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  • A 43-year-old man from Ireland presents to the clinic with complaints of diarrhea. He reports she has been having 3-5 nonbloody, loose stools per day for the last 6 months and improves when he fasts. He denies hematochezia, melena, weight loss, or family history of colon cancer. A physical examination demonstrates blistering skin lesions at the extensor surfaces of the elbow bilaterally.
Introduction
  • Clinical definition
    • chronic autoimmune disorder triggered by an environmental agent (gliadin component of gluten) in genetically predisposed individuals
      • often found in wheat and other grains such as barley and rye
    • often develops in childhood but may develop at any age
  • Epidemiology
    • demographics
      • occurs primarily in whites of northern European ancestry
      • > 1:5000 in North America  
  • Pathogenesis
    • upon exposure to gluten, an abnormal immune response leads to the production of several different autoantibodies that affects different organs
      • leads to the formation of an immune complex in the intestinal mucosa (primarily at the small intestine)
    • presence of the immune complex promotes the aggregation of killer lymphocytes, which cause mucosal damage
      • leads to the loss of villi lining (villous atrophy) and proliferation of crypt cells
    • damage of the villi lining leads to dysfunction in nutrient absorption, leading to malabsorption and anemia
  • Genetics
    • no single genetic marker exists
    • majority of patients have the variant HLA-DQ2 or HLA-DQ8 allele
      • these predisposing HLA risk alleles are necessary but not sufficient to develop celiac disease
  • Associated conditions
    • other autoimmune diseases (e.g., diabetes mellitus type 1)
Presentation
  • Symptoms 
    • steatorrhea  
      • can lead to fat soluble vitamin deficiencies 
    • abdominal pain
    • bloating
    • flatulence
    • weight loss/failure to gain weight
    • fatigue
    • some patients are asymptomatic
    • repeated infections (if IgA deficient, common in celiac patients)
      • anaphylaxis if transfused by IgA containing blood products  
  • Physical exam
    • abdominal distension
    • pallor
    • mouth ulcers
    • short stature
    • dermatitis herpetiformis 
      • pruritic, red, papulo-vesicular lesion commonly on shoulders, elbows, and knees
      • due to IgA deposits in the upper dermis
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is based on clinical symptoms and confirmed with small bowel biopsy
    • studies
      • serological blood tests
        • best initial test
        • anti-tissue transglutaminase (tTg)-IgA antibody 
        • anti-endomysial-IgA antibody
        • tests for IgA antibodies, will be negative in those with IgA deficiency
          • for patients with IgA deficiency, deamidated gliadin peptide (DGP) IgG testing is available
        • positive serology requires small bowel biopsy for confirmation of diagnosis
      • upper endoscopy with small bowel biopsy
        • best confirmatory test
        • at least 4 duodenal biopsies are recommended
        • endoscopic features including loss of folds, visible fissures, nodularity, scalloping, and prominent submucosal vascularity 
        • histologic features include     
          • increased intraepithelial lymphocytes and plasma cells
          • atrophic mucosa with loss of villi 
          • enhanced epithelial apoptosis
          • crypt hyperplasia
      • HLA testing
        • only useful in ruling out celiac disease
      • laboratory studies
        • CBC, iron studies, folic acid, vitamin B12 to evaluate level of malnutrition/malabsorption
      • dual energy X-ray absorptiometry (DEXA)
        • to identify risk of fracture and need for bone protection medication
Differential 
  • Inflammatory bowel disease 
    • distinguishing factors
      •  different histological appearance on biopsy
  • Irritable bowel syndrome 
    • distinguishing factors
      •  will have negative biopsy results
Treatment
  • First-line
    • gluten-free diet
      • allows healing of the intestinal mucosa and resolution of all symptoms
      • eliminates the heighted risk of osteoporosis and intestinal cancer
    • dietary supplements
  • Second-line
    • steroids or immunosuppressant (e.g., azathioprine)
      • consider in patients with refractory disease
Complications
  • Iron deficiency anemia
  • Osteoporosis
  • Infertility
  • Neurological problems (secondary to malabsorption)
  • Intestinal lymphoma
    • develops in 10-15% of patients 
 

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Questions (7)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.3) A 21-year-old female presents to her obstetrician because she has stopped getting her period, after being irregular for the last 3 months. Upon further questioning, the patient reveals that she has had a 17 lb. unintended weight loss, endorses chronic diarrhea, abdominal pain, and constipation that waxes and wanes. Family history is notable only for an older brother with Type 1 Diabetes. She is healthy, and is eager to gain back some weight. Her OBGYN refers her to a gastroenterologist, but first sends serology laboratory studies for IgA anti-tissue transglutaminase antibodies (IgA-tTG). These results come back positive at > 10x the upper limit of normal. Which of the following is the gastroenterologist likely to find on endoscopy and duodenal biopsy? Review Topic

QID: 104545
1

Foamy macrophages, which stain PAS positive

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Cobblestoning with biopsy showing transmural inflammation and noncaseating granulomas

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3

Friable mucosal pseudopolyps with biopsy notable for crypt abscesses

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4

Normal appearing villi and biopsy

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5

Villous atrophy with crypt lengthening and intraepithelial lymphocytes

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M2

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(M3.GI.4) A 29-year-old woman presents to her gastroenterologist with complaints of fatigue and frequent diarrhea over the last 6 months. The diarrhea resolves when the patient fasts. She has lost 10 pounds over this time frame. She has eliminated dairy from her diet with no change in her symptoms. Her temperature is 97.6°F (36.4°C), blood pressure is 118/77 mmHg, pulse is 70/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for a thin woman. A rectal exam and a fecal occult blood test are within normal limits. Physical exam is notable for the finding in Figure A. Which of the following would be found in this patient on confirmatory testing? Review Topic

QID: 102603
FIGURES:
1

Crypt abscesses in the colon

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Graulomatous inflammation of the colon

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Lymphocytic infiltration of the gastric mucosa

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4

Mucosal flattening and blunting of villi

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5

Normal appearing intestinal mucosa

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M2

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