Dysphagia as the Sole Initial Presentation of Celiac Disease

Abstract

A 33-year-old Caucasian woman presented with 3 months of dysphagia to solids. She had “tightness” in her chest with eating bananas. She reported no weight loss, abdominal pain, or diarrhea. She had no heartburn symptoms. She also did not have any allergic rhinitis symptoms. There was no family history of eosinophilic esophagitis, inflammatory bowel disease, upper gastrointestinal cancers, or celiac disease. Due to her persistent dysphagia, an esophagogastroduodenoscopy (EGD) was performed revealing mild bulbar duodenitis, and scalloping in the 2nd and 3rd portions of the duodenum (Fig. 1, Fig. 2). Biopsies were taken from her mid esophagus, distal esophagus, stomach antrum, and 2nd and 3rd portions of the duodenum. Labs revealed a tissue transglutaminase IgA of >100 units. Serum IgA, vitamin A, folic acid, Vitamin B12, Vitamin D, thyroid stimulating hormone, iron studies, complete blood count, complete metabolic panel, and Helicobacter pylori IgG antibody were all within normal limits.Figure 1Figure 2Biopsies revealed no abnormalities in the mid esophagus, mild reflux esophagitis in the distal esophagus, mild gastritis with no evidence of H. pylori in the stomach antrum, and moderate to severe villous blunting and increased intraepithelial lymphocytosis consistent with Marsh 3 celiac disease in the 2nd and 3rd portions of the duodenum. Her esophagus was empirically dilated and dysphagia persisted post dilation. The patient was started on a gluten-free diet and three months later her dysphagia resolved. Follow-up tissue transglutaminase IgA at the time of resolution of the dysphagia was undetectable indicating resolution of the celiac disease. To the best of our knowledge, this case represents the first reported case of dysphagia as initial and sole presentation of celiac disease completely resolved by gluten-free diet. This patient did not have evidence of eosinophillic esophagitis, Plummer-Vinson Syndrome, or any other culprit for her dysphagia. She also did not complain of any other typical celiac disease symptoms, such as abdominal pain and discomfort, bloating, diarrhea, constipation, and irritable bowel-like symptoms. Laboratory testing of elevated tissue transglutaminase IgA level, followed by gluten-free diet with subsequent resolution of symptoms and normalization of tissue transglutaminase IgA confirmed the patient's celiac disease course. Celiac disease is a diagnostic consideration in the evaluation of unexplained dysphagia. In patients presenting with solid food dysphagia, EGD remains the exam of choice. Whether celiac disease should be routinely excluded in patients presenting with dysphagia warrants further study.