A 37-Year-Old Man With Recurrent Diarrhea: Osmosis USMLE Study Question

February 08, 2019

Answer: B. Recommending dietary changes

This man likely has celiac disease. The physical examination shows 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, leading to steatorrhea, diarrhea, and weight loss. There is malabsorption of vitamins A, D, E, and K, 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, which would show 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 since gluten is commonly consumed in a Western diet, so recommending dietary changes is an important component of treatment.

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 malabsorption. First-line treatment is a gluten-free diet.

Read more information on celiac disease.

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