CeliacDiseaseCaseStudy_MNT
- 1. Patient BR is a 22 y/o Caucasian female referred to 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: 112lb Patient reports weight loss of 10 lbs in the past 6 months 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 4x1012/L Chloride 102 mEq/L WBC 5x109/L BUN 10mg/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-Hour 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 bologna 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 cup buttered peas ½ cup fresh fruit salad 1 small baked potato with 2 TBSP sour cream 2 chocolate brownies Diet Pepsi Snack 4 small chocolate chip cookies 1 cup 2% milk
- 2. I. 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 vulnerability, gluten exposure, environmental triggers, and autoimmune responses. Components of BR’s history that might be indicative of a food allergy are complaints of diarrhea, abdominal distention, itchy rash, occasional joint pain, and unexplained weight loss. Another sign of a possible food allergy is BR’s positive test for IgA-‐tissue transglutaminase and IgA anti-‐ endomesial antibodies. An extra thing to note that may not always necessarily be related to an allergy is cramping and distention that occurs around 2 hours after eating certain foods. 2. What are anti-endomesial and anti-tissue transglutaminase antibodies? Why are they used for testing for celiac disease? Anti-‐ endomesial antibodies are antibodies that are tested that have a high specificity for celiac disease; they may prevent need for small bowel biopsy for diagnosis. Anti-‐tissue transglutaminase antibodies are auto antigens of Celiac disease, it is indicative of villous atrophy secondary to gluten exposure causing villous damage to the small intestine of the GI tract. It can also be a marker of restoration of the GI tract. They are used because they are both very indicative of Celiac disease. There is also a higher prevalence of IgA deficiencies in people with Celiac disease. 3. Why was the small intestinal biopsy ordered? The small intestinal biopsy was ordered in order to see if there is any damage that has been done to the patient’s GI tract such as the presence of Flat Gut Syndrome, the damage of intestinal mucosa, loss of intestinal folds, and loss of villi. This damage could be indicative of Celiac Disease and the extent to which it has caused damage. 4. What effect does gluten have on the small intestinal mucosa? Gluten damages the intestinal mucosa; it causes a loss in the intestinal folds, loss of villi and replacement by immature crypt cells. This damage is also known as “Flat Gut Syndrome” this damage contributes to loss of ability to absorb nutrients properly. 5. Which symptoms beside the abdominal cramping, diarrhea, and weight loss are related to celiac disease? Why? An itchy rash can be a symptom of Celiac because skin rashes are a common reaction to any allergy due to the release of histamines when exposed to the allergen. Occasional joint pain is related to Celiac disease because Celiac causes inflammation due to the body’s response to the allergen. This inflammation can migrate to the joints causing pain and irritation. 6. What sources of gluten do you see in the patient’s 24-hour diet recall? What might be some acceptable substitutes? What are some other potential sources of gluten exposure besides diet? There are many sources of gluten in the patient’s 24-‐hour recall. These sources include: the two slices of white toast, 2 chocolate chip brownies, and 4 small chocolate chip cookies. Some proper substitutes for these gluten containing foods are as follows: to replace the 2 slices of white toast, the patient can purchase gluten-‐free bagels
- 3. or bread that is produced by certain distributors such as Kinnikinnick or others. To replace the 2 chocolate brownies and 4 small chocolate chip cookies, the patient could substitute with gluten-‐free ice creams such as strawberry, she could substitute with dark chocolate pieces, Schar brand honey grahams, or Kinnikinnick brand graham crackers or animal crackers in order to still allow her indulgence in some sweet things. Some other potential sources of gluten exposure besides the diet would be cosmetics, contaminants in processed foods, and binders in medications or 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? There is a high prevalence of anemia among patients with celiac disease in response to chronic inflammation. This inflammation interferes with the body’s ability to properly absorb/distribute iron stores because areas that are inflamed (GI in Celiac) are not accessible for the blood cells with the iron. Another more obvious reason for anemia of those with Celiac is due to malabsorption because of destroying the intestinal villi where nutrients such as iron are absorbed. Another factor that is only present in about half of people with Celiac is some intestinal bleeding due to damage. This bleeding can cause anemia because of extra loss of blood cells carrying the body’s iron (meaning loss of iron as well). Of the patient’s lab values ferritin and transferrin. 8. Why might this patient be lactose intolerant? The patient might be lactose intolerant due to damage of the intestinal mucosal cells. The enzymes that digest lactose (lactase) are on the brush border of the intestinal mucosal cells, so when these intestinal cells become damaged the villi are shortened which in turn decreases the amount of brush border available which decreases digestion of the lactose making it an irritant to the individual and causing intolerance. II. List Each Laboratory Value in Table Form: Physical Findings/Lab Value Patient’s Value Normal Range Reason for Variance Hematocrit 32.1% 34-‐45% (Low) Malnutrition/Malabsorption Hemoglobin 10.8g/dL 12.1-‐15.6 g/dL (Low) Malnutrition/Malabsorption MCV 101um^3 78-‐93 um^3 (High) Possible Folate or B12 def. Serum Albumin 3.8 g/dL 3.5-‐5 g/dL Within Normal Limits Glucose (Fasting) 80 mg/dL 70-‐99 mg/dL Within Normal Limits Cholesterol 115 mg/dL 120-‐199 mg/dL (Low) Malabsorption, malnutrition, anemia
- 4. Ferritin 18 ng/dL 12-‐150 ng/dL Within Normal Limits Transferrin 398 mg/dL 212-‐360 mg/dL (High) Possible inadequate Fe stores, Fe def anemia Sodium 140 mEq/L 135-‐145 mEq/L Within Normal Limits Potassium 3.8 mEq/L 3.5-‐5 mEq/L Within Normal Limits Chloride 102 mEq/L 98-‐107 mEq/L Within Normal Limits BUN 10 mg/dL 8-‐23 mg/dL Within Normal Limits Creatinine 0.6 mg/dL 0.4-‐1.2 mg/dL Within Normal Limits Direct Billirubin 0.2 mg/dL <0.3 mg/dL Within Normal Limits GGT 18 UL 7-‐33 UL Within Normal Limits ALT 12 UL 4-‐31 UL Within Normal Limits AST 10 UL 10-‐31 UL Within Normal Limits WBC 5x10^9/L -‐-‐ Within Normal Limits RBC 4x10^12/L -‐-‐ Within Normal Limits III. Nutrition Assessment: Assessment: 22 yo female. Medical Tx: gluten-‐free diet and nutrition consult, small intestinal biopsy ordered. Ht: 5’5’’ Wt: 112lbs BMI: 18.6 (normal) Current Complaint: 10lbs unplanned weight loss in past 6 months, diarrhea, abdominal distention (about 2 hrs after eating certain foods), itchy rash, and occasional joint pain. Family hx: father positive for type 1 diabetes, mother has asthma, no GI disorder history in family or in-‐patient. Meds: None reported Labs: Hct 32.1% (low), Hbg 10.8 g/dL (low), MCV 101 um^3 (high), ALB 3.8 g/dL (normal), Fasting Glucose 80 mg/dL (normal), cholesterol 115 mg/dL (low), ferritin 18 ng/dL (normal), transferrin 398 mg/dL (high), 140 mEq/L (normal), potassium 3.8 mEq/L (normal), chloride 102 mEq/L (normal), BUN 10 mg/dL (normal), creatinine 0.6 mg/dL (normal), direct billirubin 0.2 mg/dL (normal), GGT 18 UL (normal), ALT 12 UL (normal), AST 10 UL (normal), WBC 5x10^9/L (normal), RBC 4x10^12/L (normal) 24 hour diet history: Diet pretty well balanced, includes fruits/vegetables, fish, dairy, some excess sugar intake but not severe. Nutritional Needs:
- 5. Protein Requirements: 61g/Kg/day (1.2 g/Kg due to stress) Energy Requirements: 1,642 Kcal/day (Mifflinx1.3) Fluid Requirements: 1,642ml/day (1ml/Kcal) Clinical Diagnosis: Altered GI function (NC-‐1.4) r/t malabsorption AEB patient interview, C/O diarrhea, abdominal distention about 2 hrs after eating certain foods, unexplained wt loss. Intervention: 1. Maintain fluid intake to counteract fluid loss through diarrhea. 2. Focus on sufficient kcal and protein intake while avoiding gluten-‐ containing foods in order to maintain weight and nutritional health status. 3. Suggest outpatient follow-‐up appointment with doctor. Obtain new lab values to evaluate progress. Monitoring/Intervention: 1. Evaluate new lab values from follow-‐up appointment with medical doctor in order to see possible improvement. 2. Follow-‐up patient interview over the phone to ask patient whether or not symptoms have subsided. Behavioral Diagnosis: Food and nutrition-‐related knowledge deficit (NB-‐1.1) r/t recent attention called to possible gluten allergy AEB diarrhea, abdominal distention, unexplained wt loss, itchy rash, occasional joint pain, positive test for IgA-‐tissue transglutaminase and IgA anti-‐endomesial antibodies. Intervention: 1. Provide education about Celiac disease (importance of diet restriction, effects, how to read labels properly to know if gluten-‐containing or not) to the patient and give her resources to utilize. 2. Suggest resources for coping with Celiac, such as support groups or information online at celiac.org. 3. Provide the patient with list of possible diet options and/or substitutions she can utilize in order to maintain an appropriate diet. 4. Provide patient with a list of substances to avoid after diagnosed with Celiac disease. Monitoring/ Evaluation: 1. Obtain a 3-‐day diet record from the patient 1-‐week post-‐diagnosis. Look for gluten intake in the diet.
- 6. 2. Look for improvement in lab values from follow-‐up appointment with medical doctor.