{"version":"1.0.0","segments":[{"startTime":1.177,"endTime":3.305,"body":"♪ (music) ♪"},{"startTime":3.305,"endTime":5.589,"body":"(Cathy) Hi, welcome to \u003ci\u003eHarrison's Podclass\u003c/i\u003e"},{"startTime":5.589,"endTime":8.56,"body":"where we discuss important concepts"},{"startTime":5.589,"endTime":8.56,"body":"in internal medicine."},{"startTime":8.56,"endTime":10.794,"body":"- I'm Cathy Handy."},{"startTime":8.56,"endTime":10.794,"body":"- (Charlie) And I'm Charlie Wiener,"},{"startTime":10.794,"endTime":13.858,"body":"and we're coming to you"},{"startTime":10.794,"endTime":13.858,"body":"from the Johns Hopkins School of Medicine."},{"speaker":"Welcome to Episode 24","startTime":15.765,"endTime":19.817,"body":"A 24-Year-Old with Abdominal Pain."},{"speaker":"Here's the question","startTime":21.3,"endTime":24.132,"body":"A 24-year-old woman is evaluated"},{"speaker":"Here's the question","startTime":21.3,"endTime":24.132,"body":"by her primary care physician"},{"speaker":"Here's the question","startTime":24.132,"endTime":26.516,"body":"for diffuse crampy abdominal pain."},{"speaker":"Here's the question","startTime":26.516,"endTime":28.508,"body":"Let's do things"},{"speaker":"Here's the question","startTime":26.516,"endTime":28.508,"body":"a little different today, Cathy."},{"speaker":"Here's the question","startTime":28.508,"endTime":29.882,"body":"What else do you want to know?"},{"speaker":"Here's the question","startTime":29.882,"endTime":31.745,"body":"(Cathy) What's the timing of her symptoms?"},{"speaker":"Here's the question","startTime":31.745,"endTime":34.88,"body":"(Charlie) She reports that she's had"},{"speaker":"Here's the question","startTime":31.745,"endTime":34.88,"body":"abdominal pain for the last several years,"},{"speaker":"Here's the question","startTime":34.88,"endTime":37.176,"body":"but it's been getting worse"},{"speaker":"Here's the question","startTime":34.88,"endTime":37.176,"body":"over the past couple months."},{"speaker":"Here's the question","startTime":37.176,"endTime":40.378,"body":"(Cathy) Any associated nausea,"},{"speaker":"Here's the question","startTime":37.176,"endTime":40.378,"body":"vomiting or diarrhea?"},{"speaker":"Here's the question","startTime":40.378,"endTime":44.26,"body":"(Charlie) Recently, she's been having"},{"speaker":"Here's the question","startTime":40.378,"endTime":44.26,"body":"intermittent diarrhea without flatulence."},{"speaker":"Here's the question","startTime":44.26,"endTime":46.537,"body":"(Cathy) Alright, well, tell me more"},{"speaker":"Here's the question","startTime":44.26,"endTime":46.537,"body":"about the diarrhea--"},{"speaker":"Here's the question","startTime":46.537,"endTime":49.575,"body":"how many stools is she having each day?"},{"speaker":"Here's the question","startTime":46.537,"endTime":49.575,"body":"What's the quality?"},{"speaker":"Here's the question","startTime":49.575,"endTime":51.585,"body":"Is there anything"},{"speaker":"Here's the question","startTime":49.575,"endTime":51.585,"body":"that makes it better or worse?"},{"speaker":"Here's the question","startTime":51.585,"endTime":53.692,"body":"Is she waking up in the middle"},{"speaker":"Here's the question","startTime":51.585,"endTime":53.692,"body":"of the night with diarrhea,"},{"speaker":"Here's the question","startTime":53.692,"endTime":56.048,"body":"or is it more only after eating?"},{"speaker":"Here's the question","startTime":56.048,"endTime":59.227,"body":"(Charlie) She notes that she has"},{"speaker":"Here's the question","startTime":56.048,"endTime":59.227,"body":"approximately two to three stools a day,"},{"speaker":"Here's the question","startTime":59.227,"endTime":61.381,"body":"and they are loose but not liquid."},{"speaker":"Here's the question","startTime":61.381,"endTime":63.734,"body":"The need to go to the bathroom"},{"speaker":"Here's the question","startTime":61.381,"endTime":63.734,"body":"does not waken her at night,"},{"speaker":"Here's the question","startTime":63.734,"endTime":66.388,"body":"she is not having any nocturnal episodes."},{"speaker":"Here's the question","startTime":66.388,"endTime":68.001,"body":"Her stools do have some form,"},{"speaker":"Here's the question","startTime":68.001,"endTime":70.764,"body":"but they don't float,"},{"speaker":"Here's the question","startTime":68.001,"endTime":70.764,"body":"and they're not hard to flush."},{"speaker":"Here's the question","startTime":70.764,"endTime":73.744,"body":"She has not noticed any worsening"},{"speaker":"Here's the question","startTime":70.764,"endTime":73.744,"body":"with specific foods."},{"speaker":"Here's the question","startTime":73.744,"endTime":74.766,"body":"(Cathy) Any blood?"},{"speaker":"Here's the question","startTime":74.766,"endTime":75.812,"body":"(Charlie) No blood."},{"speaker":"Here's the question","startTime":75.812,"endTime":79.482,"body":"(Cathy) Any other systemic symptoms"},{"speaker":"Here's the question","startTime":75.812,"endTime":79.482,"body":"and that includes any VTEC symptoms,"},{"speaker":"Here's the question","startTime":79.482,"endTime":82.395,"body":"like fever, night sweats,"},{"speaker":"Here's the question","startTime":79.482,"endTime":82.395,"body":"or any weight loss?"},{"speaker":"Here's the question","startTime":82.395,"endTime":85.072,"body":"(Charlie) She does have an occasional"},{"speaker":"Here's the question","startTime":82.395,"endTime":85.072,"body":"itchy rash on her knees;"},{"speaker":"Here's the question","startTime":85.072,"endTime":86.743,"body":"that's the only other positive finding."},{"speaker":"Here's the question","startTime":86.743,"endTime":88.864,"body":"She has not had any fever or night sweats,"},{"speaker":"Here's the question","startTime":88.864,"endTime":92.156,"body":"but she has had about a 10-pound"},{"speaker":"Here's the question","startTime":88.864,"endTime":92.156,"body":"of not deliberate weight loss"},{"speaker":"Here's the question","startTime":92.156,"endTime":93.529,"body":"over the past year."},{"speaker":"Here's the question","startTime":93.529,"endTime":95.831,"body":"(Cathy) Anything relevant"},{"speaker":"Here's the question","startTime":93.529,"endTime":95.831,"body":"from her past medical history,"},{"speaker":"Here's the question","startTime":95.831,"endTime":97.849,"body":"or her social or family history?"},{"speaker":"Here's the question","startTime":97.849,"endTime":99.387,"body":"(Charlie) Other than"},{"speaker":"Here's the question","startTime":97.849,"endTime":99.387,"body":"these abdominal complaints,"},{"speaker":"Here's the question","startTime":99.387,"endTime":102.83,"body":"she has no other complaints"},{"speaker":"Here's the question","startTime":99.387,"endTime":102.83,"body":"and she takes no medications."},{"speaker":"Here's the question","startTime":102.83,"endTime":104.317,"body":"(Cathy) Okay, so we have a young woman"},{"speaker":"Here's the question","startTime":104.317,"endTime":106.495,"body":"with diffuse crampy"},{"speaker":"Here's the question","startTime":104.317,"endTime":106.495,"body":"abdominal pain for years"},{"speaker":"Here's the question","startTime":106.495,"endTime":107.943,"body":"that's now getting worse,"},{"speaker":"Here's the question","startTime":107.943,"endTime":110.583,"body":"and it's also now associated"},{"speaker":"Here's the question","startTime":107.943,"endTime":110.583,"body":"with diarrhea, rash,"},{"speaker":"Here's the question","startTime":110.583,"endTime":113.176,"body":"but most importantly"},{"speaker":"Here's the question","startTime":110.583,"endTime":113.176,"body":"10 pounds of weight loss."},{"speaker":"Here's the question","startTime":113.176,"endTime":116.075,"body":"So, I'm concerned that she may have"},{"speaker":"Here's the question","startTime":113.176,"endTime":116.075,"body":"a malabsorption syndrome."},{"speaker":"Here's the question","startTime":116.075,"endTime":117.293,"body":"(Charlie) Why do you say that?"},{"speaker":"Here's the question","startTime":117.293,"endTime":119.584,"body":"(Cathy) It doesn't sound like"},{"speaker":"Here's the question","startTime":117.293,"endTime":119.584,"body":"she has a secretory diarrhea"},{"speaker":"Here's the question","startTime":119.584,"endTime":123.064,"body":"because we only hear that she has"},{"speaker":"Here's the question","startTime":119.584,"endTime":123.064,"body":"two to three semi-formed stools per day"},{"speaker":"Here's the question","startTime":123.064,"endTime":125.493,"body":"and she doesn't have"},{"speaker":"Here's the question","startTime":123.064,"endTime":125.493,"body":"any nocturnal symptoms."},{"speaker":"Here's the question","startTime":125.493,"endTime":128.852,"body":"Secretory diarrheas will typically"},{"speaker":"Here's the question","startTime":125.493,"endTime":128.852,"body":"also occur at night."},{"speaker":"Here's the question","startTime":128.852,"endTime":131.215,"body":"What we do hear is"},{"speaker":"Here's the question","startTime":128.852,"endTime":131.215,"body":"it sounds like her episodes"},{"speaker":"Here's the question","startTime":131.215,"endTime":133.362,"body":"may be related to eating"},{"speaker":"Here's the question","startTime":131.215,"endTime":133.362,"body":"throughout the day,"},{"speaker":"Here's the question","startTime":133.362,"endTime":135.68,"body":"but it doesn't sound like"},{"speaker":"Here's the question","startTime":133.362,"endTime":135.68,"body":"an inflammatory diarrhea"},{"speaker":"Here's the question","startTime":135.68,"endTime":137.64,"body":"with no fever or no blood."},{"speaker":"Here's the question","startTime":137.64,"endTime":139.889,"body":"And while this could be"},{"speaker":"Here's the question","startTime":137.64,"endTime":139.889,"body":"irritable bowel syndrome,"},{"speaker":"Here's the question","startTime":139.889,"endTime":142.207,"body":"I'm worried about"},{"speaker":"Here's the question","startTime":139.889,"endTime":142.207,"body":"the weight loss and the rash."},{"speaker":"Here's the question","startTime":142.207,"endTime":143.464,"body":"This also doesn't sound like"},{"speaker":"Here's the question","startTime":143.464,"endTime":146.094,"body":"a pancreatic insufficiency"},{"speaker":"Here's the question","startTime":143.464,"endTime":146.094,"body":"malabsorption syndrome"},{"speaker":"Here's the question","startTime":146.094,"endTime":148.737,"body":"because she's not having any fatty stools."},{"speaker":"Here's the question","startTime":148.737,"endTime":151.108,"body":"(Charlie) Okay, so the question now asks,"},{"speaker":"Here's the question","startTime":151.108,"endTime":153.806,"body":"which of the following"},{"speaker":"Here's the question","startTime":151.108,"endTime":153.806,"body":"is the most appropriate recommendation"},{"speaker":"Here's the question","startTime":153.806,"endTime":155.743,"body":"at this point for this patient?"},{"speaker":"Here's the question","startTime":155.743,"endTime":159.619,"body":"Option A says,"},{"speaker":"Here's the question","startTime":155.743,"endTime":159.619,"body":"increase her dietary fiber intake."},{"speaker":"Here's the question","startTime":159.619,"endTime":164.094,"body":"Option B says, measurement of"},{"speaker":"Here's the question","startTime":159.619,"endTime":164.094,"body":"an anti-endomysial antibody."},{"speaker":"Here's the question","startTime":164.094,"endTime":168.273,"body":"Option C says, measurement of"},{"speaker":"Here's the question","startTime":164.094,"endTime":168.273,"body":"24-hour fecal fat."},{"speaker":"Here's the question","startTime":168.273,"endTime":172.272,"body":"Option D is, referral"},{"speaker":"Here's the question","startTime":168.273,"endTime":172.272,"body":"to gastroenterology for endoscopy."},{"speaker":"Here's the question","startTime":172.272,"endTime":175.482,"body":"Or Option E is,"},{"speaker":"Here's the question","startTime":172.272,"endTime":175.482,"body":"trial of a lactose-free diet"},{"speaker":"Here's the question","startTime":175.482,"endTime":177.772,"body":"(Cathy) There are a few I don't think"},{"speaker":"Here's the question","startTime":175.482,"endTime":177.772,"body":"we should do right now."},{"speaker":"Here's the question","startTime":177.772,"endTime":180.222,"body":"So, usually patients"},{"speaker":"Here's the question","startTime":177.772,"endTime":180.222,"body":"with lactose intolerance"},{"speaker":"Here's the question","startTime":180.222,"endTime":182.905,"body":"can relate symptoms to consumption"},{"speaker":"Here's the question","startTime":180.222,"endTime":182.905,"body":"of milk-based products,"},{"speaker":"Here's the question","startTime":182.905,"endTime":186.723,"body":"and they'll also report a strong history"},{"speaker":"Here's the question","startTime":182.905,"endTime":186.723,"body":"of crampy pain and flatulence."},{"speaker":"Here's the question","startTime":186.723,"endTime":189.627,"body":"My sister actually called me"},{"speaker":"Here's the question","startTime":186.723,"endTime":189.627,"body":"with this once and said that"},{"speaker":"Here's the question","startTime":189.627,"endTime":192.085,"body":"she was only getting symptoms"},{"speaker":"Here's the question","startTime":189.627,"endTime":192.085,"body":"after she had hot chocolate"},{"speaker":"Here's the question","startTime":192.085,"endTime":193.488,"body":"from her favorite coffee shop,"},{"speaker":"Here's the question","startTime":193.488,"endTime":196.204,"body":"which turned out"},{"speaker":"Here's the question","startTime":193.488,"endTime":196.204,"body":"was almost entirely made of milk."},{"speaker":"Here's the question","startTime":196.204,"endTime":198.095,"body":"Or it only happened"},{"speaker":"Here's the question","startTime":196.204,"endTime":198.095,"body":"when she ate ice cream."},{"speaker":"Here's the question","startTime":198.095,"endTime":202.204,"body":"So, obviously two triggers in that case"},{"speaker":"Here's the question","startTime":198.095,"endTime":202.204,"body":"and you can usually identify those."},{"speaker":"Here's the question","startTime":202.204,"endTime":204.47,"body":"(Charie) So, I assume you told your sister"},{"speaker":"Here's the question","startTime":202.204,"endTime":204.47,"body":"to stop drinking milk?"},{"speaker":"Here's the question","startTime":204.47,"endTime":206.937,"body":"(Cathy) I did and all of"},{"speaker":"Here's the question","startTime":204.47,"endTime":206.937,"body":"her symptoms resolved."},{"speaker":"Here's the question","startTime":206.937,"endTime":209.387,"body":"(Charlie) Which of the other options"},{"speaker":"Here's the question","startTime":206.937,"endTime":209.387,"body":"are not top on your list?"},{"speaker":"Here's the question","startTime":209.387,"endTime":212.504,"body":"(Cathy) Measuring fecal fat also probably"},{"speaker":"Here's the question","startTime":209.387,"endTime":212.504,"body":"won't be helpful in this case,"},{"speaker":"Here's the question","startTime":212.504,"endTime":215.838,"body":"so, as I said before, her diarrhea"},{"speaker":"Here's the question","startTime":212.504,"endTime":215.838,"body":"doesn't sound like steatorrhea"},{"speaker":"Here's the question","startTime":215.838,"endTime":217.573,"body":"and there's no nocturnal diarrhea,"},{"speaker":"Here's the question","startTime":217.573,"endTime":220.092,"body":"so, that would eliminate Option C."},{"speaker":"Here's the question","startTime":220.092,"endTime":223.215,"body":"And then going to Option A--"},{"speaker":"Here's the question","startTime":220.092,"endTime":223.215,"body":"increasing fiber intake--"},{"speaker":"Here's the question","startTime":223.215,"endTime":225.925,"body":"is usually for patients"},{"speaker":"Here's the question","startTime":223.215,"endTime":225.925,"body":"with irritable bowel syndrome,"},{"speaker":"Here's the question","startTime":225.925,"endTime":227.319,"body":"but with her weight loss and rash,"},{"speaker":"Here's the question","startTime":227.319,"endTime":230.287,"body":"I think that this would be"},{"speaker":"Here's the question","startTime":227.319,"endTime":230.287,"body":"a diagnosis of exclusion."},{"speaker":"Here's the question","startTime":230.287,"endTime":234.344,"body":"(Charlie) Option B asks about measurement"},{"speaker":"Here's the question","startTime":230.287,"endTime":234.344,"body":"of anti-endomysial antibodies--"},{"speaker":"Here's the question","startTime":234.344,"endTime":235.343,"body":"what is that?"},{"speaker":"Here's the question","startTime":235.343,"endTime":237.32,"body":"(Cathy) So, that's part of"},{"speaker":"Here's the question","startTime":235.343,"endTime":237.32,"body":"the diagnostic evaluation"},{"speaker":"Here's the question","startTime":237.32,"endTime":240.65,"body":"for suspected celiac disease"},{"speaker":"Here's the question","startTime":237.32,"endTime":240.65,"body":"or gluten enteropathy,"},{"speaker":"Here's the question","startTime":240.65,"endTime":243.019,"body":"and that's actually"},{"speaker":"Here's the question","startTime":240.65,"endTime":243.019,"body":"a good possibility in her case."},{"speaker":"Here's the question","startTime":243.019,"endTime":246.373,"body":"I'd probably start there,"},{"speaker":"Here's the question","startTime":243.019,"endTime":246.373,"body":"even before a referral for endoscopy"},{"speaker":"Here's the question","startTime":246.373,"endTime":249.995,"body":"because her symptoms of abdominal pain,"},{"speaker":"Here's the question","startTime":246.373,"endTime":249.995,"body":"rash, diarrhea, and weight loss"},{"speaker":"Here's the question","startTime":249.995,"endTime":252.038,"body":"are consistent with celiac disease."},{"speaker":"Here's the question","startTime":252.038,"endTime":255.048,"body":"Sometimes you see fatty diarrhea,"},{"speaker":"Here's the question","startTime":252.038,"endTime":255.048,"body":"but often not,"},{"speaker":"Here's the question","startTime":255.048,"endTime":257.55,"body":"and dermatitis herpetiformis"},{"speaker":"Here's the question","startTime":255.048,"endTime":257.55,"body":"is a classic rash"},{"speaker":"Here's the question","startTime":257.55,"endTime":259.59,"body":"that's associated with celiac disease"},{"speaker":"Here's the question","startTime":259.59,"endTime":262.449,"body":"and can be severe"},{"speaker":"Here's the question","startTime":259.59,"endTime":262.449,"body":"and may be what she's experiencing."},{"speaker":"Here's the question","startTime":262.449,"endTime":265.057,"body":"(Charlie) So, Option B"},{"speaker":"Here's the question","startTime":262.449,"endTime":265.057,"body":"is the correct answer."},{"speaker":"Here's the question","startTime":265.057,"endTime":270.099,"body":"Is the positive anti-endomysial"},{"speaker":"Here's the question","startTime":265.057,"endTime":270.099,"body":"antibody diagnostic for celiac disease?"},{"speaker":"Here's the question","startTime":270.099,"endTime":273.332,"body":"(Cathy) Well, it's a good test;"},{"speaker":"Here's the question","startTime":270.099,"endTime":273.332,"body":"the sensitivity and specificity are high"},{"speaker":"Here's the question","startTime":273.332,"endTime":275.001,"body":"in the 90% range,"},{"speaker":"Here's the question","startTime":275.001,"endTime":278.299,"body":"so that makes it a reasonable first test"},{"speaker":"Here's the question","startTime":275.001,"endTime":278.299,"body":"in symptomatic patients."},{"speaker":"Here's the question","startTime":278.299,"endTime":280.302,"body":"The other test that's commonly used"},{"speaker":"Here's the question","startTime":280.302,"endTime":283.754,"body":"is immunoglobulin A"},{"speaker":"Here's the question","startTime":280.302,"endTime":283.754,"body":"anti-tissue transglutaminase,"},{"speaker":"Here's the question","startTime":283.754,"endTime":286.11,"body":"or the IgA for tTG antibody,"},{"speaker":"Here's the question","startTime":286.11,"endTime":289.906,"body":"and that's also a very good serologic test"},{"speaker":"Here's the question","startTime":286.11,"endTime":289.906,"body":"and actually the preferred initial testing"},{"speaker":"Here's the question","startTime":289.906,"endTime":291.87,"body":"for diagnosis of celiac disease."},{"speaker":"Here's the question","startTime":291.87,"endTime":296.23,"body":"And that has a sensitivity and specificity"},{"speaker":"Here's the question","startTime":291.87,"endTime":296.23,"body":"around the 95%."},{"speaker":"Here's the question","startTime":296.23,"endTime":299.006,"body":"These tests have to be done"},{"speaker":"Here's the question","startTime":296.23,"endTime":299.006,"body":"while on a gluten-rich diet"},{"speaker":"Here's the question","startTime":299.006,"endTime":301.614,"body":"because they can change"},{"speaker":"Here's the question","startTime":299.006,"endTime":301.614,"body":"on a gluten-free diet."},{"speaker":"Here's the question","startTime":301.614,"endTime":304.647,"body":"But just the presence"},{"speaker":"Here's the question","startTime":301.614,"endTime":304.647,"body":"of either antibody is not diagnostic"},{"speaker":"Here's the question","startTime":304.647,"endTime":307.265,"body":"and usually duodenal biopsy"},{"speaker":"Here's the question","startTime":304.647,"endTime":307.265,"body":"is recommended."},{"speaker":"Here's the question","startTime":307.265,"endTime":309.963,"body":"So, referral to GI"},{"speaker":"Here's the question","startTime":307.265,"endTime":309.963,"body":"would be in the pathway."},{"speaker":"Here's the question","startTime":309.963,"endTime":312.976,"body":"(Charlie) So, eventually,"},{"speaker":"Here's the question","startTime":309.963,"endTime":312.976,"body":"we will likely refer this patient"},{"speaker":"Here's the question","startTime":312.976,"endTime":315.251,"body":"to a gastroenterologist for endoscopy."},{"speaker":"Here's the question","startTime":315.251,"endTime":317.928,"body":"What would you expect to find"},{"speaker":"Here's the question","startTime":315.251,"endTime":317.928,"body":"in a duodenal biopsy?"},{"speaker":"Here's the question","startTime":317.928,"endTime":320.76,"body":"(Cathy) Typically, in celiac disease"},{"speaker":"Here's the question","startTime":317.928,"endTime":320.76,"body":"there is villous atrophy,"},{"speaker":"Here's the question","startTime":320.76,"endTime":322.294,"body":"absent or reduced tight villi"},{"speaker":"Here's the question","startTime":322.294,"endTime":325.299,"body":"and cuboidal appearance"},{"speaker":"Here's the question","startTime":322.294,"endTime":325.299,"body":"of the surface epithelial cells."},{"speaker":"Here's the question","startTime":325.299,"endTime":329.527,"body":"Also, you'll find increased lymphocytes"},{"speaker":"Here's the question","startTime":325.299,"endTime":329.527,"body":"and plasma cells in the lamina propria."},{"speaker":"Here's the question","startTime":329.527,"endTime":332.913,"body":"But these can also go away"},{"speaker":"Here's the question","startTime":329.527,"endTime":332.913,"body":"with removal of gluten from the diet."},{"speaker":"Here's the question","startTime":332.913,"endTime":335.328,"body":"(Charlie) So, the teaching point"},{"speaker":"Here's the question","startTime":332.913,"endTime":335.328,"body":"in this case is that in a patient"},{"speaker":"Here's the question","startTime":335.328,"endTime":340.414,"body":"with long-term abdominal complaints"},{"speaker":"Here's the question","startTime":335.328,"endTime":340.414,"body":"and notably, weight loss and skin findings"},{"speaker":"Here's the question","startTime":340.414,"endTime":344.907,"body":"be suspicious of the diagnosis"},{"speaker":"Here's the question","startTime":340.414,"endTime":344.907,"body":"of celiac disease or gluten enteropathy."},{"speaker":"Here's the question","startTime":344.907,"endTime":349.177,"body":"Your diagnostic workup can start with"},{"speaker":"Here's the question","startTime":344.907,"endTime":349.177,"body":"measurement of serum autoantibodies"},{"speaker":"Here's the question","startTime":349.177,"endTime":352.403,"body":"but eventually will likely"},{"speaker":"Here's the question","startTime":349.177,"endTime":352.403,"body":"lead to referral to a gastroenterologist"},{"speaker":"Here's the question","startTime":352.403,"endTime":354.394,"body":"for a duodenal biopsy."},{"speaker":"Here's the question","startTime":354.394,"endTime":357.289,"body":"(Cathy) To read more about this,"},{"speaker":"Here's the question","startTime":354.394,"endTime":357.289,"body":"you can check out \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"Here's the question","startTime":357.289,"endTime":359.942,"body":"on Disorders"},{"speaker":"Here's the question","startTime":357.289,"endTime":359.942,"body":"of the Gastrointestinal System,"},{"speaker":"Here's the question","startTime":359.942,"endTime":363.926,"body":"and also you can check out"},{"speaker":"Here's the question","startTime":359.942,"endTime":363.926,"body":"the latest guideline from 2013,"},{"speaker":"Here's the question","startTime":363.926,"endTime":366.099,"body":"from the American College"},{"speaker":"Here's the question","startTime":363.926,"endTime":366.099,"body":"of Gastroenterology,"},{"speaker":"Here's the question","startTime":366.099,"endTime":369.091,"body":"on the diagnosis and management"},{"speaker":"Here's the question","startTime":366.099,"endTime":369.091,"body":"of celiac disease."},{"speaker":"Here's the question","startTime":369.091,"endTime":371.749,"body":"♪ (music) ♪"}]}