A 36-year-old man comes to the office due to frequent "loose stools" for the past 10 months. The patient describes stools that are large in volume, liquid to semisolid, occurring up to 3-4 times a day, and often foul-smelling. He also reports excessive flatulence and occasional nausea and abdominal cramping. The patient says he may have lost some weight because his clothes are much looser than before. He has no prior medical problems and takes no medications. Family history is notable for hypertension and coronary artery disease in his father. The patient immigrated to the United States from Italy with his family when he was 2 years old and has not traveled out of the country since then. He does not use tobacco or illicit drugs and drinks alcohol occasionally. The patient works in a family-owned restaurant and has had no sick contacts. He consumes a balanced diet and notes no specific association of diarrhea to food. The patient has been in a monogamous relationship with his wife for the past 10 years. Temperature is 36.6 C (97.9 F), blood pressure is 130/86 mm Hg, and pulse is 72/min. Weight is 63.5 kg (140 lb). The sclerae are anicteric, and mucous membranes are moist without any lesions. Cardiopulmonary examination is unremarkable. The abdomen is soft, nondistended, and nontender, with no organomegaly. Bowel sounds are increased. Rectal examination shows no masses or tenderness and an empty rectal vault. Stool occult blood testing is negative. Samples for blood count, erythrocyte sedimentation rate, TSH, and serum electrolytes are obtained. This patient is most likely to respond to which of the following therapies?

Question

A 36-year-old man comes to the office due to frequent "loose stools" for the past 10 months.  The patient describes stools that are large in volume, liquid to semisolid, occurring up to 3-4 times a day, and often foul-smelling.  He also reports excessive flatulence and occasional nausea and abdominal cramping.  The patient says he may have lost some weight because his clothes are much looser than before.  He has no prior medical problems and takes no medications.  Family history is notable for hypertension and coronary artery disease in his father.  The patient immigrated to the United States from Italy with his family when he was 2 years old and has not traveled out of the country since then.  He does not use tobacco or illicit drugs and drinks alcohol occasionally.  The patient works in a family-owned restaurant and has had no sick contacts.  He consumes a balanced diet and notes no specific association of diarrhea to food.  The patient has been in a monogamous relationship with his wife for the past 10 years.  Temperature is 36.6 C (97.9 F), blood pressure is 130/86 mm Hg, and pulse is 72/min.  Weight is 63.5 kg (140 lb).  The sclerae are anicteric, and mucous membranes are moist without any lesions.  Cardiopulmonary examination is unremarkable.  The abdomen is soft, nondistended, and nontender, with no organomegaly.  Bowel sounds are increased.  Rectal examination shows no masses or tenderness and an empty rectal vault.  Stool occult blood testing is negative.  Samples for blood count, erythrocyte sedimentation rate, TSH, and serum electrolytes are obtained. This patient is most likely to respond to which of the following therapies?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf22_0163_8f63_9968e338aa80_MD0005_00 The mainstay of treatment for patients with celiac disease (CD) is a gluten-free diet. Dietary counseling is therefore an important part of the overall management of such patients. Those who are diagnosed with CD should be referred to a dietician to tailor a diet to their specific needs. The principal source of gluten in the diet is wheat, rye, and barley, and consequently all patients with CD should be advised to refrain from eating foods containing these products. In addition, patients should be informed that the consumption of soy beans, rice, corn, and potatoes is safe. Most patients will show some clinical improvement approximately 2-3 weeks after the initiation of a gluten-free diet; however, normalization of the villus architecture can take a few months. For patients who do not achieve symptomatic improvement, a detailed dietary history should be obtained since the most common reason for lack of response is poor diet adherence. In patients who are adherent and continue to have symptoms, further evaluation for comorbidities or alternative diagnoses (eg, lactose intolerance) should be performed. In addition to eliminating gluten from the diet, patients with CD should also have levels of iron, folate, calcium, and other vitamins (A, D, E, B₁₂) monitored. Similarly, they should have a DXA scan to evaluate for bone loss (due to vitamin D deficiency) and receive the pneumococcal vaccine due to associated hyposplenism. ₁₂ (Choice A) 5-aminosalicylates are one of the mainstays of treatment for inflammatory bowel disease such as Crohn disease or ulcerative colitis, but these do not have a role in the treatment of CD. (Choice B) Systemic antibiotics are indicated only in patients with chronic bacterial infections, small intestinal bacterial overgrowth, or Whipple disease (arthralgias, diarrhea, weight loss). They have no role in the management of patients with CD. (Choice C) Bile-acid binding resins can be useful in the treatment of diarrhea associated with irritable bowel syndrome. (Choice E) Oral corticosteroids are not routinely used in patients with CD except in those with refractory disease who fail to respond to gluten-free diets. Educational objective: The mainstay of treatment of celiac disease is the elimination of gluten-containing food products from the diet. References: Celiac disease: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/24444577)

A 36-Year-Old Man Comes to the Office Due to Frequent