Marissa UhlhornCase Study TwoCeliac Disease

FSHN 450Due Date: 10/2/15

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1.What is the etiology of celiac disease? Is there anything in BR’s history that might indicate a food allergy?

Etiology: Genetic susceptibility Environmental trigger- inflammation or illness Exposure to gluten Autoimmune Response

Indications of a food allergy: Diarrhea Abdominal pain (after eating certain foods) Itchy rash Unexplained weight loss (malabsorption) Cramping (after eating certain foods)

2.What are anti-endomesial and anti-tissue transglutaminase antibodies? Why are they used for testing for celiac disease?These antibodies are non-specific and sense the presence of the protein, gluten to cause an autoimmune response. They are the most sensitive and specific blood test for celiac disease.

3.Why was a small intestinal biopsy ordered? The biopsy was ordered to determine if it certain the patient has celiac disease. The small bioposy could show if the patient has flat gut syndrome or damage to the intestinal mucosa. This would show the possible loss of intestinal folds and villi.

4. What effect does gluten have on the small intestinal mucosa?Gluten could cause flat gut syndrome in a patient with celiac disease, damaging the intestinal folds and villi. This could decrease the surface area of nutrients being absorbed, and could result in malnutrition.

5. Which symptoms beside the abdominal cramping diarrhea and weight loss are related to celiac disease? Why?BR has two other symptoms that are related to celiac disease. These include: an itchy rash (dermatitis) and occasional joint pain (possible arthritis)

Celiac disease is an autoimmune disease, attacking other parts of the body, resulting in these symptoms including pain and inflammation.

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: White toast, chocolate brownies, and chocolate chip cookies

Substitutes: Gluten free bread, corn/almond/soy/potato/brown rice flour, or gluten free multi-purpose flour to replace regular all purpose flour (containing gluten) in the chocolate brownies and cookies (or gluten free brownies and cookies- pre packaged)

Other exposures: Cosmetics, contaminants in processed foods, and binders 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?A type of anemia called anemia of chronic inflammation is seen in patients with inflammatory diseases. The immune system’s response to inflammation can interfere with the body’s production of red blood cells, resulting in anemia. Due to the flat gut syndrome and damage to the intestinal mucosa, iron may not be absorbed well in the intestine.

8. Why might this patient be lactose intolerant?When a patient has celiac disease, the villi on the intestinal mucosa are damaged or even flattened. These villi also make up the “brush border” which contains enzymes that help digest the sugars found in lactose. The lack of these enzymes would result in possible lactose intolerance.

II. List each laboratory value in table form:

Value Normal Range Patient Value Reason for Deviation

Hematocrit 34-45% 32.1% Possible anemia

Hemoglobin 12.1-15.6 g/dl 10.8 g/dl Possible anemia

RBC 3.9-5.5 million/mm3 4 x 1012/L

WBC 3200-10,600/microL 5 x 109/ L Tissue injury (intestinal)

MCV 78-93 mm3/RBC 101 (um3) Possible anemia

Serum Albumin 3.5-5.0 gm/dl 3.8 g/dl No deviation

Cholesterol 120-199 mg/dL 115 mg/dl Malabsorption

Ferritin 12-150 mg/dl 18 mg/dl No deviation

Transferrin 212-360 398 mg/dl Possible anemia

Sodium 136-144 mEq/L 140 mEq/L No deviation

Potassium 3.5-5.0 mEq/L 3.8 mEq/L No deviation

Chloride 98-107 mEq/L 102 mEq/L No deviation

BUN 8-23 mg/dl 10 mg/dl No deviation

Creatinine 0.4-1.2 mg/dl 0.6 mg/dl No deviation

Total Billirubin 1.0 mg/dl 0.2 mg/dl No deviation

GGT 7-33 U/L 18 U/L No deviation

ALT 4-31 U/L 12 U/L No deviation

AST 10-31 U/L 10 U/L No deviation

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.

Assessment: Anthropometrics:

o 22 y/o Caucasian femaleo Ht: 5’ 5”o Wt 112 lbs (51 kg)o BMI: 18.6 (lower end of normal)o Weight loss (10 lbs in past 6 months)

Nutrition consult and intestinal biopsy ordered Biochemical Data-Labs: Hematocrit 32.1% (low), Hemoglobin 10.8 g/dl (low), WBC

5x 109/L (high), MCV 101 um3 (high), cholesterol 115 mg/dl (low), Transferrin 398 mg/dl (high)

o All other lab values are normalo Positive IgA-tissue transglutaminase and IgA anti-endomesial antibodies

Family history: father with type 1 diabetes, mother with asthma Physical findings: Itchy rash, 10 pounds of weight loss in past 6 months Diet history: Consumption of gluten (bread, brownies, cookies), consumption of dairy

(possible lactose intolerance associated with celiac disease)

Kcal Needs: For patients <30 BMI: 25-30 kcal/kg/day

25kcal* 51kg= 1,275 kcal 30kcal*51kg= 1530 kcal

1,275 to 1,530 kcal/day

Protein Needs: For patients <BMI: 1.2-2 g protein/kg/day

1.2g *51kg= 61.2 g/kg/day2.0 g* 51kg=102 g/kg/day

61.2-102g of Protein/kg/day

Diagnosis: Clinical Domain:Altered GI function R/T unintended weight loss and diarrhea AEB decreased cholesterol levels (115 mg/dl) and loss of 10 lbs in the past 6 months.

Intervention:Clinical Domain:

1. Encourage ~½ lb weight gain per week to get to ideal weight (120 lbs)2. Check patient's readiness to learn stage and plan education appropriately3. Encourage patient to keep a food diary and write symptoms after eating (if any)4. Help patient come up with meal/snack ideas that do not contain gluten

Monitoring/Evaluating:Clinical Domain:

1. Monitor weight status2. Analyze food and symptom diary 3. Evaluate patient knowledge of gluten free food options and how it is working4. Monitor cholesterol levels

Diagnosis:Behavioral Domain:

Food and nutrition related knowledge deficit R/T consumption of gluten containing foods AEB cramping and distention after eating certain foods.

Intervention:Behavioral Domain:

1. Help the patient come up with meal and snack ideas that are gluten free (that they enjoy)2. Check patient's readiness to learn stage and adjust education accordingly3. Encourage the patient to keep a food diary and record symptoms if in pain after eating4. Provide information about gluten containing foods that may be causing pain/cramping5. Provide information about lactose containing foods that may also need to be eliminated

Monitoring/EvaluatingBehavioral Domain:

1. Assess the patient's knowledge of consuming a gluten free diet2. Evaluate the patient's food and symptom diary3. Monitor GI symptoms (diarrhea, cramping, abdominal distention) and weight status

Diagnosis:Intake Domain:

Malnutrition R/T unintended weight loss and diarrhea AEB decreased hematocrit and hemoglobin levels.

Intervention:Intake Domain:

1. Encourage ~1/2 lb weight gain per week until ideal weight (120 lbs) is reached2. Encourage and assist patient in choosing healthy balanced meals that are gluten free3. Check patient's readiness to learn stage and adjust educational tools to their stage4. Educate patient about the damaging effects gluten has on the intestine-causing the

diarrhea and malabsorption

Monitoring/Evaluating:Intake Domain:

1. Monitor hematocrit and hemoglobin levels2. Monitor weight status3. Assess the patient's symptoms (if increased or decreased with gluten free diet)4. Check in with the patient and their compliance to their diet change