An 89yearold man with past medical history of hypothyroidism, coronary artery disease, and atrial fibrillation on warfarin, is sent from his primary care physician for two week history of new onset diarrhea. The patient had four to five watery bowel movements daily with some vague right upper quadrant pain, nausea and vomiting. An extensive outpatient workup including gastroenterology referral did not reveal a diagnosis. On physical exam the patient appeared to be clinically dehydrated with dry mucous membranes and skin tenting. He was alert and oriented to person, place, and time. The abdominal exam was unremarkable; specifically there was no abdominal tenderness and a negative Murphy’s sign. Admission laboratory findings were significant for an elevated creatinine consistent with acute renal failure via RIFLE criteria. A broad differential diagnosis was generated which included infectious, autoimmune, malignant, and dietary etiologies. The workup for this patient was negative including clostridium difficile PCR, stool osmolality, stool leukocyte, stool ova and parasites, stool culture, right upper quadrant sonogram, CT scan of abdomen, transglutaminase IgG and IgA, gliadin IgG and IgA. In the hospital, the patient was evaluated by his gastroenterologist with a plan for an upper endoscopy and colonoscopy. The upper and lower endoscopies revealed a normal esophagus, stomach, colon and no gross lesions. Biopsy samples were obtained from the stomach, small intestine and colon. Pathology results were consistent with Celiac disease. The patient was now newly diagnosed with celiac disease and started on a glutenfree diet with resolution of symptoms.
Celiac disease is a malabsorption disorder resulting from inflammatory insult to the small intestine mucosa secondary to ingestion of wheat gluten. Once considered a rare disease, it is now known to be relatively common, affecting one in 120 to 300 persons in Europe and North America. It is being diagnosed with an increasing frequency in adults, with about 20 percent of cases in patients over the age of 60. The initial work up for suspected Celiac disease includes serology with IgA/IgG antiendomysial antibody and IgA/IgG antigliadin antibody. The IgA antiendomysial sensitivity is 8598%, specificity 97100%. The IgA/IgG antigliadin sensitivity, specificity tend to be lower than that of the IgA antiendomysial antibody.
Celiac disease is a relatively common disorder in the United States and should be considered in elderly patients presenting with diarrhea. Negative serologic results do not rule out celiac disease and further work up including pathology should be considered.
To cite this abstract:Chaudhry A, Kalra S. New Onset Celiac Disease in an 89 Year Old Man. Abstract published at Hospital Medicine 2012, April 1-4, San Diego, Calif. Abstract 97763. Journal of Hospital Medicine. 2012; 7 (suppl 2). https://www.shmabstracts.com/abstract/new-onset-celiac-disease-in-an-89-year-old-man/. Accessed April 7, 2020.