A 32-year-old South Asian man initially presented to a gastroenterologist after abnormal liver function tests and mild anemia were detected on a routine physical examination. A colonoscopy and sonogram of the liver were performed. The colonoscopy was normal and the sonogram showed fatty liver. The patient remained asymptomatic afterwards except for occasional heartburn. At this time he was seen in our Gastroenterology (GI) clinic and further evaluation was initiated. A thorough history and physical examination were performed. The patient denied any diarrhea or history of recent travel, though his past travel history included a six-year period of stay in the Caribbean Islands five years prior to this presentation. Family history was not contributory. The patient denied any toxic habits. Physical examination was normal. With a clinical suspicion of Celiac disease laboratory work was requested which showed anti-gliadin IgA, IgG, anti-endomysial and tissue transglutaminase antibodies to be positive. Initial aminotransferases tests showed aspartate aminotransferase (AST) of 111 U/L and alanine aminotransferase (ALT) of 120 U/L. Esophagogastroduodenoscopy (EGD) was performed which showed a partial Schatzki ring in the lower third of esophagus and a diffuse granular mucosa with fissuring in the second and third part of the duodenum. Biopsy of the second part of the duodenum showed villous atrophy with crypt elongation, replacement of surface epithelial cells by cuboidal cells with loss of brush border and increase in lymphocytes relative to the number of epithelial cells. Lamina propria showed increased plasma cells, lymphocytes and polymorphs consistent with celiac disease.
Bone scan revealed osteoporosis involving lumbar spine and osteopenia involving both hips. T and age matched Z scores are shown in Table 1. The patient was started on a strict gluten free diet, vitamin D, calcium and alendronate 10 mg orally every day. Subsequent endoscopy done 6 months later showed grade I esophagitis, erythematous non-bleeding gastropathy and granular mucosa in the third part and bulb of the duodenum. Repeat biopsies of the duodenum showed regeneration of villous height and regression of crypt hyperplasia. The surface epithelium showed increased columnar cells with basal nuclei and brush borders consistent with partial restoration and improvement in celiac disease. Repeat bone scan eighteen months later showed osteopenia with significant improvement of BMD (Table 1). No significant symptoms related to side effects of alendronate were reported during the 18 months treatment period. Repeat aminotransferases revealed AST of 26 U/L and ALT of 42 U/L.