Case Study

Celiac Disease

Fall 2016

Assignment 3

Due date: Sep 29, 2016

Yeyan Jin

CSUID:829840439

FSHN 450

I pledge on my honor that I have not given or received any unauthorized assistance on this assignment

Case Study Three Celiac Disease

FSHN 450 Due Date: 9/30/16

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-human tissue transglutaminase and IgA anti-endomesial antibodies.

Treatment plan : Gluten-free diet and nutrition consult.

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 g/dl 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 Glucose (fasting) 80 mg/dl GGT 18 U/L Cholesterol 115 mg/dl ALT 12 U/L Ferritin 18 ng/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 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 c 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 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? Etiology: genetic susceptibility, exposure to gluten, environmental trigger, autoimmune response IgA-human tissue transglutaminase and IgA anti-endomesial antibodies are both positive.

2.What are anti-endomesial and anti tissue transglutaminase antibodies? Why are they used for testing for celiac disease? Anti-endomesial antibodies are detects antibodies to endomysium, the thin connective tissue layer that covers individual muscle fibers. Anti tissue transglutaminase antibodies are autoantibodies against the transglutaminase protein. They are classes of antibody proteins that the immune system produces in response to a perceived threat (a kind of protein find in wheat). 3. What effect does gluten have on the small intestinal mucosa? Can not be digested on the small intestinal mucosa, then it will digested by bacteria and produce gas. 4. Which symptoms beside the abdominal cramping diarrhea and weight loss are related to celiac disease? Why? Type 1 diabetes and autoimmune thyroid disorders. Both diseases are immune-regulated and associated with autoimmune thyroiditis and rheumatoid arthritis. 5. 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? Corn flake, white toast, chocolate brownies and chocolate chip cookies. Buy gluten free corn flake, gluten chocolate brownies and gluten free chocolate chip cookies. Oatmeal, almond, gluten free flour.

6. 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? Because celiac disease usually come with diarrhea which will decrease body fluid that will decrease blood flow and get anemia. And celiac disease also leads to malnutrition which will also get anemia. Hgb and Hct are associated with anemia. 7. Why might this patient be lactose intolerant? It because the damage from celiac disease. Which will cause secondary lactose intolerant. II. List each laboratory value in table form: Value Normal Range Patient Value Reason for Deviation PatientsValue NormalRange ProbablereasonforvarianceGlucose 115 mg/dl Lessthan140mg/dl NormalBUN 10 mg/dl 7to20mg/dl NormalNa+ 140 mEq/L 135to145mEq/L NormalK+ 3.8 mEq/L 3.5to5.0mEq/L NormalCl- 102 mEq/L 96to106mEq/L NormalAST 10 U/L 10to34U/L NormalHgb 10.8 g/dl 13.5to17.5g/dl Lowerthannormal.Anemia

causedbyCDHct 32.1 % 38.8to50% Lowerthannormal.Anemia

causedbyCDSerumalbumin3.8g/dl 3.5-5g/dl NormalWBC 5 x 109/L 4.5to11*10^9/L Normal

RBC 4x10^3/L 3.9to5.03*10^6/mm^3 Normal

MCV101um3 80to100um3 Higherthannormal,Macrocyticanemia

Creatinine0.6mg/dl 0.7to1.3mg/dl Lowerthannormal,malnutrition,diarrhea

GGT18U/L 8to65U/L NormalCholesterol115mg/dl Lessthan200mg/dl NormalALT12U/L 7to35U/L NormalFerritin18ng/dl 12to150ng/dl Normal

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 intake domain, one PES statement in the clinical domain and one PES statement in the behavioral domain and an intervention and evaluation for each one.

IV. Include a recent research reference which supports your intervention plan. Include a copy of the abstract in your report. Keep eating gluten contained food will keep the same syndrome of CD, so I make her not to eat any gluten contained food. Gujral N. Celiac Disease: Prevalence, Diagnosis, Pathogenesis and Treatment. World Journal of Gastroenterology 18.42 (2012): 6036. Abstract Celiac disease (CD) is one of the most common diseases, resulting from both environmental (gluten) and genetic factors [human leukocyte antigen (HLA) and non-HLA genes]. The prevalence of CD has been estimated to approximate 0.5%-1% in different parts of the world. However; the population with diabetes, autoimmune disorder or relatives of CD individuals have even higher risk for the development of CD, at least in part, because of shared HLA typing. Gliadin gains access to the basal surface of the epithelium, and interact directly with the immune system, via both trans- and para-cellular routes. From a diagnostic perspective, symptoms may be viewed as either "typical" or "atypical". In both positive serological screening results suggestive of CD, should lead to small bowel biopsy followed by a favourable clinical and serological response to the gluten-free diet (GFD) to confirm the diagnosis. Positive anti-tissue transglutaminase antibody or anti-endomysial antibody during the clinical course helps to confirm the diagnosis of CD because of their over 99% specificities when small bowel villous atrophy is present on biopsy. Currently, the only treatment available for CD individuals is a strict life-long GFD. A greater understanding of the pathogenesis of CD allows alternative future CD treatments to hydrolyse toxic gliadin peptide, prevent toxic gliadin peptide absorption, blockage of selective deamidation of specific glutamine residues by tissue, restore immune tolerance towards gluten, modulation of immune response to dietary gliadin, and restoration of intestinal architecture. (C) 2012 Baishideng. All rights reserved.

ADIME Assessment BMI= 50/1.65/1.65=18 BMI is lower than normal, considered as malnutrition. Medical: She has diarrhea, abdominal distention, an itchy rash, occasional joint pain and unexplained weight loss. Hgb and Hct are lower than normal, so she may have anemia. Creatinine is also normal which means she may be in malnutrition. She is keep losing weight. Social: She is very young. It may be difficult for her to eat with her friends as a CD patient. Diet: There are still some foods contain gluten which will still hurt her digest system. Diagnosis Behavioral: Lack of knowledge about gluten free food r/t keep eating gluten food AEB CD disease Clinical: Malnutrition r/t anemia AEB Hgb and Hct are lower than normal Intake: Keep eating gluten food r/t C/D AEB cramping and distention Intervention Take gluten free corn flake instead of corn flake for breakfast, take gluten chocolate brownies instead of chocolate brownies for dinner and take gluten free chocolate chip cookies instead of chocolate chip cookies for snack. Eliminate gluten intake will help her reduce the symptom of CD, and getting better to absorb other nutrient contents to get out malnutrition. Monitoring/Evaluation For the next following meetings, I would like to have her 3-days diet record to see if she stops eating any gluten products. And I would also like to make her keep tracking her weight to make sure she is gaining weight instead of losing weight.