A 31-year-old man comes to the office due to increased flatulence and 2 or 3 loose, bulky stools per day. The patient initially presented 2 years ago with similar symptoms and was found to have a positive anti-tissue transglutaminase antibody test and duodenal villous atrophy. His symptoms resolved after appropriate interventions were implemented but have recurred over the last 3 months. The patient reports no recent travels or dietary changes and has had no fever, chills, abdominal pain, hematochezia, or melena. He has lost about 2.2 kg (5 lbs) since his symptoms recurred. He has no other medical issues and his only medication is an over-the-counter multivitamin. He works as an accountant and is recently divorced from his wife. The patient says lately he has been going out for drinks with his coworkers more frequently but does not use tobacco or illicit drugs. Vital signs are within normal limits. The abdomen is soft, nondistended, and nontender. Bowel sounds are normoactive. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management of this patient's symptoms?

Question

A 31-year-old man comes to the office due to increased flatulence and 2 or 3 loose, bulky stools per day.  The patient initially presented 2 years ago with similar symptoms and was found to have a positive anti-tissue transglutaminase antibody test and duodenal villous atrophy.  His symptoms resolved after appropriate interventions were implemented but have recurred over the last 3 months.  The patient reports no recent travels or dietary changes and has had no fever, chills, abdominal pain, hematochezia, or melena.  He has lost about 2.2 kg (5 lbs) since his symptoms recurred.  He has no other medical issues and his only medication is an over-the-counter multivitamin.  He works as an accountant and is recently divorced from his wife.  The patient says lately he has been going out for drinks with his coworkers more frequently but does not use tobacco or illicit drugs.  Vital signs are within normal limits.  The abdomen is soft, nondistended, and nontender.  Bowel sounds are normoactive.  The remainder of the physical examination shows no abnormalities.  Which of the following is the most appropriate next step in management of this patient's symptoms?

Quizplus · Accepted Answer

Explanation: This patient has celiac disease, as indicated by the anti-tissue transglutaminase antibody and villous atrophy on small bowel biopsy, and previously had improvement in his symptoms with initiation of a gluten-free diet. Celiac disease is a chronic malabsorptive disorder of the small intestine caused by immune-mediated hypersensitivity to gluten. Patients can experience diarrhea, abdominal pain, weight loss, and nutritional deficiencies due to malabsorption (eg, iron, folate, vitamin B₁₂). Most patients experience symptomatic improvement within 2 weeks of eliminating dietary gluten. ₁₂ The most common cause of persistent or recurrent symptoms (>90%) is continued gluten intake from inadvertent ingestion or poor compliance. A detailed dietary review, optimally with the aid of a dietician, can identify the source of gluten intake (possibly from beer in this patient). Serologic studies (eg, anti-tissue transglutaminase, anti-gliadin antibodies) correlate with disease activity and can be helpful in assessing compliance; antibodies should decline 50% in 8 weeks and normalize within 12 months on a gluten-free diet. Inappropriately elevated titers indicate continued gluten ingestion. Patients with persistent symptoms despite dietary compliance should be evaluated with a repeat upper endoscopy to evaluate for other diagnoses or refractory sprue (Choice E). (Choice A) Stool studies (eg, culture, ova and parasite, fecal fat, electrolytes) are useful to determine other causes of diarrhea. However, this patient has known celiac disease, and the recurrence of his prior symptoms most likely indicates recurrent disease. Stool studies could be considered if symptoms do not resolve with a gluten-free diet. (Choice C) Untreated celiac disease leads to long-term sequelae, including osteopenia, severe anemia, and increased risk of malignancy. Treatment with antidiarrheals may mask symptoms temporarily but would not treat the underlying disorder. (Choice D) Probiotic supplements are useful in some diarrheal illnesses (eg, travelers' diarrhea, antibiotic-associated diarrhea) but are not beneficial for celiac disease. Educational objective: Celiac disease is a chronic malabsorptive disorder caused by immune-mediated hypersensitivity to gluten. The most common cause of continued or recurrent symptoms is gluten intake from inadvertent ingestion or poor compliance. A detailed dietary review can help identify the source of gluten.

A 31-Year-Old Man Comes to the Office Due to Increased