++
For further information, see CMDT Part 15-27: Malabsorption
+++
Essentials of Diagnosis
++
Typical symptoms
Weight loss
Chronic diarrhea
Abdominal distention
Growth retardation
Atypical symptoms
Dermatitis herpetiformis
Iron deficiency anemia
Osteoporosis
Abnormal serologic test results
Abnormal small bowel biopsy
Clinical improvement on gluten-free diet
+++
General Considerations
++
Caused by an immunologic response to gluten that results in diffuse damage to the proximal small intestinal mucosa with malabsorption of nutrients
Gluten is a storage protein found in certain grains that is partially digested in the intestinal lumen into glutamine-rich peptides
Most cases present in childhood or adulthood, although symptoms may manifest between 6 and 24 months of age
++
++
"Classic" symptoms of malabsorption more commonly present in infants (< 2 years)
Diarrhea
Steatorrhea
Weight loss
Abdominal distention
Weakness
Muscle wasting
Growth retardation
Older children and adults are less likely to manifest signs of serious malabsorption but may report
Chronic diarrhea
Dyspepsia
Flatulence
Variable weight loss
Many adults have minimal or no gastrointestinal symptoms but present with extraintestinal "atypical" manifestations
Physical examination
In mild cases: may be normal
In more severe cases: may reveal signs of malabsorption, loss of muscle mass or subcutaneous fat, pallor, easy bruising, hyperkeratosis, or bone pain
Abdominal examination may reveal distention with hyperactive bowel sounds
Dermatitis herpetiformis in < 10%
+++
Differential Diagnosis
++
Irritable bowel syndrome
Malabsorption due to other causes
Lactase deficiency
Viral gastroenteritis
Eosinophilic gastroenteritis
Whipple disease
Giardiasis
Mucosal damage caused by acid hypersecretion associated with gastrinoma
Non-celiac gluten sensitivity
Frequency and cause of this entity is debated
A large 2013 study found that symptoms improved in gluten-sensitive patients when placed on a FODMAP-restricted diet and worsened to similar degrees when challenged in a double-blind crossover trial with gluten or whey proteins
A 2018 double-blind crossover trial in patients self-reporting gluten sensitivity found significantly higher symptom scores during the fructan challenge than during gluten or placebo challenges
Finally, a 2019 randomized trial conducted in healthy volunteers found no difference in gastrointestinal symptoms between those given diets with gluten supplements versus placebo
These data suggest that self-reported wheat sensitivity is not due to gluten intolerance and that the symptom improvement reported by patients with gluten restriction is due to broader FODMAP elimination
++
Obtain complete blood count, prothrombin time, serum albumin, iron or ferritin, calcium, alkaline phosphatase, red cell folate, vitamins B12, A, and D levels
Iron deficiency or megaloblastic anemia occurs because of iron or ...