A 37 Year Old Woman Comes For An Evaluation Of Frequent Bouts of Loose Stools For The Past 5 Years

A 37 year old woman presents to a gastroenterologist on referral from her primary care physician for the workup of chronic diarrhea and multiple other GI symptoms. The patient gives a history of frequent bouts of loose stools or watery diarrhea for the past 5 years. She is getting increasing frustrated with her symptoms and has tried to change her diet but has no significant improvement in her symptoms. The patient also describes having frequent abdominal cramping, flatulence, bloating, fatigue and an itchy rash on her trunk. She denies any blood in her stools, or any symptoms of vomiting, or joint pains.

Physical Examination:

• A thin appearing woman in no acute distress.
• Abdomen is mildly distended and hypertympanic, on auscultation bowel sounds are hyper active. no masses or organomegaly. 
• She has a faint papular rash on her back and anterior legs. 

The close view of her rash on her back is shown in the picture below:

Among the workup done for the diagnosis following were of note:

• no abnormal masses or defects in the colon on barium enema.
• Stool sudan stain: positive for high fecal fat content.
• positive antigliadin and antiendomysial antibodies. 
• A biopsy was done of the jejunum and following histopathology was seen:

The patient was diagnosed as a case of Celiac Sprue. and the rash as Dermatitis herpetiformis. 

Case Discussion:

Celiac sprue is a genetic disorder of gluten intolerance (i.e wheat, barley, rye) in which antiendomysial and antigliadin antibodies cause jeujenal mucosal damage.

Age of Onset: It occurs in a bimodal distribution with presentation within the 1st year or in the third decade of life.

Clinical Features: Patients usually have:

• Failure to thrive
• bloating
• loose watery stools
• steatorrhea
• weight loss
• flatulence
• fatigue
• sometimes depression and anxiety.
• Abdominal distension
• peripheral edema
• papular rash on trunk and extensor surfaces.

Lab Workup: will show following:

• Decreased K, Mg and Ca.
• Albumin may be decreased.
• Iron is frequently low with an associated low Hb and anemia
• Sudan stain detects fat in stool.
• Presence of antiendomysial and antigliadin antibodies in serum.
• Jeujenal biopsy demonstrates loss of duodenal and jujenal villi. 

Treatment: A gluten free diet is the key to treatment and may be all that is needed to eliminate the symptoms. Sometime corticosteroids may be required to decrease bowel inflammation in refractory cases. Patient who respond to gluten free diet has an excellent prognosis.