Mahmud Z Jiiani, Huma Habib.
Diarrhea with Weight Loss in an Adult Male.
Med Channel Jan ;7(4):48-50.

The onset of celiac disease in late age is being increasingly recognized now. In our part of the world, where this disease is relatively uncommon, it can easily be misdiagnosed, or diagnosed late. This is also because here other causes of diarrhea and debility are much more common which particularly include infectious causes. This case also highlights the different modalities, which may be adopted in developing countries to diagnose this condition.

PRESENTATION: A 41-year old male Mr. S.A., a field officer in Karachi Nuclear Power Plant was admitted under our care with a history of diarrhea, progressive weight loss, pallor and generalized weakness for the last about three years. Stools were watery, pale, five to six times per day, and often floated over water. It was associated with colicky abdominal pain. There was no mucus or blood. He occasionally had nausea, vomiting, and abdominal distention. There was a history of significant weight loss, of about 19kg within two years despite a good appetite. He was having severe anemia over the last 2-3 years with hemoglobin ranging between 5-6 gms %. There was a history of jaundice 22 years back. On enquiry, he revealed that he had 1-2 soft, bulky, greasy and odorless stools since childhood. He was a non-smoker, but addicted to paan and tobacco. He was married with five kids. Prior to admission, he had seen various other doctors for treatment of his ailment but to no avail. On examination, he was severely anemic and emaciated but mentally quite clear. Abdomen was soft and non-tender with exaggerated bowel sounds. Lab reports showed Hb 6.7 gms, MCV 116, TLC 3.2, platelets normal, ESR 65, Thyroid function test was normal, random blood glucose 93, Blood Urea, S. Creatinine and electrolytes were normal, LFT showed an ALT of 81, (N.R. <40), rest was normal. Fasting Calcium and Phosphate were normal. Urine routine examination was normal. Stool examination showed undigested food. Ultrasound upper abdomen normal, red cell folate was 122.4 (N.R. 175-700 NG/ml), Serum Folate 9.1NG/ml (3-17), Serum B 12-37.1, PG/ ml (200-950). His bone marrow examination revealed megaloblastic changes.

The patient was then transfused 4 units of blood and his post transfusion hemoglobin was 12.36 and MCV 99, TLC 5.1, ESR 10. Provisional diagnosis of chronic malabsorption was considered and further investigations showed normal DXylose Test and also a normal small bowel enema. Fecal fat content was marginally raised. However, an endoscopic small bowel biopsy showed partial villous atrophy, which suggested a picture consistent with Adult Celiac Disease. He was advised gluten-free diet, including wheat, barley, oats, rye, and all their products. He was started on oral folic acid, Injection Cyanocobalamin, and provided nutritional supplements. His diarrhea started to improve and settled completely within 5-6 days. He was discharged after transfusion and followed up in the Out Patient Clinic. He rapidly put on weight with no recurrence of his anemia. He has remained asymptomatic for the last five years with regular follow-up. He, however, recently introduced Gluten in his diet following which his diarrhea relapsed. This settled again on its own on withdrawal of dietary Gluten.

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