A 6-year-old girl is brought to the office due to intermittent abdominal cramps, bloating, and diarrhea for 2 months. She also has excessive flatulence, which typically occurs after meals. The patient has had no fever or vomiting. She eats a well-balanced diet and takes no medications or vitamins. Vital signs are appropriate for age. Examination shows a mildly distended abdomen with no hepatosplenomegaly or tenderness. Laboratory evaluation reveals elevated tissue transglutaminase antibodies. Which of the following locations should be biopsied to confirm the diagnosis in this patient?

Question

A 6-year-old girl is brought to the office due to intermittent abdominal cramps, bloating, and diarrhea for 2 months.  She also has excessive flatulence, which typically occurs after meals.  The patient has had no fever or vomiting.  She eats a well-balanced diet and takes no medications or vitamins.  Vital signs are appropriate for age.  Examination shows a mildly distended abdomen with no hepatosplenomegaly or tenderness.  Laboratory evaluation reveals elevated tissue transglutaminase antibodies.  Which of the following locations should be biopsied to confirm the diagnosis in this patient?

Quizplus · Accepted Answer

11ec160b_3930_4a95_9249_7bb438b5f7f4_MD0001_00 This patient with chronic gastrointestinal symptoms and elevated tissue transglutaminase (TTG) antibodies likely has celiac disease. This chronic, malabsorptive disorder is caused by an immune-mediated reaction to dietary gliadin (the major component of gluten) found in wheat, barley, and rye. In patients with celiac disease, gliadin triggers an inflammatory reaction within the small intestine that leads to the classic symptoms of abdominal pain, distension, flatulence, and diarrhea. Laboratory evaluation usually reveals antibodies against TTG, a crosslinking enzyme that interacts with glutamine-rich proteins (including exogenous gliadin). Endoscopy with biopsy characteristically shows villus atrophy, lymphocytic infiltration of the intraepithelial cells, and crypt hyperplasia. Biopsy of the duodenum and proximal jejunum are most likely to confirm the diagnosis because these areas of the intestine are exposed to the highest concentration of gliadin. (Choice A) Helicobacter pylori infection, which predisposes to gastritis and peptic ulcer disease, can cause abdominal pain (often postprandial) and bloating, and gastric biopsy can confirm the diagnosis. However, elevated TTG antibodies are not associated with H pylori. (Choices C, D, and E) Because celiac disease primarily involves the proximal small bowel, biopsies from the distal jejunum and terminal ileum may be normal in patients with celiac disease and are not recommended; the colon is not affected in celiac disease. Educational objective: Celiac disease is caused by an immune-mediated reaction to gluten and classically leads to chronic gastrointestinal symptoms. Diagnosis is confirmed by elevated tissue transglutaminase IgA antibody levels and duodenal biopsy showing villus flattening, intraepithelial lymphocyte infiltration, and crypt hyperplasia.

A 6-Year-Old Girl Is Brought to the Office Due to Intermittent