A 28-year-old woman presented with a 5-month history of weight loss of 10 kg and postprandial epigastric pain without diarrhea.
On physical examination she was pale and had epigastric pain due to abdominal palpation.
Analytical: Hb 8.6 g/dl, Htco 28%, MCV 64, Fe 6 mcg/dl, ferritin 1 ng/ml, transferrin saturation 1.5%, vitamin B12 and folic acid normal.
Antigliadin antibodies 24.5 (0-20 IU/ml) and anti-endomysium antibodies > 20.
Rest of biological parameters within normal limits.
Ca19.9, CEA, normal alpha-fetoprotein.
Hemolysis was negative.
Gastroduodenal-intestinal transit x-ray: several duodenal stenoses with ulceration and diverticular images in distal duodenum-yelocaly.
Esophagogastroscopy: duodenal mucosa with atrophic aspect and linear postbulbar ulcerations.
Pathological anatomy: severe vesicular and extensive inflammatory.
No granulomas, lymphoid tissue or carcinoma were found.
Biopsy with Crosby capsule directed to stenotic zone: similar histological findings.
Abdominal CT: no significant findings.
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A gluten-free diet was initiated with progressive clinical and analytical improvement and subsequent normalization of all parameters.
Eight years after diagnosis the patient remains asymptomatic with annual controls.
Endoscopy and histology revealed normal intestinal mucosa and laboratory tests, including celiac disease antibodies, showed no significant findings.
Duodenal stenosis is an unusual presentation of celiac disease (3).
Intestinal ulceration and stenosis are believed to occur in areas with inflammatory mucosa.
These lesions are typically located in the proximal small intestine and are generally described in advanced stages of celiac disease (1.2).
More recently, Schweger and Murray (3) have described 5 more cases indicating that these complications, although rare, may occur more frequently than previously thought and seem to appear earlier in the course of the disease.
Erosions of the second duodenal portion in celiac patients have been recently described endoscopically (4).
Our patient had no typical celiac disease symptoms, with constipation and epigastric pain.
Radiology showed duodenal stenosis and ulceration, and we had to perform the differential diagnosis between celiac disease and Crohn's disease, lymphoma, intestinal carcinoma, and ulcerative jejunitis.
Analytical, endoscopic and histological findings, as well as the subsequent evolution of the patient on a gluten-free diet, confirmed the disease.
In this disease, the early development of duodenal stenosis and ulcerations should be taken into account, and more in those patients with non- celiac disease or previous nonspecific symptoms, due to the aforementioned typical clinical changes may precede celiac disease.
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A. Castiella, I. Aramberri1, J. Fernández, C. Carrera1, L. Legasa2, I. Ruiz3 and E. Zapata
Gastroenterology Unit, 1 Family Medicine, 2 Radiology Services and 3 Pathological Anatomy.
Mendaro Hospital.
Gipuzkoa
