From the Guidelines
The most appropriate next step in the workup of this patient with suspected celiac disease or inflammatory bowel disease is to obtain serological testing and refer for endoscopy with biopsy, specifically option A) Colonoscopy with ileoscopy and biopsies, as it allows for the evaluation of both the colon and the ileum, which can be affected in inflammatory bowel disease, and also assesses for celiac disease. The patient's symptoms of abdominal pain and frequent, loose stools, which started after a Caribbean cruise, suggest a possible infectious or inflammatory cause, but also raise the possibility of celiac disease, given the temporal relationship with potential gluten exposure. According to the guidelines for best practices in monitoring established coeliac disease in adult patients 1, diagnosis of CeD in adulthood is based on serology (TG2Ab) and duodenal biopsy while the patient is on a gluten-containing diet. However, given the patient's symptoms and the need to rule out other causes of gastrointestinal symptoms, such as inflammatory bowel disease, a colonoscopy with ileoscopy and biopsies is the most appropriate next step, as it allows for the evaluation of the entire colon and the ileum, and can help diagnose or rule out conditions such as Crohn's disease or ulcerative colitis. Additionally, this procedure can also assess for celiac disease by evaluating the small bowel for villous atrophy and obtaining biopsies for histological examination. It's essential to avoid starting a gluten-free diet before celiac testing is complete, as this can lead to false-negative results, and similarly, avoid starting corticosteroids or other anti-inflammatory medications before IBD evaluation when possible, as these may mask findings. These diagnostic steps are crucial because both conditions require histological confirmation before initiating specific treatments, and early diagnosis can prevent complications such as nutritional deficiencies, growth issues, and disease progression. The guidelines from various scientific societies support this diagnostic algorithm, emphasizing the importance of serological testing and endoscopic evaluation with biopsy in the diagnosis of celiac disease and inflammatory bowel disease 1.
From the Research
Diagnostic Approach
The patient presents with abdominal pain and frequent, loose stools, which started after a Caribbean cruise. The symptoms suggest a possible gastrointestinal disorder, such as celiac disease or inflammatory bowel disease.
- The most appropriate next step in her workup would be to conduct tests that can help identify the underlying cause of her symptoms.
- According to the guidelines, celiac disease is usually detected by serologic testing of celiac-specific antibodies, and the diagnosis is confirmed by duodenal mucosal biopsies 2.
- Fecal calprotectin is a non-invasive biomarker of gut inflammation, which can be used to assess disease activity and predict long-term outcomes in patients with celiac disease and non-celiac enteropathies 3, 4.
- However, some studies suggest that fecal calprotectin may not be useful in the diagnostic work-up of uncomplicated celiac disease, but it can be used to rule out organic disease in patients with irritable bowel syndrome 5.
Recommended Tests
Based on the patient's symptoms and the guidelines, the recommended tests would be:
- Celiac serologies to detect celiac-specific antibodies
- Fecal calprotectin to assess gut inflammation
- C-reactive protein (CRP) to evaluate inflammation
Test Options
Among the given options, the most appropriate next step would be:
- B) Celiac serologies, fecal calprotectin, and C-reactive protein (CRP), as these tests can help identify celiac disease and assess gut inflammation 2, 3, 6.
Note: The other options, such as colonoscopy with ileoscopy and biopsies, hydrogen breath test for small intestinal bacterial overgrowth, and computed tomography enterography, may be considered later in the diagnostic workup, depending on the results of the initial tests.