A 45-year-old man presents with steatorrhoea, weight loss, and fatigue. Laboratory findings: anaemia with macrocytosis, low serum B12, low folate, raised anti-tissue transglutaminase IgA, low serum iron. Duodenal biopsy shows villous atrophy and crypt hyperplasia. He is started on a strict gluten-free diet. After 12 months, symptoms persist with ongoing malabsorption. What complication should be suspected?
- A Refractory coeliac disease (RCD) or enteropathy-associated T-cell lymphoma (EATL) ✓
- B Co-existing small intestinal bacterial overgrowth
- C Inadvertent gluten ingestion
- D Collagenous colitis
Explanation
Failure to respond to a strict gluten-free diet after 12 months, confirmed by dietitian assessment, should prompt evaluation for refractory coeliac disease (RCD Type I or II) or EATL (a rare but life-threatening T-cell lymphoma arising in the small bowel, strongly associated with Type II RCD with aberrant intraepithelial lymphocyte clones). While dietary non-compliance and SIBO are common causes of non-response, persistent symptoms beyond 12 months of confirmed strict GFD mandate repeat biopsies and immunophenotyping. EATL presents with recurrent ulcerating mucosal lesions and carries a poor prognosis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.