{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 11, Ep 1 of 1: Small Bowel Mucosal","html":"","width":"100%","height":180,"duration":1074,"description":"What to think about when a small-bowel biopsy shows enteropathy and celiac has already been excluded on a gluten-containing diet. Walks the non-celiac differential mechanistically: wheat-related symptom syndromes, autoimmune enteropathy, Whipple disease, drug-induced enteropathies, checkpoint inhibitor enteritis, bacterial overgrowth, and tropical sprue. The histology, the medication list, and the exposure history read in parallel resolve the fork.\n \nTopics covered\n\nNon-celiac gluten sensitivity and FODMAPs\nIgE-mediated wheat allergy\nAutoimmune enteropathy and IPEX\nWhipple disease\nDrug-induced enteropathy (olmesartan, NSAID)\nCheckpoint inhibitor enteritis\nSmall intestinal bacterial overgrowth\nTropical sprue\n \n \nKey decisions\n\nCeliac must be excluded on a gluten-containing diet first; a gluten-free patient needs a gluten challenge or HLA testing, where a negative haplotype excludes celiac.\nVillous atrophy with depleted goblet and Paneth cells plus deep crypt apoptosis in a celiac-negative diet-failure points to autoimmune enteropathy; test anti-enterocyte antibodies and treat with open-capsule budesonide.\nWhipple is diagnosed on distal duodenal/jejunal biopsy showing foamy PAS-positive macrophages that are acid-fast-negative; treat with IV ceftriaxone then a year of oral trimethoprim-sulfamethoxazole for CNS coverage.\nOlder patient on olmesartan with severe diarrhea, weight loss, negative celiac serology, and villous atrophy: stop the drug, not start a gluten-free diet or steroids.\nCheckpoint inhibitor enteritis: hold the drug, rule out infection including C. diff and CMV, start steroids ~1 mg/kg, escalate to infliximab or vedolizumab if refractory within a few days.\nSIBO gives low B12 with high folate; diagnose by breath testing (rise of at least 20 ppm within 90 minutes) and treat with rifaximin plus correcting the cause; tropical sprue gives combined low folate AND B12 and is treated with tetracycline plus folate.\n \n \nThis is an AI-generated podcast, and some...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}