Resistant

A 30-year-old woman presents with repeated episodes of watery diarrhea for almost one and a half years, in association with flatulence, and abdominal discomfort following meals. Further questioning reveals a weight loss of 10kg during this time period.

Her medical and family histories are unremarkable, while she neither smokes nor drinks. There is no history of recent travel, or drinking unfiltered water or unpasteurized milk.

A sample of stool is found to be frothy and foul smelling; they float when mixed with water. Microscopy shows no evidence of amoeba, ova, or cysts, and the stools test negative for blood. The fecal osmolar gap is 95 mOsm/kg.

Select Relevant Investigations
Anti-TTG-IgA test

Performed

120U/ml (normal <50)
Upper GI Endoscopy + Biopsy

Performed

An upper GI endoscopy reveals erythema and decreased folds in the upper duodenum, with scalloping of the duodenal folds.
Histology reveals complete atrophy of the villi with infiltration of lymphocytes in the mucosal wall.
Stool chymotrypsin activity

Performed

Stool chymotrypsin activity is within normal limits.
Colonoscopy

Performed

Colonoscopy reveals no untoward findings.

Select Relevant Management
Gluten-free diet
Quadruple Therapy
Corticosteroids
Mebeverine