Refractory disease, symptom mimics, and confounding comorbidities complicate these 3 cases. Can you tease out the answers?
Patient History: A 76-year-old woman with no significant medical history and on no medications presents for evaluation of chronic diarrhea for the last 8 months. Stool infectious studies, erythrocyte sedimentation rate, and C-reactive protein, are negative. Colonoscopy also is negative but random biopsies demonstrate collagen deposition in the lamina propria, consistent with microscopic colitis.
What is the next best step in management? Start subcutaneous methotrexate; perform an upper endoscopy with small bowel biopsies; start oral prednisone; start cholestyramine; obtain MR enterography
Answer: B. Perform an upper endoscopy with small bowel biopsies. Patients with microscopic colitis who fail to respond to conventional therapy should undergo evaluation for celiac with an upper endoscopy for biopsies of the small bowel to assess for villous atrophy. In patients with comorbid microscopic colitis and celiac disease, often dietary modification can help to control symptoms, though they may ultimately require steroids if this is ineffective.
For more information: Green PH, Yang J, Cheng J, Lee AR, Harper JW, Bhagat G. An association between microscopic colitis and celiac disease. Clin Gastroenterol Hepatol. 2009;7:1210-1216 .
Patient History: A 72-year-old man presents with diarrhea, nausea, and weight loss over 4 years. His medical history is significant for CAD, HTN, & hyperlipidemia. His medications include aspirin, olmesartan, hydrochlorothiazide, and rosuvastatin. IgA tissue transglutaminase is normal and a gluten-free diet did not change his diarrhea.
Patient History, cont'd. Colonoscopy with random biopsies reveals thickened collagenous bands. Testing for HLA-DQ8 is positive.
What is the most likely diagnosis? Collagenous colitis; irritable bowel syndrome; tropical sprue; drug-induced enteropathy; seronegative celiac disease
Answer: D. Drug-induced enteropathy. Olmesartan-associated enteropathy is a rare cause of severe enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhea and weight loss that is unresponsive to a gluten-free diet.
For more information: Teixeira M, Macedo S, Martins A, et al. Olmesartan-associated enteropathy: An unexpected cause of diahrroea. Eur J Case Rep Intern Med. 2019;12:001093.
Patient History: An 18-year-old woman is referred for refractory celiac disease. She says she has experienced diarrhea for 2 years. Initial evaluation based on her symptoms included a stool pathogen panel which was negative. She was found to have a mild microcytic anemia, positive IgA gliadin antibody, and positive IgA tissue transglutaminase antibody.
Patient History, con'td. She went on a gluten-free diet but has had minimal improvement in symptoms.
Which of the following is the next best step in management? Check immunoglobulin levels; dietitian consult to identify hidden sources of gluten; screen for human immunodeficiency virus; check endomysial antibody; ask about nonsteroidal anti-inflammatory drug use
Answer: Dietitian consult to identify hidden sources of gluten. Following a gltuen-free diet can be cumbersome, though, and strict avoidance of gluten can be difficult due to hidden sources of gluten in many commercial food products. There is evidence that compliance with a gluten-free diet is improved following counseling with a registered dietician and is often the first step in managing celiac disease that doesn’t respond to standard dietary modification.
For more information: Thompson T. Gluten contamination of commercial oat products in the United States. N Engl J Med 2004;351:2021–2022.
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Thirty percent of patients diagnosed with celiac disease continue to report symptoms despite being on a gluten-free diet, a significant concern as there is 2-4 times increased risk of coronary artery disease and small bowel cancers associated with the condition. What is the best remedy for refractory symptoms? Celiac disease also has clinical and histologic similarities to other enteropathies which can delay definitive diagnosis -- and approriate treatment.These issues and others are included in the 3 case challenges that follow below. Find out what you know about celiac disease.