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Endgames Case Review

A woman with a 10 year history of abdominal pain

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k603 (Published 29 March 2018) Cite this as: BMJ 2018;360:k603
  1. Jessica Richelieu, medical student1,
  2. John WI Morse, internist and gastroenterologist2,
  3. David C Pfeiffer, professor3
  1. 1University of Washington School of Medicine, Seattle, Washington, USA
  2. 2Kings Lane Medical Clinic, Salt Spring Island, British Columbia, Canada
  3. 3Department of Biological Sciences and WWAMI Medical Education Program, University of Idaho, Moscow, Idaho, USA
  1. Correspondence to D Pfeiffer dpfeiffer{at}uidaho.edu

A 64 year old woman with a history of Still’s disease presented with more than 10 years of abdominal pain and bloating. Her symptoms were initially intermittent, but over the last six months they had worsened and she had experienced weight loss of 10 kg.

She recalled being told that she had a “leaky gut” by a health professional nine years ago, and that she was advised to follow a gluten-free diet. She believed her symptoms had improved after this, but over time she returned to her original diet and her symptoms eventually returned. Computed tomography scanning and abdominal ultrasound two years ago were normal. A hepatobiliary scan showed a borderline low gallbladder ejection fraction of 34%. She underwent an upper endoscopy to rule out the possibility of a peptic ulcer. No ulcer was found, but several small gastric fundal polyps were observed and biopsied. These were attributed to proton pump inhibitor (pantoprazole) use. Antral biopsies were normal but duodenal biopsies (figs 1 and 2) showed mild villus blunting and intraepithelial lymphocytosis. These were attributed to a disease of autoimmune origin; however, anti-transglutaminase (tTG) testing was negative. A colonoscopy revealed hyperplastic polyps, but was otherwise unremarkable.

Fig 1

Duodenal biopsy showing mild villus blunting (arrows) (haematoxylin and eosin stain, original magnification×200)

Fig 2

Duodenal biopsy showing intraepithelial lymphocytosis. Arrows indicate nuclei of representative lymphocytes (haematoxylin and eosin stain, original magnification×200) …

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