Celiac Disease (short case)

Question 1

HPI of Pt with Celiac Disease

Answer 1

• 35 yo female in a family clinic
• CC is stomach issues: Her stomach “never feels good”
• “Crampy” and it comes and goes (colicky pain)
• Generally feels worse AFTER meals
• She has diarrhea- 1 episode per day
• Sx have been going on for several months.
• Onset: gradually, she cant recall when sx started
• She has never tried cutting out gluten
• She has a well-rounded diet
• Her parents never discussed their medical issues so she doesn’t know if they have any GI issues
• Tums didn’t help, she denies upper GI issues. She points to the pain in her lower abdomen.
• Alleviates: feels slightly better after going to the bathroom
• Severity: 3/10
• She has maybe lost 5 lbs
• She denies fever, nausea, vomiting, sweating
• She denies blood in her stools, She denies dysuria.

Question 2

DDx Celiac Disease

Answer 2

• Ulcerative colitis, traveler’s diarrhea, food allergy, PUD, PID/STI
• IBS
• Crohn’s
• Cholecystitis
• Colorectal cancer
• Lupus
• GI infection
• Depression/anxiety
• Lactose intolerance
• hyperthyroidism
• pancreatitis

Question 3

Celiac Disease: PE findings

Answer 3

Skin: No ecchymoses. (+) Scattered maculopapular rash on the elbows with excoriations around it. Otherwise skin is normal

Neck: No thyromegaly. No nodules. No LAD.

Abdominal: Normal active BS in all 4 quadrants. Soft non tender non distended. No organomegaly. No guarding or rebound, no peritoneal signs.

Respiratory: No abnormal findings.
Cardiac: RRR, no murmurs, rubs, or gallops, no heaves. No edema. Pulses are 2+ throughout.

Digital Rectal Exam: sphincter tone is normal. No gross blood or occult blood.

Question 4

Diagnosis:

Serologic Testing for Celiac Disease

Answer 4

• *Endomysial IgA Ab

- *Transglutimase Ab (TTG)

Question 5

What is the Gold standard diagnostic test for Celiac Disease?

Answer 5

small bowel biopsy=definitive dx

Question 6

Celiac Disease:

-Pathophysiology

Answer 6

Small bowel autoimmune inflammation 2/2 alpha-gliadin in gluten –> loss of villi & absorptive area–> impaired fat absorption.

*Increased incidence: females, European Descent (irish/finnish)

Question 7

Celiac disease: clinical manifestations

Answer 7

1. Malabsorption: diarrhea, abdominal pain/distention, bloating, steatorrhea, weight loss
2. Dermatitis herpetiformis: pruritic, papulovesicular rash on extensor surfaces, neck, trunk and scalp

Question 8

Celiac Disease: Management

Answer 8

gluten free diet (avoid wheat, rye, barley)

-avoid beer

Question 9

T/F: Oats, rice, and corn cause celiac disease

Answer 9

FALSE. These foods don’t cause celiac dz

Question 10

Celiac Disease: demographic

Answer 10

•Mostly in Caucasian patients with northern European ancestry
•Many undiagnosed
•More prevalent than recognized
Usually presents between ages 10-40

Question 11

T/F: negative serology excludes celiac disease dx

Answer 11

False. Negative serology doesn’t 100% exclude celiac disease. Could be negative because of:
•IgA deficiency
•Low gluten/gluten free diet

Question 12

Celiac disease:

• Referrals?
• Other aspects of tx plan

Answer 12

•Gluten-Free diet
•Refer to a RD!
•Replete any nutritional deficiencies
•Evaluate for bone loss with DXA
•Pneumococcal vaccination
•Improvement of dermatitis herpetiformis may be more delayed than the response to intestinal manifestations
--Consider screening family members
--False negative more common in mild disease