Villous Atrophy in a Patient with Chronic Mesenteric Ischemia: Celiac Disease or Ischemic Enteropathy? A Case Report

Abstract

Background: Duodenal villous atrophy in a patient with chronic mesenteric ischaemia presents a diagnostic challenge because vascular insufficiency and enteropathy may produce overlapping gastrointestinal manifestations. Case Presentation: We describe a 43-year-old man with chronic diarrhoea and low body weight since childhood, whose digestive symptoms worsened with abdominal pain and undernutrition. CT angiography and selective arteriography identified severe involvement of the coeliac trunk and complete ostial occlusion of the superior mesenteric artery. Aorto-superior mesenteric and aorto-coeliac revascularisation procedures were performed in March 2026. Duodenal biopsies obtained in July 2026 demonstrated subtotal villous atrophy (Marsh 3b) and 40% intraepithelial lymphocytosis. Anti-gliadin IgA was 62.2 U/mL, and IgG exceeded 100 U/mL, with a positivity threshold of 12 U/mL. Clinical improvement was reported following the introduction of a gluten-free diet. Nevertheless, specific coeliac serological results, total IgA measurement, HLA-DQ2/DQ8 typing and follow-up duodenal histology were not documented. Discussion: The histological abnormalities and reported dietary response raise the possibility of an associated coeliac-like enteropathy, while the severe mesenteric arterial disease and surgically observed intestinal distress support a vascular contribution. Conclusion: The available evidence cannot establish the relative contributions of these mechanisms or confirm coeliac disease. This case illustrates the importance of recognising diagnostic uncertainty when villous atrophy and chronic mesenteric ischaemia coexist.