Gastrointestinal System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M51_F1.jpg"}},{"insert":"\n\n"},{"insert":"\u0022No soy, no eggs, and no nuts\u0022, you mutter to yourself while staring at an energy bar. Skipping breakfast was not the greatest idea.\n\nA knock on your door returns you to the present. The duty nurse pokes her head in and announces the arrival of your first patient. You put on a warm smile, as Joan, a 34-year-old investment banker, walks in.\n\nYou offer her a seat and ask how you can be of assistance. \u0022Doctor, I don\u0027t know where to even begin,\u0022 she starts. \u0022I\u0027ve just been having an awful time for so long.\u0022\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M51_F4.jpg"}},{"insert":"\n\n"},{"insert":"Joan describes a 2-year history of recurrent loose stools, intermittent abdominal pain, and bloating. The stools were malodorous, bulky, and difficult to flush down. There was no blood or mucus in the stool. Nor was there pain on defecation or tenesmus. She denies experiencing fever, nausea, vomiting, or easy satiety. Her bowel habits were completely normal before this.\n\n\u0022Recently, I\u0027ve started to become tired very easily. I just don\u0027t seem to have enough energy to get through the day,\u0022 she says and continues, \u0022oh and I\u0027ve lost weight, like a good amount. I\u0027ve had to adjust the seams on most of my outfits about 3 times since this started.\u0022\n\nJoan does not recall any of her relatives having similar complaints. A quick perusal of her medical records shows that she has seen two other doctors regarding her complaints. The last physician diagnosed her with irritable bowel syndrome.\n\nOn cue, she speaks up. \u0022The last time I saw a doctor, I was told that I had irritable bowel syndrome. I\u0027m not comfortable with this diagnosis though, and I thought that I should have a second opinion.\u0022\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M51_F3.jpg"}},{"insert":"\n\n"},{"insert":"On examination, Joan\u0027s temperature is 98 \u00b0F (36.7 \u00b0C). Her pulse is 80 bpm, blood pressure is 100\/70 mmHg, and respiratory rate is 20\/min. She weighs 54 kg and is 1.72 m tall, given her a body mass index (BMI) of 18.25 kg\/m2.\n\nDuring the general examination, you note several groups of vesicles over the extensor surface of her arms. The vesicles have an erythematous base, while multiple excoriation marks are seen nearby. Examination of the organ systems yields no abnormal findings.\n\nNoticing your interest in the rash, Joan says, \u0022this rash started around half a year ago. I think it\u0027s some kind of food allergy because it seems to flare up whenever I have baked stuff.\u0022\n\nShe continues, \u0022I kind of noticed a pattern. It sounds silly but when the rash flares up, the pain and loose stools seem to get worse too. I thought I\u0027ve been eating way too much sugar and processed carbs, so I joined a friend of mine in a detox meal plan with just vegetables and fish. That was the only time recently that I\u0027ve felt good\u0022.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M51_F13.jpg"}},{"insert":"\n\n"},{"insert":"What do you think Joan has?\n"}]}
1. Inflammatory bowel disease
2. Celiac disease
3. Gluten hypersensitivity