Non celiac Enteropathies : A Clinical and Pathological Insight beyond Serology -An observational study in adults over 18 years in Rajasthan

Abstract Background & objectives: Non celiac enteropathies are a heterogenous group of diseases that mimics celiac disease both clinically and histologically. It encompass a wide range of etiologies. This article aims to provide a comprehensive clinical and pathological insight into non-celiac enteropathies presenting with celiac-like morphology and discordant serology, highlighting the diverse etiologies, diagnostic challenges, and implications for patient care. Methods: 200 patients with chronic diarrhea (>4 weeks), steatorrhea, documented weight loss (>5% over 3–6 months), unexplained iron deficiency or megaloblastic anemia, hypoalbuminemia without hepatic or renal cause, vitamin deficiencies (including B12 and fat-soluble vitamins), or recurrent abdominal pain associated with diarrhea and systemic features were enrolled. Upper GI endoscopy followed by duodenal biopsy done and sections reported as per proforma and graded as per Modified Marsh system. A diagnostic algorithm followed to interpret endoscopy, biopsy and clinical findings. Results: Mean age of participants was 37.3 ± 15.1 years, with a male predominance (62.5%). Marsh grade 1, 2, 3a, 3b and 3c were 10%, 9%, 51%, 15% and 15% respectively with negative serology while true celiac disease was seen in 34.5% cases.. The various etiologies found were Alcoholism (10%), NSAID (10%), Olmesartan (9%), H. Pylori (7.5%), Giardiasis (5%), Tropical sprue (1%), HIV (1.5%), azathioprine (1.5%), IBD (1%), peptic duodenitis (4%), Megaloblastic anemia (1.5%), cow milk (2.5%) and soy protein allergy (1.5%). Interpretation & conclusions: Celiac-like histological features are not disease-specific and may reflect diverse underlying pathologies. So diagnosis should not rely solely on histology or serology but instead require a comprehensive approach incorporating dietary history, medication review, targeted infectious work-up, immunological testing, and, where relevant, therapeutic trials.