Grand Rounds: A 42-Year-Old Man with Chest, Abdominal Discomfort. By Ari Thomas, Danielle Levine and Laurel Edington

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1 Grand Rounds: A 42-Year-Old Man with Chest, Abdominal Discomfort By Ari Thomas, Danielle Levine and Laurel Edington

2 Case Presentation 42-year old male Chief complaint chest and abdominal discomfort for two days

3 History of Present Illness Pain increasing in intensity Nausea and early satiety No outside meals No recent abdominal trauma, rectal bleeding or black stools

4 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

5 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

6 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

7 Current Medications Ramipril Aspririn n-3 Fatty Acids Folic Acid Isosorbide Dinitrate Atorvastatin Multivitamins Fenofibrate Nicotinic Acid Amlopidine Extended-release Metoprolol Succinate

8 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)

9 Differential Diagnosis Acute chest syndrome Acute abdominal syndrome Inflammatory disorder Cancer

10 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

11 Acute Coronary Syndrome Electrocardiogram Normal sinus rhythm No ST-segment or T-wave abnormalities Chest radiography No acute cardiopulmonary process

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

13 CT Scan

14 Exploratory Laparotomy Reactive follicular and interfollicular hyperplasia Lipogranulomas Lipids from GI tract o Inflammatory abdominal disorder No evidence lymphoproliferative disorders o No cancer

15 Small-Bowel Biopsy

16 Celiac Disease Confirmation IgA tissue transglutaminase antibodies IgA endomysial antibodies

17 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

18 Treatment Gluten-free diet Intramuscular iron supplementation Multivitamin

19 Mechanisms of Disease Autoimmune disorder provoked by intaking gluten Affects small bowel o Abnormal immune response to o o o gliadin in gluten protein Type 1 helper T cells cause inflammation in epithelium and lamina propria of small intestine Alters structure of intestinal villi Malabsorption

20 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

21 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

22 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

23 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: Medline Plus: Medical Dictionary. Besthesda, MD: U.S. National Library of Medicine, (Accessed January 13, 2015 at 3. Leffler, D. Celiac Disease Diagnosis and Management: A 46-Year-Old Woman With Anemia. Jama 2011; 306: 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:

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