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Unknown #172. Case Presentation. 33-year-old woman has a 6-month history of increasing diarrhea without bleeding or a sense of urgency. She has three or four bowel movements daily compared with her previous pattern of one or two bowel movements each day. PMHx – hypothyroidism

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case presentation
Case Presentation
  • 33-year-old woman has a 6-month history of increasing diarrhea without bleeding or a sense of urgency. She has three or four bowel movements daily compared with her previous pattern of one or two bowel movements each day.
  • PMHx – hypothyroidism
  • Soc Hx – no smoking, ETOH, no travel hx, has a dairy-free diet
  • Fam Hx – non-contributory
slide3
ROS
  • 4.7 kg (10 lb) weight loss during this time.
  • The patient has regular menses
  • No rectal bleeding, melena, or hematochezia
physical and studies
Gen – NAD

CV – RRR, S1, S2

Pulm – CTA B

Abd – soft/NT/ND/normoactive BS, no HSM

Ext – slight rash on arms, no c/c/e

9.8

6.5 250

MCV – 75

RDW – 19 (nml 11.5-14.5)

Fe – 8 (nml > 10)

Anti-tissue transglutaminase IgA- positive

Chem – wnl

LFT’s – wnl

Stool Cx – no growth to date

Bone density - osteopenia

Physical and studies
question
Question

Which of the following diagnostic studies should be scheduled next?

  • Urea breath test
  • Serum calcitonin measurement
  • Upper endoscopy with small bowel biopsies
  • Serum gastrin measurement
answer
Answer

Which of the following diagnostic studies should be scheduled next?

  • Urea breath test
  • Serum calcitonin measurement
  • Upper endoscopy with small bowel biopsies
  • Serum gastrin measurement
celiac sprue
Celiac Sprue
  • Autoimmune disorder precipitated by the ingestion of gluten, found in wheat, barley, and rye
  • Affects approximately 1% of the population
  • Immune response to gliadin causes inflammatory reactions, mostly in the upper small intestine
  • Also called gluten-sensitive enteropathy and nontropical sprue also called gluten-sensitive enteropathy and nontropical sprue
clinical manifestations
Clinical Manifestations
  • In adults, women>men
  • Diarrhea
  • Abdominal pain or discomfort
  • Iron-deficiency anemia
  • Osteoporosis
  • Others – constipation, neurologic symptoms, dermatitis herpetiformis, hypoproteinemia, hypocalcemia
diagnosis
Diagnosis
  • Serologic testing (ELISA for IgA)
    • Antigliadin antibodies (33% PPV)
    • Antiendomysial antibodies (100% PPV) – endomesium is smooth muscle connective tissue (presence pathognemonic)
      • Anti tissue transglutaminase antibodies (autoantigen compontent of endomesium) - highly sensitive (95%) and specific (94%)
  • Small bowel biopsy
    • Intraepithelial lymphocytosis, mucosal inflammation
    • Crypt hyperplasia
    • Villous atrophy
  • Response to gluten-free diet
diagnosis11
Diagnosis
  • Gold-standard for diagnosis is endoscopic intestinal bx with characteristic features PLUS CD assoc positive serologies

World Gastroenterology Organisation (WGO-OMGE). WGO-OMGE practice guideline: celiac disease. Paris (France): World Gastroenterology Organisation (WGO-OMGE); 2007. 18 p.

treatment
Treatment
  • Nutritional therapy (gluten-free diet)
  • Assess for vitamin deficiencies
  • Osteoporosis screening
complications
Complications
  • Intestinal adenocarcinoma
  • Enteropathy associated T-cell lymphoma
  • Refractory sprue
ad