By Ari Thomas, Danielle Levine and Laurel Edington

Grand Rounds: A 42-Year-Old Man with Chest, Abdominal Discomfort

Case Presentation

•  42-year old male •  Chief complaint – chest and abdominal

discomfort for two days

History of Present Illness

• Pain increasing in intensity • Nausea and early satiety • No outside meals • No recent abdominal trauma, rectal

bleeding or black stools

History of Present Illness Cont.

• Substernal chest pressure consistent with usual angina •  Not responsive to single

sublingual nitroglyercin tablet

•  Only responsive to a group of administered medicines

Patient Medical History

•  Has hypertension, hyperlipidemia, coronary artery disease, and angina

•  Myocardial infarction at 32 years old – Coronary artery angioplasty with stent placement

and subsequent bypass grafting

Patient Medical History Cont. •  Family history of colon cancer – Recent colonoscopy was unremarkable

•  Chronic diarrhea for ten years •  Past six months experienced: daily headaches,

nocturia, feeling warm at night but no fevers or night sweats, occasional early satiety and 35 lb. weight loss

•  Takes cholesterol-lowering medication

Current Medications •  Ramipril •  Aspririn •  n-3 Fatty Acids •  Folic Acid •  Isosorbide Dinitrate •  Atorvastatin

•  Multivitamins •  Fenofibrate •  Nicotinic Acid •  Amlopidine •  Extended-release

Metoprolol Succinate

Social and Family History

•  Married with 2 children •  Occupation: nurse •  Remote history of blood exposure to HIV and

hepatitis B and C (work-related) •  No tobacco or recreational drug use •  Additional family history of prostate cancer and

coronary artery disease (both father)

Differential Diagnosis

●  Acute chest syndrome ●  Acute abdominal syndrome ●  Inflammatory disorder ●  Cancer

Physical Exam

●  Chest clear—ruled out acute chest syndrome ●  Normal cardiac examination ●  Abdomen soft, nondistended, no

hepatosplenomegaly or masses ●  Normal bowel sounds, normal rectal exam ●  Upper right quadrant tender

o  Upper abdominal disorder

Acute Coronary Syndrome

�  Electrocardiogram ¡  Normal sinus rhythm ¡  No ST-segment or

T-wave abnormalities �  Chest radiography

¡  No acute cardiopulmonary process

Inflammatory Disorders

●  Lipase, aminotransferase, and amylase levels elevated o  Pancreatitis o  Liver disease, injury, cancer o  Autoimmune, inflammatory disorder

CT Scan

Exploratory Laparotomy

●  Reactive follicular and interfollicular hyperplasia

●  Lipogranulomas ●  Lipids from GI tract

o  Inflammatory abdominal disorder ●  No evidence lymphoproliferative disorders

o  No cancer

Small-Bowel Biopsy

Celiac Disease Confirmation

●  IgA tissue transglutaminase antibodies ●  IgA endomysial antibodies

Physicians Overlooked Celiac Disease

●  Surgery was non-diagnostic and invasive ●  Simple blood test succeeded, more specific ●  Important for physicians to consider celiac

disease when patients present with symptoms suggestive of celiac disease

Treatment

●  Gluten-free diet ●  Intramuscular iron supplementation ●  Multivitamin

Mechanisms of Disease

●  Autoimmune disorder provoked by intaking gluten ●  Affects small bowel

o  Abnormal immune response to gliadin in gluten protein

o  Type 1 helper T cells cause inflammation in epithelium and lamina propria of small intestine

o  Alters structure of intestinal villi o  Malabsorption

Symptoms ●  Intestinal Symptoms

o  Abdominal pain o  Diarrhea o  Elevation of aminotransferase levels o  Increased risk of pancreatitis

●  Extragastrointestinal Symptoms o  Rashes o  Arthralgias o  Neurologic and psychiatric effects o  Fatigue o  Infertility

●  Other associations with type 1 diabetes, thyroiditis, and hepatitis

Prevalence

●  1-2% of general population in North America, South America, Europe, North Africa, the Middle East, and India

●  Increasing diagnosis due to improved testing methods and increased prevalence

●  Celiac disease still under-diagnosed in the US

Gluten-Free Fad Diet

●  Placebo component to unnecessarily removing gluten from diet

●  Non-celiac gluten intolerance has not presented itself to be a real medical issue

●  GFD can cause gastrointestinal problems in people without celiac disease

●  Research on the subject is preliminary

Works Cited �  1. Ole-Petter Riksfjord Hamnvik, M.D., Fidencio Saldana, M.D., Bruce D. Levy,

M.D., and Joseph Loscalzo, M.D., Ph.D. N Engl J Med 2014; 371:1333-1338.  

�  2. Medline Plus: Medical Dictionary.  Besthesda, MD: U.S. National Library of Medicine, 2012.  (Accessed January 13, 2015 at http://www.nlm.nih.gov/medlineplus/mplusdictionary.html.)

  �  3. Leffler, D. Celiac Disease Diagnosis and Management: A 46-Year-Old Woman

With Anemia. Jama 2011; 306:1582–1592. �  4. Rubio-Tapia, A., Hill, I. D., Kelly, C. P., Calderwood, A. H., & Murray, J. A.

American College of Gastroenterology Clinical Guideline: Diagnosis and Management of Celiac Disease. The American Journal of Gastroenterology 2013, 108:656–677.