A 35-year-old woman comes to the office due to a 6-month history of diarrhea. She has had several loose stools per day without visible blood or mucus. The patient has also noticed bloating and abdominal discomfort following meals. She eats a varied diet and cannot identify any particular foods associated with her symptoms. The patient is unsure if she has lost weight but says that her friends have remarked that she "doesn't look healthy." The patient's medical history includes iron-deficiency anemia and menorrhagia. Her only medication is an oral iron supplement and she has no known drug allergies. Family history is remarkable for hypothyroidism in her mother. The patient has had no recent travel and works from home.
Temperature is 36.4 C (97.5 F) , blood pressure is 115/63 mm Hg, pulse is 70/min, and respirations are 14/min. Sclera are anicteric and mucous membranes are moist. Auscultation of the heart and lungs is normal. The abdomen is soft and nontender. Bowel sounds are hyperactive. Rectal examination is normal, and fecal occult blood testing is negative. No skin rashes are present. The remainder of the examination is unremarkable.
Laboratory results show a hemoglobin of 9.6 mg/dL with mean corpuscular volume of 71 µm³. Anti-tissue transglutaminase antibody is positive. Which of the following is the most appropriate next step in management of this patient?

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11ec193a_981f_7a4f_853d_33f09f6c065d_MD0002_00 Celiac disease is a chronic malabsorptive disorder of the small intestine caused by immune-mediated hypersensitivity to gluten. Patients commonly experience diarrhea, abdominal pain, and malabsorptive complications (eg, iron deficiency anemia, nutritional deficiencies, weight loss). Serologic studies (anti-transglutaminase IgA or anti-endomysial IgA antibodies) are typically the initial screening test for celiac disease. Some physicians measure total serum IgA levels concurrently due to the high prevalence of IgA deficiency in patients with celiac disease. However, IgA level testing is required only in patients with suggestive clinical features but negative serologic tests (Choice E). Low serum IgA levels should prompt IgG-based assays. Patients with positive serologies or those with highly suggestive symptoms (regardless of serology results) should undergo small bowel enteroscopy with biopsy to establish a diagnosis. Initiation of a gluten-free diet should occur after biopsy, as the reduction in inflammation decreases biopsy sensitivity (Choice C). Alternatively, a cutaneous biopsy showing dermatitis herpetiformis is also diagnostic. (Choice A) Antigliadin antibodies are no longer recommended for screening or diagnosis due to low specificity for celiac disease. (Choice D) Human leukocyte antigen (HLA) testing is typically reserved for patients who have discordant serology and biopsy results, those who were on a gluten-free diet prior to testing, or those with refractory disease despite a gluten-free diet. Patients with HLA DQ2 and DQ8 have an increased risk for celiac disease. Educational objective: Patients with clinical features suggesting celiac disease should undergo serologic studies (anti-transglutaminase IgA or anti-endomysial IgA antibodies); IgA levels should be checked in those with negative results. Patients with positive serologies or highly suggestive symptoms should then undergo endoscopy with biopsy to establish a diagnosis. A cutaneous biopsy showing dermatitis herpetiformis is also diagnostic. __________ References: ACG clinical guidelines: diagnosis and management of celiac disease. (http://www.ncbi.nlm.nih.gov/pubmed/23609613)

A 35-Year-Old Woman Comes to the Office Due to a 6-Month