Do NOT prescribe a gluten-free diet unless we are positive this is #celiac disease! 
Normal small intestinal histology
#Celiac disease histology
Increased intraepithelial lymphocytes without villous atrophy
-celiac
-infections
-SIBO
-H. pylori
-autoimmune
-other
-celiac
-infections
-SIBO
-H. pylori
-autoimmune
-other
Location of IELs can help!
Drug-induced enteropathy
💊 ARBs (olmesartan)
💊 checkpoint inhibitors
💊 mycophenolate
💊 methotrexate
Think of drug-induced in:
-seronegative
-common offending medications
-THICK COLLAGEN BAND
💊 ARBs (olmesartan)
💊 checkpoint inhibitors
💊 mycophenolate
💊 methotrexate
Think of drug-induced in:
-seronegative
-common offending medications
-THICK COLLAGEN BAND
Collagenous sprue
-stop offending medications
-if permissive serologies, consider gluten-free diet
-will likely need immunosuppression
-stop offending medications
-if permissive serologies, consider gluten-free diet
-will likely need immunosuppression
Immune deficiencies
⚠️Patients can have CVID AND #celiac disease (hard to diagnose as serologies often negative...)
⚠️Patients can have CVID AND #celiac disease (hard to diagnose as serologies often negative...)
Tropical sprue 🏝
-prolonged antibiotics and high-dose folate (and possibly other vitamin) repletion
💡Take travel history!
-prolonged antibiotics and high-dose folate (and possibly other vitamin) repletion
💡Take travel history!
Autoimmune enteropathy
Clue: no goblet or Paneth cells
Clue: multisystem involvement is possible (thyroiditis, ILD, AIHA, autoimmune hepatitis, nephrotic/nephritic syndrome)
Clue: no goblet or Paneth cells
Clue: multisystem involvement is possible (thyroiditis, ILD, AIHA, autoimmune hepatitis, nephrotic/nephritic syndrome)
Antibodies in autoimmune enteropathy: limited utility
AGCAs are common and nonspecific: 30-40% prevalence in healthy individuals
AGCAs are common and nonspecific: 30-40% prevalence in healthy individuals
Autoimmune enteropathy algorithm
Labs and histology to help guide workup of enteropathy
@AmyOxentenkoMD summary on enteropathy
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