A 12-month-old infant is evaluated for failure to thrive, pale bulky foul-smelling stools, and marked abdominal distension following the introduction of wheat cereals into his diet. Serum anti-tissue transglutaminase (anti-tTG) IgA antibodies are strongly positive. What is the underlying pathology in celiac disease?

Answer and explanation

Correct answer: A. Immune-mediated enteropathy from gluten

  1. Step 1: Correlate clinical picture: Introduction of gluten-containing grains (wheat, barley, rye) precipitating malabsorptive steatorrhea, distension, and growth faltering.
  2. Step 2: Analyze serology: High-titer anti-tissue transglutaminase (anti-tTG) IgA and endomysial antibodies.
  3. Step 3: Define histology: Immune-mediated enteropathy of the duodenum/jejunum showing intraepithelial lymphocytosis, crypt hyperplasia, and blunting/loss of villi (villous atrophy).
Answer
Immune-mediated enteropathy triggered by dietary gluten, resulting in small intestinal villous atrophy and crypt hyperplasia.
Why not the others: 'Bacterial overgrowth', 'exocrine pancreatic enzyme absence' and 'gastric parietal cell destruction' cause other malabsorption patterns; positive anti-tTG IgA with villous atrophy defines gluten-triggered enteropathy.

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