A 37-Year-Old Woman With Bloating and Itchy Vesicles: Osmosis USMLE Study Question of the Week

September 29, 2017

Answer: B. Suggesting dietary changes

This patient likely has celiac disease. The physical examination reveals pruritic vesicles and bullae that are due to autoimmune deposition of immunoglobulin A (IgA) at dermal papillae tips; this is called dermatitis herpetiformis, a condition often associated with celiac disease.

IgA antibodies to gliadin, endomysium, and tissue transglutaminase cause malabsorption lead to steatorrhea, diarrhea, weight loss, and failure to thrive in children. Malabsorption of vitamins A, D, E, and K is noted, as well as inadequate calcium absorption. The damage to the gut lining can cause iron malabsorption leading to iron deficiency anemia. Diagnosis can be made with serology testing for IgA endomysial, gliadin, and tissue transglutaminase antibodies. The diagnosis can also be confirmed with a small intestine biopsy that reveals blunting of the villi, called villous atrophy, mucosal inflammation, and crypt hyperplasia.

The cornerstone of treatment of celiac disease is the elimination of gluten from the diet. This requires major lifestyle changes because gluten is commonly consumed in a Western diet. Thus, dietary counseling is recommended to improve compliance.

Major Takeaway: Celiac disease is an autoimmune disease in which affected individuals have an immunologically-mediated response to gluten, leading to mucosal damage in the small intestine. This subsequently leads to maldigestion and malabsorption. Thus, first-line treatment is a gluten-free diet.

For more on Celiac disease, read here.


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