Objectives:

• Evaluate a patient with diarrhea
• Recognize clinical manifestations of gluten-sensitive enteropathy
• Manage a patient with gluten-sensitive enteropathy

1		A 32-year-old male complains about fatigue and episodic abdominal pain. His pain is located in the periumbilical region and the left lower quadrant. It is cramplike in nature and is associated with flatulence and diarrhea. Passing gas alleviates his symptoms. He noted that milk and other dairy products worsen his symptoms. His weight has remained stable. His prior medical history, family and social history, and physical examination are unremarkable. Laboratory tests reveal a hemoglobin of 11.5 g/dl and a normal blood glucose and TSH. What is the most appropriate next step in your evaluation?
			A)	Lactose breath test.
			B)	Dietary trial with lactose-free food.
			C)	Enteroclysis.
			D)	Colonoscopy.
			E)	Tissue transglutaminase antibody titer.
2		The patient tries a lactose-free diet but this is of no benefit and his abdominal cramping and diarrhea continue. At this point, you are considering additional diagnoses. Which of the following is UNLIKELY in this patient?
			A)	Bacterial overgrowth syndrome.
			B)	Gluten-sensitive enteropathy.
			C)	Giardia lamblia.
			D)	Clostridium difficile.
			E)	Whipple's disease.
3		You continue to work up this patient's diarrhea with stool cultures, stool for C. difficile toxin, PCR for immunofluorescence for Giardia and Cryptosporidium, and 3 stools for ova and parasites. All of the studies are negative. You now turn your attention to possible bacterial overgrowth syndrome. The best test for bacterial overgrowth syndrome is:
			A)	Quantitative stool culture.
			B)	Stool leukocytes.
			C)	72-hour fecal fat.
			D)	D-xylose breath test.
			E)	B and D.
4		This patient's D-xylose test is negative and you consider the possibility of gluten-sensitive enteropathy. Of the following, the BEST test for the diagnosis of gluten-sensitive enteropathy is:
			A)	Anti-endomysial antibodies.
			B)	Tissue transglutaminase antibodies.
			C)	Anti-gliadin antibodies.
			D)	Radiolabeled wheat flour absorption test.
			E)	None of the above.
5		The results of his tissue transglutaminase test are positive. You send him to a gastroenterologist, who educates him on gluten-sensitive enteropathy (aka celiac disease) and performs an endoscopy. A small bowel biopsy demonstrated blunted villi with a significant increase in intraepithelial lymphocytes, consistent with gluten-sensitive enteropathy. With a gluten-free diet, the patient experiences a significant increase in his energy level. Two years later he comes for a routine visit. He has gradually reintroduced some wheat products into his diet and tolerates this very well. What do you recommend?
			A)	Resume gluten-free diet.
			B)	Continue dietary challenge and repeat examination in 6 months.
			C)	Repeat small bowel biopsy.
			D)	Check tissue transglutaminase antibody titer.
			E)	Avoid wheat, but try barley or rye products.