A 40-year-old woman comes to the office for follow-up after a recent upper gastrointestinal endoscopy. She initially had a 3-month history of diarrhea and weight loss. The patient's tissue transglutaminase antibody (IgA) assay was positive, and small-bowel biopsy performed during the endoscopy confirmed the diagnosis of celiac disease. Since the endoscopy, she has been following a strict gluten-free diet and has experienced significant improvement in symptoms. The patient's medical history is unremarkable and she has had normal menstrual periods. Her only medication is a daily multivitamin, and she does not use tobacco, alcohol, or illicit drugs.
Vital signs and physical examination are normal.
Laboratory results show a hemoglobin level of 11.4 mg/dL (increased from 10.2 mg/dL 4 weeks ago).
Which of the following additional tests is indicated at this time?

Question

A 40-year-old woman comes to the office for follow-up after a recent upper gastrointestinal endoscopy.  She initially had a 3-month history of diarrhea and weight loss.  The patient's tissue transglutaminase antibody (IgA) assay was positive, and small-bowel biopsy performed during the endoscopy confirmed the diagnosis of celiac disease.  Since the endoscopy, she has been following a strict gluten-free diet and has experienced significant improvement in symptoms.  The patient's medical history is unremarkable and she has had normal menstrual periods.  Her only medication is a daily multivitamin, and she does not use tobacco, alcohol, or illicit drugs.
Vital signs and physical examination are normal.
Laboratory results show a hemoglobin level of 11.4 mg/dL (increased from 10.2 mg/dL 4 weeks ago).
Which of the following additional tests is indicated at this time?

Quizplus · Accepted Answer

11ec193a_981e_de0e_853d_e36ab72b8103_MD0002_00 Bone loss is very common in patients with celiac disease, largely due to malabsorption of vitamin D and resultant secondary hyperparathyroidism. Bone disease may present as asymptomatic osteopenia/osteoporosis or as osteomalacia with bone pain, muscle weakness, and impaired ambulation. Laboratory evaluation commonly shows low serum 25-hydroxyvitamin D and elevated parathyroid hormone levels. Alkaline phosphatase may be elevated, and hypocalcemia and hypophosphatemia may be observed in severe cases. In light of the increased risk of bone loss in patients with celiac disease, bone density measurement by DXA should be performed at the time of diagnosis, regardless of age or menopausal status (Choice C). Patients with bone disease should receive calcium and vitamin D supplementation. Bone density often improves with a gluten-free diet, and usually recovers more rapidly in the axial (eg, lumbar spine) than in the appendicular skeleton. (Choice B) Celiac disease is associated with a modestly increased risk of nonischemic dilated cardiomyopathy. Case reports suggest that myocardial function may recover completely with gluten restriction. However, cardiomyopathy due to celiac disease is rare, and screening echocardiography is not required in asymptomatic patients. (Choice D and E) Serum IgA tissue transglutaminase antibody (or deamidated gliadin antibody) levels can be used to assess the response of celiac disease to a gluten-free diet but may take 3-12 months to return to normal. Some experts also advise repeat upper endoscopy with biopsy to assess response, but this is typically done after 4-6 months of dietary modification or when a patient fails to improve as expected. Educational objective: Bone loss is common in celiac disease due to malabsorption of vitamin D. Manifestations may include osteopenia/osteoporosis or osteomalacia with bone pain, muscle weakness, and impaired ambulation. DXA should be performed at the time of diagnosis of celiac disease. In addition to a gluten-free diet, patients with bone disease should receive calcium and vitamin D supplementation. __________ References: ACG clinical guidelines: diagnosis and management of celiac disease. (http://www.ncbi.nlm.nih.gov/pubmed/23609613) Bone and celiac disease. (http://www.ncbi.nlm.nih.gov/pubmed/26875096)

A 40-Year-Old Woman Comes to the Office for Follow-Up After