A 45-year-old man with longstanding celiac disease on a strict gluten-free diet presents with recurrent small bowel obstruction and weight loss. CT shows thickened jejunal wall with enlarged mesenteric lymph nodes. What is the most likely complication?

• A Refractory celiac disease Type II with aberrant T-cell proliferation
• B Adenocarcinoma of the small bowel
• C Enteropathy-associated T-cell lymphoma (EATL) ✓
• D Lymphocytic colitis as a separate entity

Explanation

Enteropathy-associated T-cell lymphoma (EATL) is the most feared complication of celiac disease, typically arising from refractory celiac disease type II (aberrant intraepithelial T-cell clone). It presents with abdominal pain, weight loss, and obstruction from mesenteric lymphadenopathy and bowel wall infiltration. It carries a poor prognosis. Refractory CD Type II is a precursor lesion. Small bowel adenocarcinoma is also increased in celiac disease but is less likely given the mesenteric node involvement pattern.

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

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Written and medically reviewed by the StethoPrep medical team.