Internal Medicine

0521779407-C01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:53

290 Celiac Sprue and Malabsorption

Physical

■mooth, red tongue; cracking at mouth corners; blistering skin rash

(dermatitis herpetiformis); protrusion of abdomen (“pot belly” in

children); pallor; bruising; edema

tests

Basic Blood:

■anemia (iron deficiency; folate/vitamin B12 deficiency); hypo-

albuminemia; elevated alkaline phosphatase; reduced serum cal-

cium, magnesium, zinc

Basic Urine:

■none usually helpful; see xylose test under specific diagnostic tests

Specific Diagnostic:

■Blood: Total serum IgA; IgA antibodies: transglutaminase (more sen-

sitive than endomysial; alpha-gliadin and reticulin have lower speci-

ficity)

■Functional tests of malabsorption: elevated quantitative fecal fat (72-

hour); reduced xylose absorption (25 g ingested; 5-hour urine excre-

tion)

■Small intestinal biopsy (via upper GI endoscopy to distal

duodenum): flat villi with change of elongated columnar cells to

cuboidal shape; lymphocyte infiltration of enterocyte surface layer;

lymphocyte and plasma cell infiltration of subepithelium (lamina

propria)

differential diagnosis

■maldigestion due to pancreatic insufficiency (chronic pancreatitis)

or pancreatic duct obstruction (pancreatic carcinoma); fecal fat ele-

vated but xylose absorption normal

■other intestinal enteropathies (extensive small intestinal Crohn’s dis-

ease, hypogammaglobulinemia, tropical sprue, Whipple’s disease;

carcinomatosis; these diseases rarely produce the completely flat

intestinal biopsy seen in celiac sprue)

■drugs that cause malabsorption: colchicine, neomycin, cholestyra-

mine, laxatives

■post-gastric surgery malabsorption

■systemic diseases associated with malabsorption: thyrotoxicosis,

hypothyroidism, Addison’s disease, diabetes with autonomic neu-

ropathy, systemic sclerosis