Snap Shot A 43 year-old man from Ireland presents with complaints of diarrhea. He reports she has been having 3-5 loose stool per day for the last six months. The condition improves when he fasts. Introduction A chronic hereditary intestinal malabsorption disorder caused by intolerance to gluten a cereal protein found in wheat and rye and less so in barley and oats Gluten acts as an antigen and forms an immune complex in the intestinal mucosa promoting aggregation of killer lymphocytes lymphocytes cause mucosal damage with loss of villi and proliferation of crypt cells The prevalence of celiac disease varies: 1:300 in southwest Ireland > 1:5000 in North America. no single genetic marker exists Presentation Symptoms asymptomatic diarrhea can lead to fat soluble vitamin deficiency iron-deficiency anemia failure to thrive growth retardation weight loss Physical exam dermatitis herpetiformis pruritic, red, papulovesicular lesion on shoulders, elbows, and knees due to IgA deposits in the upper dermis Symptoms are absent in children until they eat food containing gluten failure to thrive pass pale, malodorous, bulky stools suffers painful abdominal bloating repeat infection if IgA deficiency present (common in Celiac patients) Evaluation Diagnosed by biopsy showing a pathognomonic blunting of intestinal villi and flat mucosa with lymphocytic and plasma cell infiltration IgA Anti-tissue Transglutaminase Antibodies is the single best serologic test, with confirmation through duodenal biopsy. Anti-endomysial antibody (EMA) titers show high sensitivity and specificity proposed as screening test for celiac disease also IgG/IgA antigliadin antibodies Treatment Avoid dietary gluten Dietary supplements Treat dermatitis herpetiformis with dapsone Prognosis, Prevention, and Complications Intestinal lymphoma develops in 10-15%