This is a 61-year-old woman, allergic to diazepam, non-smoker, with pathological history of celiac disease since the 21st, but who was diagnosed at the age of 40 with anatomopathological confirmation.
In addition, she suffers from chondrocalcinosis and osteoporosis under treatment with calcium carbonate plus calcium glucoferol.
It also presents a small hiatal hernia described in an endoscopic study in treatment with lactose intolerance diagnosed in 2009.
Being previously stable, she has started a year ago with continuous deaf epigastralgia with nocturnal and postprandial predominance.
Pain does not irradiate and is accompanied by general malaise, occasional generalized pruritus, asthenia and weight loss of 8 kg in the last 6 months, as well as changes in bowel habits with a greater number of stools, constipation and short periods.
The patient maintained a diet free of gluten and lactose, so it was decided to refer him to the hospital where he entered internal medicine for study.
Physical examination revealed a blood pressure of 120/72 mmHg, a heart rate of 70 bpm, a body temperature of 36.5 oC, acceptable general condition, palpable skin dryness, without mucosal adenopathy,
A body mass index of 17.9.
Cardiorespiratory arrest, with no murmurs and a vesicular murmur preserved and without pathological sounds.
The abdomen was blandom and palpable, painful to palpation epigastrium and mesogastrium, without masses, visceromegaly or palpable inguinal lymphadenopathy.
Extremities without edema or signs of venous thrombosis and neurological examination were normal.
The hemogram showed mild macrocytic anemia (hemoglobin 11 g/dL, hematocrit 36.7 %, MCV 101.6 fL), platelets and leukocyte formula with normal characteristics.
The erythrocyte sedimentation rate was 28 mm/h, coagulation and biochemical tests were normal.
Proteinogram, thyroid hormones, immunoglobulins (IgG, IgM, IgA), vitamin B12 and folic acid were within normal limits.
Faecal occult blood and negative tumor markers
Fecal maladjustment revealed fecal maladjustment 66.3%, fecal nitrogen 1.3 g/24 h, fecal fat 9.1 g/24 h, starch 12.3 g/24 h, and intestinal fat 146 g/24 h 4.9 h.
Antitransglutaminase antibodies were negative.
Given the patient's history, the study of maladjustment was repeated to assess the functionality of intestinal malabsorption, whose results confirm this diagnosis.
Histologically, an affectation of the duodenal mucosa with Marsh grade III despite carrying a diet consisting of gluten and lactose and negativizing antitransglutaminase antibodies was observed.
An abdominal-pelvic CT scan showed no relevant pathological findings.
A new esophagogastroduodenoscopy study was performed, which visualizes macroscopically the duodenal mucosa without visible ulcers, supporting the diagnostic suspicion of refractory celiac disease.
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The patient was discharged for clinical improvement after 8 days of hospitalization.
Outpatient treatment with sucralfate and budesonide 3 mg/day was prescribed in addition to their usual medication.
