CORRECT

INCORRECT

The correct answer is E. The correct answer is E. Serologic screening for anti-tissue transglutaminase IgA antibodies is sensitive and specific for celiac disease:

Duodenal biopsy: flattened villi.

Etiology: allergic, immunologic, or toxic reaction to the gliadin component of gluten (from wheat, barley, rye and related grains).

component of (from wheat, barley, rye and related grains). Other serologic tests include anti-gliadin (IgA or IgG) and anti-endomysial (IgA) antibodies.

(IgA or IgG) and (IgA) antibodies. The flattening of villi reduces intestinal surface area and thereby impairs digestion and absorption.

and thereby impairs digestion and absorption. Undigested or partially digested nutrients pass through the small intestine to the colon, where they are acted on by bacteria to cause diarrhea and flatulence.

to cause and flatulence. The symptoms and pathologic changes usually reverse with the complete removal of gliadin from the diet.

Antibodies to cyclic citrullinated peptide (choice A), along with the presence of rheumatoid factor, are seen with rheumatoid arthritis. Patients present with symmetric tender, swollen, warm joints of the hands and wrists. Other joints of the knees, ankles, and elbows can also be involved. Subcutaneous rheumatoid nodules are present near the elbows. There is no direct connection between rheumatoid arthritis and celiac disease.

Helicobacter pylori infections (choice B) are responsible for the majority of gastric and duodenal ulcers seen in patients with peptic ulcer disease. Upper endoscopy failed to reveal such a lesion in the gastric antrum or the proximal duodenum. Villous atrophy is not related to Helicobacter infection.

Anti-mitochondrial antibodies (choice C) are found in the majority of patients with primary biliary cirrhosis (PBC). This autoimmune condition more commonly affects older females (age 40-60 years), primarily involves the intrahepatic biliary tracts, and causes lymphocytic and granulomatous destruction of bile ducts. There is no association with celiac disease. Patients may also present with fat malabsorption and steatorrhea, similar to our patient, from lack of bile secretion into the GI tract. However, patients with celiac disease have a more broad nutritional deficiency and marked weight loss.

Anti-smooth muscle antibodies (choice D) are seen in autoimmune hepatitis. Females are more affected than males. Patients can also have elevated anti-nuclear antibodies (ANA) and present with fatigue and jaundice.

MedEssentials (4th Ed.): pp. 357

First Aid (2018): pp. 375.1

First Aid (2017): pp. 364.1

First Aid (2016): pp. 358.1

Pathoma (2018): pp. 107.2

Pathoma (2014-2017): pp. 107.2

Choice A: 7% chose this answer.

Choice B: 6% chose this answer.

Choice C: 3% chose this answer.

Choice D: 3% chose this answer.

Choice E: 82% correctly chose this answer.