A 45-year-old woman with chronic diarrhoea, bloating, and weight loss of 8 kg has positive TTG-IgA antibody (>10× ULN). Duodenal biopsy shows Marsh grade IIIC changes. She is started on a strict gluten-free diet (GFD) but remains symptomatic at 12 months. Which is the most likely cause of non-responsive coeliac disease?
- A Inadvertent gluten contamination in the diet ✓
- B Refractory coeliac disease type I or II — T-cell proliferative disorder
- C Concurrent microscopic colitis
- D Development of enteropathy-associated T-cell lymphoma (EATL)
Explanation
In non-responsive coeliac disease, the most common reason is inadvertent ongoing gluten exposure — approximately 50% of cases. Patients may unknowingly consume gluten through cross-contamination in food processing, restaurants, or mislabelled products. This should be systematically excluded with a detailed dietary review by a specialist dietitian and repeated serology before investigating rarer causes. Refractory coeliac disease (types I and II) and EATL are serious complications but are rare (<5% of non-responsive cases). Microscopic colitis may coexist but is secondary.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.