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.