A 28-year-old male with a...

A 28-year-old male presented to the emergency department with abdominal pain that worsened after eating wheat products. He lost 7 kg and experienced abdominal distension, nausea, and vomiting. He had no fever, night sweats, or joint pain. His physical exam was unremarkable except for a thin body habitus with no lymphadenopathy. A digital rectal exam showed no abnormalities. He had no significant medical or family history. Laboratory examination showed hypochromic microcytic anemia and abnormal liver function (AST 214 IU/L, ALT 217 IU/L) with elevated alkaline phosphatase levels (183 IU/L). Both autoimmune and viral serology tests were negative. Tests for an infectious cause of diarrhea were also negative. An abdominal X-ray showed small and large bowel loops bloated with gas. The abdominal sonogram revealed a normal liver with patent vasculature and evidence of thickened loop of bowel. An abdominal computed tomography (CT) with IV contrast was performed for further analysis (Fig 1 and 2). Additional examination revealed a significant increase in tissue transglutaminase (TTG) antibodies IgA and IgG, with values of 4,965.5 CU and 431.9 CU.