A 45-year-old man presents with chronic diarrhea, abdominal bloating, and a 10 kg weight loss over 6 months. Small bowel biopsy shows subtotal villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes. Anti-tissue transglutaminase (anti-tTG) IgA antibodies are markedly elevated. What is the definitive treatment?

• A Oral metronidazole for 7 days
• B Oral prednisone 40 mg/day
• C Azathioprine immunosuppression
• D Strict lifelong gluten-free diet ✓

Explanation

Celiac disease is an immune-mediated enteropathy triggered by gluten (gliadin fraction from wheat, barley, rye) in genetically susceptible individuals (HLA-DQ2/DQ8). Villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis, and positive anti-tTG IgA confirm the diagnosis. A strict, lifelong gluten-free diet is the cornerstone of treatment; adherence leads to symptomatic remission and histologic recovery. Steroids are reserved for refractory celiac disease.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.