Lower Abdominal Distress in 2 Patients: What Next?
Both patients complain of diarrhea x1 year; neither presents with weight loss, melena, or hematochezia. What test, which treatment would you choose?
A 40-year-old woman with a 1-year history of diarrhea presents for evaluation. Serologic testing for celiac disease reveals IgA 55 (normal 61-356 mg/dL) and serum tissue transglutaminase (IgA) of 18 (normal <19 units).
Which of the tests above should be ordered next?
Answer: E. Deaminated gliadin IgG. Patients with celiac disease are at increased risk for IgA deficiency vs the general population; when the level is low, IgA-based serologic testing becomes much less reliable in the evaluation of celiac disease. IgG-based testing is recommended in this setting, specifically deaminated gliadin IgG. Tissue typing, evaluating for HLA DQ2 or DQ8, can help to rule out celiac disease; serologic testing, however, is more cost effective and can provide sufficient information to make the diagnosis.
Suggested reading: Chang L, Lembo A, Sultan S. American Gastroenterological Association Institute Technical Review on the pharmacological management of irritable bowel syndrome. Gastroenterol. 2014;147:1149-72.
A 28-year-old man with no significant medical history presents with one year of intermittent abdominal pain and diarrhea. He denies weight loss, melena, hematochezia, or night time awakening to have a bowel movement. His pain improves with bowel movements. Labs and results of tissue biopsy taken during colonoscopy are negative.
Which one of the above is not indicated for managing this patient’s condition?
Answer: E. Probiotics. This patient meets Rome III diagnostic criteria for irritable bowel syndrome-diarrhea predominant. According to current data, rifaximin and alosetron are more effective than no therapy in the treatment of IBS-D.
Suggested reading: Shah A, Morrison M, Burger D, et al. Systematic review with metaâanalysis: the prevalence of small intestinal bacterial overgrowth in inflammatory bowel disease. Aliment Pharmacol Ther. 2019;49:624-35.
