Sjögren’sdisease, and other food intolerances. Infections with a bacteria calledHelicobacter pylori(which is linked to ulcers), and the use of over-the-counter painkillers 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 withdermatitis herpetiformis, an extremely itchy rash that’s considered to be the skin manifestation of celiac disease, may also have a stage 1 Marsh score.

Stage 2With stage 2, you see more lymphocytes than normal as well as bigger depressions than normal between the intestinal villi. These depressions are called “crypts.“Larger-than-normal crypts are called “hyperplastic.” 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 2 is pretty rare—it’s mostly seen in people who have dermatitis herpetiformis. This rash can appear anywhere on the body, but is most commonly seen on theextensor surfacesof the knees, elbows, shoulders, buttocks, sacral region, neck, face, and scalp.

Stage 2

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.”

Larger-than-normal crypts are called “hyperplastic.” 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 2 is pretty rare—it’s mostly seen in people who have dermatitis herpetiformis. This rash can appear anywhere on the body, but is most commonly seen on theextensor surfacesof the knees, elbows, shoulders, buttocks, sacral region, neck, face, and scalp.

Stage 3

image of marsh score 3 intestinal lining - celiac disease

Most healthcare providers won’t diagnose celiac disease until your intestinal lining Marsh Score reaches stage 3.In this stage, the changes of stage 2 are present—more lymphocytes than normal and larger-than-normal depressions—as well as shrinking and flattening intestinal villi, what is known asvillous atrophy.

Stage 3 celiac disease has three substages:

Most people who are diagnosed with celiac disease have a stage 3 Marsh score.

What Is Stage 4 Celiac?

This stage has since been removed from the Marsh Classification since it is believed to involve different disease processes.

Endoscopy and Celiac Disease DiagnosisEndoscopic biopsy is the most accurate way todiagnose celiac disease.This procedure involves inserting a small scope through your mouth and into your stomach and small intestine. This allows your healthcare provider to see the inside of your GI tract and take a small sample of tissue for analysis in a laboratory.Video capsule endoscopy (VCE) is a test that involves swallowing a small wireless camera to help your healthcare provider visualize your small intestine. VCE levels of sensitivity are 89%, which means the test can correctly identify the presence of celiac disease about 89% of the time.

Endoscopy and Celiac Disease Diagnosis

Endoscopic biopsy is the most accurate way todiagnose celiac disease.This procedure involves inserting a small scope through your mouth and into your stomach and small intestine. This allows your healthcare provider to see the inside of your GI tract and take a small sample of tissue for analysis in a laboratory.

Video capsule endoscopy (VCE) is a test that involves swallowing a small wireless camera to help your healthcare provider visualize your small intestine. VCE levels of sensitivity are 89%, which means the test can correctly identify the presence of celiac disease about 89% of the time.

SummaryGastroenterologists use Marsh scores to determine the stage of celiac disease based on the damage to your small intestinal lining. Your Marsh score will determine whether you have celiac disease and how much it has damaged your intestinal villi.Agluten-free dietis the only treatment for celiac disease.After you start going gluten-free, your symptoms should improve within a few days, and with time, even bad intestinal damage will completely heal.By managing your symptoms, you can still lead a full life with celiac disease.

Summary

Gastroenterologists use Marsh scores to determine the stage of celiac disease based on the damage to your small intestinal lining. Your Marsh score will determine whether you have celiac disease and how much it has damaged your intestinal villi.

Agluten-free dietis the only treatment for celiac disease.After you start going gluten-free, your symptoms should improve within a few days, and with time, even bad intestinal damage will completely heal.By managing your symptoms, you can still lead a full life with celiac disease.

10 SourcesVerywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Tarar ZI, Zafar MU, Farooq U, et al.The progression of celiac disease, diagnostic modalities, and treatment options.J Investig Med High Impact Case Rep. 2021;9:23247096211053702. doi:10.1177/23247096211053702Zhu J, Mulder CJJ, Dieleman LA.Celiac disease: Against the grain in gastroenterology.J Can Assoc Gastroenterol. 2019;2(4):161–169. doi:10.1093/jcag/gwy042Sergi C, Shen F, Bouma G.Intraepithelial lymphocytes, scores, mimickers and challenges in diagnosing gluten-sensitive enteropathy (celiac disease).World J Gastroenterol. 2017;23(4):573–589. doi:10.3748/wjg.v23.i4.573Antiga E, Caproni M.The diagnosis and treatment of dermatitis herpetiformis.Clin Cosmet Investig Dermatol. 2015;8:257–265. doi:10.2147/CCID.S69127Celiac Disease Foundation.Diagnosis.Perrotta G, Guerrieri E.Celiac disease: Definition, classification, historical and epistemological profiles, anatomopathological aspects, clinical signs, differential diagnosis, treatments and prognosis. Proposed diagnostic scheme for celiac disease (DSCNC).Arch Clin Gastroenterol. 2022;8(1):008-19. doi:10.17352/2455-2283.000106Holmes G.No-biopsy diagnostic approach to coeliac disease.Gastroenterol Hepatol Bed Bench. 2023;16(2):112-117. doi:10.22037/ghfbb.v16i2.2706Celiac Disease Foundation.Testing.Celiac Disease Foundation.Treatment & follow-up.Johns Hopkins Medicine.Celiac disease.

10 Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Tarar ZI, Zafar MU, Farooq U, et al.The progression of celiac disease, diagnostic modalities, and treatment options.J Investig Med High Impact Case Rep. 2021;9:23247096211053702. doi:10.1177/23247096211053702Zhu J, Mulder CJJ, Dieleman LA.Celiac disease: Against the grain in gastroenterology.J Can Assoc Gastroenterol. 2019;2(4):161–169. doi:10.1093/jcag/gwy042Sergi C, Shen F, Bouma G.Intraepithelial lymphocytes, scores, mimickers and challenges in diagnosing gluten-sensitive enteropathy (celiac disease).World J Gastroenterol. 2017;23(4):573–589. doi:10.3748/wjg.v23.i4.573Antiga E, Caproni M.The diagnosis and treatment of dermatitis herpetiformis.Clin Cosmet Investig Dermatol. 2015;8:257–265. doi:10.2147/CCID.S69127Celiac Disease Foundation.Diagnosis.Perrotta G, Guerrieri E.Celiac disease: Definition, classification, historical and epistemological profiles, anatomopathological aspects, clinical signs, differential diagnosis, treatments and prognosis. Proposed diagnostic scheme for celiac disease (DSCNC).Arch Clin Gastroenterol. 2022;8(1):008-19. doi:10.17352/2455-2283.000106Holmes G.No-biopsy diagnostic approach to coeliac disease.Gastroenterol Hepatol Bed Bench. 2023;16(2):112-117. doi:10.22037/ghfbb.v16i2.2706Celiac Disease Foundation.Testing.Celiac Disease Foundation.Treatment & follow-up.Johns Hopkins Medicine.Celiac disease.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

Tarar ZI, Zafar MU, Farooq U, et al.The progression of celiac disease, diagnostic modalities, and treatment options.J Investig Med High Impact Case Rep. 2021;9:23247096211053702. doi:10.1177/23247096211053702Zhu J, Mulder CJJ, Dieleman LA.Celiac disease: Against the grain in gastroenterology.J Can Assoc Gastroenterol. 2019;2(4):161–169. doi:10.1093/jcag/gwy042Sergi C, Shen F, Bouma G.Intraepithelial lymphocytes, scores, mimickers and challenges in diagnosing gluten-sensitive enteropathy (celiac disease).World J Gastroenterol. 2017;23(4):573–589. doi:10.3748/wjg.v23.i4.573Antiga E, Caproni M.The diagnosis and treatment of dermatitis herpetiformis.Clin Cosmet Investig Dermatol. 2015;8:257–265. doi:10.2147/CCID.S69127Celiac Disease Foundation.Diagnosis.Perrotta G, Guerrieri E.Celiac disease: Definition, classification, historical and epistemological profiles, anatomopathological aspects, clinical signs, differential diagnosis, treatments and prognosis. Proposed diagnostic scheme for celiac disease (DSCNC).Arch Clin Gastroenterol. 2022;8(1):008-19. doi:10.17352/2455-2283.000106Holmes G.No-biopsy diagnostic approach to coeliac disease.Gastroenterol Hepatol Bed Bench. 2023;16(2):112-117. doi:10.22037/ghfbb.v16i2.2706Celiac Disease Foundation.Testing.Celiac Disease Foundation.Treatment & follow-up.Johns Hopkins Medicine.Celiac disease.

Tarar ZI, Zafar MU, Farooq U, et al.The progression of celiac disease, diagnostic modalities, and treatment options.J Investig Med High Impact Case Rep. 2021;9:23247096211053702. doi:10.1177/23247096211053702

Zhu J, Mulder CJJ, Dieleman LA.Celiac disease: Against the grain in gastroenterology.J Can Assoc Gastroenterol. 2019;2(4):161–169. doi:10.1093/jcag/gwy042

Sergi C, Shen F, Bouma G.Intraepithelial lymphocytes, scores, mimickers and challenges in diagnosing gluten-sensitive enteropathy (celiac disease).World J Gastroenterol. 2017;23(4):573–589. doi:10.3748/wjg.v23.i4.573

Antiga E, Caproni M.The diagnosis and treatment of dermatitis herpetiformis.Clin Cosmet Investig Dermatol. 2015;8:257–265. doi:10.2147/CCID.S69127

Celiac Disease Foundation.Diagnosis.

Perrotta G, Guerrieri E.Celiac disease: Definition, classification, historical and epistemological profiles, anatomopathological aspects, clinical signs, differential diagnosis, treatments and prognosis. Proposed diagnostic scheme for celiac disease (DSCNC).Arch Clin Gastroenterol. 2022;8(1):008-19. doi:10.17352/2455-2283.000106

Holmes G.No-biopsy diagnostic approach to coeliac disease.Gastroenterol Hepatol Bed Bench. 2023;16(2):112-117. doi:10.22037/ghfbb.v16i2.2706

Celiac Disease Foundation.Testing.

Celiac Disease Foundation.Treatment & follow-up.

Johns Hopkins Medicine.Celiac disease.

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