MM-celiac disease case study #3

1. Celiac'Disease:'Case'Study'
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Mia$Matthews$
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MNT,$Fall$2015$
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October$2nd,$2015$
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“I#have#not#given,#received#or#used#any#unauthorized#assistance#on#this#assignment”#
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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$
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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.$$
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2.What$are$anti,endomesial$and$anti$tissue$transglutaminase$antibodies?$Why$are$they$used$for$testing$
for$celiac$disease?$
$Anti$tissue$transglutaminase$antibodies$are$enzymes$that$cause$the$crosslinking$of$certain$
proteins$and$anti,endomesial$antibodies detect$antibodies$to$endomysium,$the$thin$connective$tissue$
layer$that$covers$individual$muscle$fibers.They$are$autoantibodies$in$the$blood$that$the$body$produces$
as$part$of$the$immune$response.$The$immune$response$leads$to$inflammation$of$the$SI$and$
damage/destruction$of$villi$that$line$the$intestinal$wall.$Celiac$disease$is$an$autoimmune$disorder$
characterized$by$an$inappropriate$immune$response$to$gluten,$so$IgA$antibody$tests$are$used$to$
diagnose$the$disorder.$IgA$tests$are$very$specific,$and$if$tests$are$positive,$shows$that$the$immune$
system$is$producing$these$antibody$proteins$due$to$perceiving$gluten$as$a$threat,$so$diagnosis$can$be$
made.$
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3.Why$was$a$small$intestinal$biopsy$ordered?$$
$A$small$intestinal$biopsy$was$ordered$because$this$evaluation$is$still$considered$the$gold$
standard$and$is$used$to$confirm$diagnosis$of$celiac$disease.$
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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.$$
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5.$Which$symptoms$beside$the$abdominal$cramping$diarrhea$and$weight$loss$are$related$to$celiac$
disease?$Why?$
$BR’s$symptoms$of$an$itchy$rash$and$unintentional$weight$loss$are$both$related$to$celiac$disease$
as$well.$Presence$of$an$itchy$rash$(dermatitis)$is$a$symptom$indicative$of$a$food$allergy$and$recent$
unintentional$weight$loss$is$a$result$of$malabsorption/malnutrition,$which$is$a$symptom$of$celiac$
disease.$$
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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.$$
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7.$There$is$a$high$prevalence$of$anemia$among$patients$with$celiac$disease.$Why$is$this$the$case?$$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$$101$(um3));$RBC–$4$x$1012/L;$WBC$5$x$
109/L$.$All$low$levels,$which$indicates$presence$of$anemia.$
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8.$$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$lactose.$
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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$WNL$
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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.$
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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$Kcals/day=1,270ml/day$
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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$