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Celiac disease — ABIM Board MCQ

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HardGastroenterology/HepatologyCeliac diseaseABIM Board

A 39-year-old woman with biopsy-confirmed celiac disease reports persistent diarrhea and weight loss after eight months on a gluten-free diet. Tissue-transglutaminase IgA has normalized, but she has not met with a specialist dietitian. Which next step should precede diagnosing refractory celiac disease?

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Correct answer: A — Verify celiac histology and obtain dietitian assessment for gluten exposure

The best answer is “Verify celiac histology and obtain dietitian assessment for gluten exposure”. Most ongoing symptoms reflect inadvertent gluten exposure, an incorrect original diagnosis or another disorder rather than true refractory celiac disease. Expert dietitian review, confirmation of the initial histology and serology, and evaluation for alternative causes should precede repeat biopsy and refractory classification. Normalized serology does not prove complete mucosal healing or exclude intermittent exposure.

Reference: ACG Clinical Guideline: Diagnosis and Management of Celiac Disease: https://pubmed.ncbi.nlm.nih.gov/36602836/