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Unknown #172

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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Unknown #172

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  1. Unknown #172

  2. 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

  3. ROS • 4.7 kg (10 lb) weight loss during this time. • The patient has regular menses • No rectal bleeding, melena, or hematochezia

  4. 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

  5. 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

  6. 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

  7. 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

  8. Clinical Manifestations • In adults, women>men • Diarrhea • Abdominal pain or discomfort • Iron-deficiency anemia • Osteoporosis • Others – constipation, neurologic symptoms, dermatitis herpetiformis, hypoproteinemia, hypocalcemia

  9. dermatitis herpetiformis

  10. 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

  11. 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.

  12. Duodenal mucosa in celiac

  13. Treatment • Nutritional therapy (gluten-free diet) • Assess for vitamin deficiencies • Osteoporosis screening

  14. Complications • Intestinal adenocarcinoma • Enteropathy associated T-cell lymphoma • Refractory sprue

  15. OBJECTIVE: Confirm a suspected diagnosis of celiac sprue.

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