1. Celiac
Disease:
Case
Study
Mia
Matthews
MNT-­‐
Fall
2015
October
2nd
,
2015
“I
have
not
given,
received
or
used
any
unauthorized
assistance
on
this
assignment”

2. Case
Study
Two
Celiac
Disease
FSHN
450
Due
Date:
10/2/15
Patient
BR
is
a
22
year
Caucasian
old
female
referred
to
the
gastroenterology
clinic
for
C/O
diarrhea,
abdominal
distention,
an
itchy
rash,
occasional
joint
pain
and
unexplained
weight
loss.
Patient
reports
that
cramping
and
distention
occur
about
2
hours
after
eating
certain
foods.
Blood
tests
ordered
showed
the
patient
was
positive
for
IgA-­‐tissue
transglutaminase
and
IgA
anti-­‐endomesial
antibodies.
Treatment
plan
:
Gluten-­‐free
diet
and
nutrition
consult
and
small
intestinal
biopsy
ordered
Ht
5’5”
Wt
112
“
Patient
reports
weight
loss
of
10
pounds
in
past
6
months.
Occupation:
commercial
artist
Family
history:
father
positive
for
type
1
diabetes,
mother
has
asthma.
No
history
GI
disorders
in
patient
or
family.
Laboratory:
Hematocrit
32.1
%
Sodium
140
mEq/L
Hemoglobin
10.8
%
Potassium
3.8
mEq/L
RBC–
4
x
1012
/L
Chloride
102
mEq/L
WBC
5
x
109
/L
BUN
10
mg/dl
MCV
101
(um3)
Creatinine
0.6
mg/dl
Serum
albumin
3.8g/dl
Total
Billirubin
0.2
mg/dl
Glucose
(fasting)
80
mg/dl
GGT
18
U/L
Cholesterol
115
mg/dl
ALT
12
U/L
Ferritin
18
mg/dl
AST
10
U/L
Transferrin
398
mg/dl
24
hours
Diet
History:
Breakfast
¾
cup
orange
juice
¾
cup
corn
flakes
½
cup
2%
milk
12
oz
Coffee
with
1
tsp
sugar
Lunch
4
oz
sliced
ham
on
two
slices
white
toast
with
1
leaf
lettuce
and
1
slice
tomato
3
oz
potato
chips
1
slice
watermelon
Iced
tea
with
2
tsp
sugar
Dinner
4
oz
baked
salmon
with
lemon
butter
½
c
buttered
peas
½
cup
fresh
fruit
salad
1
small
baked
potato
with
2
TBSP
sour
cream
2
chocolate
brownies

3. Diet
Pepsi
Snack
4
small
chocolate
chip
cookies
1
cup
2%
milk
I.
Answer
the
following
questions:
1.What
is
the
etiology
of
celiac
disease?
Is
there
anything
in
BR’s
history
that
might
indicate
a
food
allergy?
The
etiology
of
celiac
disease
includes:
genetic
susceptibility;
exposure
to
gluten;
an
environmental
trigger
(inflammation,
illness);
an
autoimmune
response.
The
fact
that
BR’s
father
has
type
1
DM,
which
is
an
autoimmune
disorder,
and
mother’s
history
of
asthma
might
indicate
pts.
genetic
susceptibility
to
developing
a
food
allergy.
Also
pts.
C/O
diarrhea,
abdominal
distention,
an
itchy
rash
(dermatitis),
unexplained
weight
loss
(malabsorption)
are
all
signs
and
symptoms
of
a
food
allergy.
2.What
are
anti-­‐endomesial
and
anti
tissue
transglutaminase
antibodies?
Why
are
they
used
for
testing
for
celiac
disease?
Anti
tissue
transglutaminase
antibodies
are
enzymes
that
cause
the
crosslinking
of
certain
proteins
and
anti-­‐endomesial
antibodies detect
antibodies
to
endomysium,
the
thin
connective
tissue
layer
that
covers
individual
muscle
fibers.They
are
autoantibodies
in
the
blood
that
the
body
produces
as
part
of
the
immune
response.
The
immune
response
leads
to
inflammation
of
the
SI
and
damage/destruction
of
villi
that
line
the
intestinal
wall.
Celiac
disease
is
an
autoimmune
disorder
characterized
by
an
inappropriate
immune
response
to
gluten,
so
IgA
antibody
tests
are
used
to
diagnose
the
disorder.
IgA
tests
are
very
specific,
and
if
tests
are
positive,
shows
that
the
immune
system
is
producing
these
antibody
proteins
due
to
perceiving
gluten
as
a
threat,
so
diagnosis
can
be
made.
3.Why
was
a
small
intestinal
biopsy
ordered?
A
small
intestinal
biopsy
was
ordered
because
this
evaluation
is
still
considered
the
gold
standard
and
is
used
to
confirm
diagnosis
of
celiac
disease.
4.
What
effect
does
gluten
have
on
the
small
intestinal
mucosa?
In
celiac
disease,
gluten
activates
an
autoimmune
response
where
the
immune
system
secretes
antibody
proteins.
This
response
leads
to
inflammation
of
small
intestine
and
damage
to
the
villi
in
the
small
intestinal
wall.
When
villi
are
damaged
or
destroyed,
the
body
is
much
less
capable
of
absorbing
nutrients
resulting
in
malabsorption
and
eventual
malnutrition.
5.
Which
symptoms
beside
the
abdominal
cramping
diarrhea
and
weight
loss
are
related
to
celiac
disease?
Why?
BR’s
symptoms
of
an
itchy
rash
and
unintentional
weight
loss
are
both
related
to
celiac
disease
as
well.
Presence
of
an
itchy
rash
(dermatitis)
is
a
symptom
indicative
of
a
food
allergy
and
recent
unintentional
weight
loss
is
a
result
of
malabsorption/malnutrition,
which
is
a
symptom
of
celiac
disease.
6.
What
sources
of
gluten
do
you
see
in
the
patients
24-­‐hour
diet
recall?
What
might
be
some
acceptable
substitutes?
What
are
some
other
potential
sources
of
gluten
exposure
besides
diet?
Sources
of
gluten
in
pts.
24-­‐hour
diet
recall
include:
two
slices
white
toast;
3
oz
potato
chips;
2
chocolate
brownies;
4
small
chocolate
chip
cookies.
Could
substitute
gluten-­‐free
bread,
rice,
gluten-­‐free

4. desserts,
corn,
soy,
etc.
Some
other
potential
sources
besides
diet
include:
cosmetics;
contaminants
in
processed
foods;
binder
in
medications/supplements.
7.
There
is
a
high
prevalence
of
anemia
among
patients
with
celiac
disease.
Why
is
this
the
case?
Which
of
the
patient’s
laboratory
values
are
associated
with
anemia?
This
is
due
to
the
consequence
of
malabsorption/
malnutrition
in
those
with
celiac
disease,
since
the
autoimmune
response
causes
damage
to
the
villi,
which
absorb
nutrients
in
the
SI,
so
iron
deficiency
anemia
can
develop
(due
to
malabsorption
of
iron
and
B
vitamins).
The
pts.
lab
values
associated
with
anemia
include:
Hematocrit
32.1
%;
Hemoglobin
10.8
g/dl;
MCV
101
(um3)
);
RBC–
4
x
1012
/L;
WBC
5
x
109
/L
.
All
low
levels,
which
indicates
presence
of
anemia.
8.
Why
might
this
patient
be
lactose
intolerant?
Pt.
may
be
lactose
intolerant
because
a
nutritional
concern
of
celiac
disease
is
that
secondary
lactose
intolerance
is
common,
which
is
a
temporary
form
of
lactose
intolerance
that
develops
as
a
result
of
the
disease.
This
occurs
due
to
the
damage
of
the
mucosa
(lining
of
the
small
intestine)
as
a
result
of
celiac
disease,
which
decreases
amount
of
brush
border
enzymes,
which
contains
lactase
(the
enzyme
needed
to
breakdown
lactose).
The
decrease
in
lactase
in
the
SI
results
in
temporary
intolerance
due
to
inability
to
breakdown
lactose.
II.
List
each
laboratory
value
in
table
form:
Value
Normal
Range
Patient
Value
Reason
for
Deviation
Hematocrit
34.9-44.5%
32.1%
Low-­‐
Iron
deficiency/
anemia
Hemoglobin
12.0-15.5 g/dl
10.8
g/dl
Low-­‐iron
deficiency/
anemia
RBC
4.2-5.4 million
cells/mcL
4
x
1012
/L
Low-­‐
anemia
WBC
3,200-10,600
cells/mcL
5
x
109
/L
High-­‐
increased
from
immune
response;
inflammation
MCV
75-98 fl
101
(um3)
Low-­‐
microcytic
anemia
Serum
albumin
3.5-5.5 g/dl
3.8g/dl
WNL
Glucose
(fasting)
70-­‐99
mg/dl
80
mg/dl
WNL
Cholesterol
120-199 mg/dl
115
mg/dl
Low-­‐
recent
unintentional
wt.
loss
Ferritin
15-200 ng/ml
18
mg/dl
WNL
Transferrin
170-­‐370
mg/dl
398
mg/dl
High-­‐
low
levels
of
iron
in
body/
anemia
Sodium
135-145 mEq/L
140
mEq/L
WNL
Potassium
3.5-5.0 mEq/L
3.8
mEq/L
WNL
Chloride
95-105 mEq/L
102
mEq/L
WNL
BUN
7-18 mg/dl
10
mg/dl
WNL
Creatinine
0.6-1.2 mg/dl
0.6
mg/dl
WNL
Total
bilirubin
0.3-­‐1.9
mg/dl
0.2
mg/dl
Low-­‐
celiac
disease;
deficiency
in
B
vitamins;
malnutrition

5. GGT
0-­‐51
U/L
18
U/L
WNL
ALT
8-20 U/L
12
U/L
WNL
AST
8-20 U/L
10
U/L
WNL
III.
Conduct
a
nutrition
assessment
of
the
patient
and
report
in
ADIME
format.
Don’t
forget
your
assessed
Kcal
and
protein
needs.
Include
one
PES
statement
in
the
clinical
domain
and
one
PES
statement
in
the
behavioral
domain
and
one
PES
statement
in
the
intake
domain
and
an
intervention
and
evaluation
for
each
one.
Nutrition
Assessment:
• Pt.
C/O
diarrhea,
abdominal
distention,
itchy
rash,
occasional
joint
pain
and
unexplained
weight
loss~
consistent
with
celiac
disease.
• Cramping
and
distention
occur
about
2
hours
after
eating
certain
foods~
issue
in
SI
• Pt.
positive
for
IgA-­‐tissue
transglutaminase
and
IgA
anti-­‐endomesial
antibodies~
screening
indicator
of
disease
• Underweight;
weight
loss
of
10
pounds
in
past
6
months~
due
to
malabsorption/
malnutrition~
consequence
of
disease
• Family
history
(father=
type
1
diabetes;
mother=
asthma)~
genetic
susceptibility
to
food
allergies
• Low
RBC,
Hct,
Hgb,
MCV,
Transferrin,
Total
Bilirubin~
consistent
with
iron
deficiency,
deficiency
of
B
vitamins,
malnutrition/malabsorption~
anemia;
consistent
with
consequences
of
disease
• PRO
needs:
pt.
with
BMI<30:
1.2
g/Kg
actual
BW;
pt=50.8Kg*1.2g=61
g
PRO/day;
Kcal
needs:
pt.
with
unintentional
weight
loss:
25
Kcal/Kg
actual
BW;
pt=50.8Kg*25kcal=
1,270
Kcals/day;
Fluid
needs:
estimates
on
the
basis
of
Kcal
intake:
1ml/1kcal;
pt.=1,270
Kcals/day=1,270ml/day
Nutrition
Diagnosis:
• Unintended
weight
loss
(NC-­‐3.2)
R/T
destruction
of
SI
mucosa
AEB
loss
of
10#
in
past
6
mnths
o Intervention:
Put
pt.
on
strict
gluten-­‐free
diet
to
help
heal
SI
and
increase
absorption
of
nutrients
and
promote
overall
weight
gain
to
IBW
about
125#
o Monitoring/
Evaluation:
Monitor
with
routine
weight
management;
have
pt.
weigh
themselves
everyday
to
ensure
weight
gain;
adjust
kcal,
Pro,
fluid
needs
as
necessary
• Food
and
nutrition
related
knowledge
deficit
(NB-­‐1.1)
R/T
lack
of
understanding
sensitivity
to
gluten-­‐containing
foods
AEB
presence
of
gluten
sources
in
24-­‐
hour
diet
history
recall
o Intervention:
Educate
pt.
on
the
consequences
of
consuming
gluten
containing
foods;
advise
pt.
to
consume
whole
or
enriched
gluten
free
grains
such
as
brown
rice,
wild
rice,
buckwheat,
quinoa;
provide
pt.
with
possible
substitution
o Monitoring/Evaluation:
Have
pt.
keep
food
intake
diary
every
week;
assess
food
intake
diary
once
a
week
to
ensure
no
gluten-­‐containing
foods
are
being
consumed;
evaluate
possible
foods
contaminated
with
gluten
in
diet
history
• Malnutrition
(NI-­‐5.2)
R/T
poor
absorption
of
nutrients
AEB
low
lab
values
of
Hct,
Hgb,
RBC,
MCV
(presence
of
anemia)
o Intervention:
Require
“gluten-­‐free”
diet
to
increase
absorption
of
nutrients;
put
pt.
on
iron
and
vitamin
supplement
(B
vitamins,
folate)
until
SI
heals
and
absorption
improves
o Monitoring/Evaluation:
Monitor
laboratory
levels
of
Hct,
Hgb,
RBV,
MCV,
ferritin,
total
bilirubin
3X
a
week
to
ensure
increasing
levels
of
nutrients
and
to
evaluate
status
of
anemia