Differentiating celiac disease from other diseases

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Differentiating Celiac Disease from Other Diseases

The table below summarizes the findings that differentiate causes of chronic diarrhea

Cause	Diarrhea		Osmotic gap		History				Physical exam	Age onset	Additional findind	Gold standard dignosis
	Watery	Fatty	< 50 mOsm per kg	> 50 mOsm per kg*	Weight loss	Abdominal pain	FTT	Anemia					Lab findings
Celiac disease	+/-	+/-	-	+	+	+	+	+	Abdominal distention Tetany Mouth ulcers Dermatitis herpetiformis Signs of the fat-soluble vitamins A, D, E, and K deficiency		Gluten-free diet	IgA tissue transglutaminase Ab
Lactose intolerance	+	-	-	+	-	+	-	-	Abdominal tenderness		Avoidance of dietary lactose Substitution to maintain nutrient intake Regulation of calcium intake Use of enzyme lactase	Intestinal biopsy
Cystic fibrosis	-	+			+	+	+	+
Laxative overuse	+	-
Congenital chloride diarrhea										Neonate	History of polyhydramnios Mutations in the SLC26A3 gene Encodes for an epithelial anion exchanger	Excessive fecal secretion of chloride	hyponatremia, hypochloremia, and metabolic alkalosis
Crohns	+	-	+	-	+	+		Abdominal pain followed by diarrhea	Abdominal tenderness when palpated in severe disease Blood seen on rectal exam Fever Tachycardia Hypotension		Topical mucosamine and corticosteroids are preferred Mesalamine and sulfasalazine are used for remission	Colonoscopy with biopsy
Hyperthyroidism	+	-	+	-				Excessive sweating Heat intolerance Increased bowel movements	Lump in the neck Proptosis Tremors Increased DTR		Carbimazole and methimazole Beta blockers like propylthiouracil Iodine-131	TSH with T3 and T4
VIPoma	+	-	+	-				Watery diarrhea Dehydration (thirst, dry skin, dry mouth, tiredness, headaches, and dizziness) Lethargy, muscle weakness Nausea, vomiting Crampy abdominal pain Weight loss Flushing	Tachycardia Rash Facial flushing Abdominal distention Abdominal tenderness in the right upper abdominal quadrant		Sandostatin or chemotherapy for malignant tumors Surgical removal of the tumor	Elevated VIP levels Followed by imaging
Irritable bowel syndrome	+	-	-	-				Abdominal pain or discomfort recurring at least 3 days per month in the past 3 months and associated with 2 or more of the following: Improves with defecation Onset associated with change in frequency of stool Onset associated with change in appearance of stool 25% of bowel movements are loose stools History of straining is also common	Abdominal tenderness Hard stool in the rectal vault		High dietary fiber Osmotic laxatives such as polyethylene glycol, sorbitol, and lactulose Antispasmodic drugs (e.g. anticholinergics such as hyoscyamine or dicyclomine)	Clinical diagnosis ROME III criteria Pharmacologic studies based criteria
lactose intolerance	-	+	-	+				Bloating, Flatulence Abdominal pain, and/or chronic diarrhea after ingestion of lactose	Abdominal tenderness when palpated in severe disease Fever Hypotension Tachycardia Nausea and vomiting		Restriction of lactose and maintain calcium and vitamin D intake.	Lactose breath hydrogen test
Whipple disease	-	+	-	+				Arthralgias Weight loss Diarrhea Abdominal pain	Leukocytopenia Thrombocytopenia Skin hyperpigmentation		Doxycycline and hydroxychloroquine are bactericidal	Upper endoscopy with biopsies of the small intestine for T. whipplei testing (histology with PAS staining, polymerase chain reaction [[[PCR]]] testing, and immunohistochemistry)

(solute-linked carrier family 26 member A3)