A 45-year-old man comes to the office due to 2 months of worsening mid-abdominal pain, abdominal cramps, and black stools. He has also had fatigue and a 5-kg (11-lb) weight loss over the same period. The patient has a history of chronic diarrhea since adolescence and was diagnosed with celiac disease 10 years ago. His baseline diarrhea improves when he avoids dietary gluten, but he has difficulty doing so due to frequent work-related travel. The patient has no other chronic medical issues and takes a daily multivitamin. He does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. The patient appears thin and pale. The abdomen is mildly distended with mild generalized tenderness. There is no guarding or rebound tenderness. Bowel sounds are increased. Stool is positive for occult blood. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 45-year-old man comes to the office due to 2 months of worsening mid-abdominal pain, abdominal cramps, and black stools.  He has also had fatigue and a 5-kg (11-lb) weight loss over the same period.  The patient has a history of chronic diarrhea since adolescence and was diagnosed with celiac disease 10 years ago.  His baseline diarrhea improves when he avoids dietary gluten, but he has difficulty doing so due to frequent work-related travel.  The patient has no other chronic medical issues and takes a daily multivitamin.  He does not use tobacco, alcohol, or illicit drugs.  Vital signs are within normal limits.  The patient appears thin and pale.  The abdomen is mildly distended with mild generalized tenderness.  There is no guarding or rebound tenderness.  Bowel sounds are increased.  Stool is positive for occult blood.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

Explanation: Patients with untreated celiac disease are at risk for developing enteropathy-associated T-cell lymphoma (EATL), an aggressive hematologic malignancy that primarily affects the proximal jejunum. Manifestations typically begin with abdominal pain and B symptoms (eg, weight loss, fatigue, fever). Bowel obstruction, bowel perforation, and gastrointestinal bleeding are common as the disease progresses. Most patients with EATL present late in the disease process when curative options are limited. As such, prognosis tends to be poor with median survival of only 10 months. (Choice A) Cytomegalovirus colitis is rarely seen in individuals who are not severely immunocompromised (eg, AIDS). Manifestations typically include fever, bloody diarrhea, and abdominal pain. This patient with long-standing, poorly controlled celiac disease is more likely to have EATL. (Choice B) Bacterial overgrowth of the small intestine typically manifests with bloating, flatulence, and abdominal discomfort. Weight loss is rare but may occur due to severe diarrhea or malabsorption. Melena would be atypical. (Choice C) Gastrinoma is an uncommon neuroendocrine tumor that often manifests with abdominal pain, chronic diarrhea, weight loss, and gastrointestinal bleeding. Patients frequently also have heartburn or peptic ulcer disease. This patient with a long history of untreated celiac disease is more likely to have EATL. (Choice E) Crohn disease is associated with transmural gastrointestinal inflammation and can manifest with crampy abdominal pain, diarrhea, weight loss, and bloody stools. This patient with long-standing, untreated celiac disease is more likely to have EATL. Educational objective: Patients with untreated celiac disease are at risk of developing enteropathy-associated T-cell lymphoma (EATL). Manifestations typically include abdominal pain, B symptoms, and gastrointestinal bleeding. Bowel obstruction or perforation may also occur. Patients with celiac disease who adhere to a strict gluten-free diet have minimal risk of EATL.

A 45-Year-Old Man Comes to the Office Due to 2