Case Study 1: Celiac Disease

Christina Ellis

I. Understanding the Disease and Pathophysiology

1. The small bowel biopsy results state, flat mucosa with villus atrophy and hyperplastic crypts-inflammatory infiltrate in lamina propria. What do these results tell you about the change in anatomy of the small intestine? These results indicate that the damages done to the patients small intestine has resulted in reduced absorptive surface area and a loss of digestive enzymes. There are hyperplastic crypts which indicate that there is an abnormal increase in the number of cells on the crypt where it is rich in lymphocytes, eosinophils, and plasma cells. Villi are hair like extensions that cover the lining of the small intestines. The job of the villi is to absorb nutrients from food and nourish the bloodstream for the body to use. When the villi are damaged, they cannot function properly and this puts the patient at risk for malabsorption and malnutrition, as well as GI distress. (Nelms, Sucher, & Roth, 2010) 2. What is the etiology of celiac disease? Is anything in Mrs. Gainess history typical of patients with celiac disease? Explain. Celiac Disease occurs when the small intestine is exposed to the gliadin component of gluten. In response to the intestinal damage, an inflammatory response occurs due to the infiltration of white blood cells in the mucosa. Antibodies that include IgA, EMA and AGA serve as components of the diagnostic procedures because they reflect the autoimmunity of the disease (Cleavland Clinic, 2013). The damage done to the villi will interfere with a persons absorption of nutrients. This can also lead to a person to be malnourished. Influential factors include a younger age when gluten is introduced, a shorter length of breastfeeding, and presence of viral infections during infancy. The patient does not have nausea or vomiting but is suffering from diarrhea. The diarrhea typically starts after the patient has eaten and has led the patient to avoid eating. The immediate diarrhea is a typical symptom associated with celiac disease (Nelms, Sucher, & Roth, 2010). 3. How is celiac disease related to the damage to the small intestine that endoscopy and biopsy results indicate? To confirm the diagnosis, a doctor may perform an endoscopy. A patient with celiac disease will have villi that are total or partially flattened in a person with celiac disease. Enzymes located on the brush border are drastically reduced. There are a higher number of white blood cells present at the base of the villi border (Celiac Sprue Association, 2013).

4. What are AGA and EMA antibodies? Explain the connection between the presence of antibodies? Explain the connection between the presence of antibodies and the etiology of the disease. The immune system produces certain antibodies when the body perceives a threat such as celiac disease. AGA antibody is autoantibody directed against the gliadin portion. EMA antibodies are developed in reaction to the ongoing damage to the intestinal lining. A patient that tests positive for AGA and EMA antibodies may suggest the patient has celiac disease. This positive test indicates that the patient needs a biopsy to establish the diagnosis (American Association for Clinical Chemistry, 2013). 5. What is a 72-hour fecal fat test? What are the normal results for this test? The fecal test measures the fat in the stool. This helps estimate the amount of dietary fat the person is absorbing. Normal results are less than 7 grams of fat per 24 hours (David C. Dugdale, 2012). 6. Mrs. Gaines laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean? The patients fecal fat is about the normal levels of 7 g fat/24 hours. This indicates she has steatorrhea due to the high amount of fecal content in the stool. This may mean food is not being absorbed properly which leads to malabsorption. (David C. Dugdale, 2012) 7. Why was the patient placed on a 100- g fat diet when her diet history indicates that her symptoms are much worse with fried foods? The patient was having a fecal fat test done. It was important to determine if fat was being digested properly. One way of preparing for a fecal fat test is by following a diet that has 100 g of fat for three days.

II Understanding the Nutrition Therapy

8. Gluten restriction is the major component of the medical nutrition therapy for celiac disease. What is gluten? Where is it found? Gluten is a mixture of proteins that provides an elastic texture in dough. It is found in wheat, rye, malt, barley, and sometimes in oats due to cross contamination. (Nelms, Sucher, & Roth, 2010). Hidden food sources of gluten include modified food starch, textured vegetable protein and flavorings (Mahan & Escott-Stump, 2008, p. 687). Be careful when eating out, because foods can be cross-contaminated. 9. Can patients on a gluten-free diet tolerate oats? Patients may eat oats as long is the oats are not contaminated with wheat gluten during processing. Typically up to 50 g of oats a day is safe and generally tolerated according to nutrition practice guidelines (Nelms, Sucher, & Roth, 2010). A patient should be on a well-established gluten-free diet before introducing oats.

10. What sources other than foods might introduce gluten to the patient? Gluten may be present in medications, anything processed such as thickeners or vitamins, supplements, imitation bacon, soy sauce, etc. (University of Chicago Celiac Disease Center). Play dough can even be a source of gluten. 11. Can patients with celiac disease also be lactose intolerant? Yes. It is common for lactase to be deficient in the presence of celiac disease. Lactase is one of the enzymes that can be lost due to the damage of the villi and enzyme secretion. Initially the patient will be put on a lactose-free diet, but gradually they will be able to add back lactose containing items to their diet. (Nelms, Sucher, & Roth, 2010)

III Nutrition Assessment

12. Calculate the patients percent UBW and BMI, and explain the nutritional risk associated with each value. % UBW= 100 x 92 lbs./ 112 = 82% The patients %UBW indicates that she has experienced severe weight loss. This puts the patient at risk for malnutrition. Associated health problems may include lower performing immune system, more illnesses, and a higher risk of death. BMI= 16.3 The BMI is below 18.5 which means that the patient is underweight. This puts the patient at risk for nutrient deficiencies, such as vitamin D and calcium which can later cause osteoporosis. It can also lead to iron-deficiency anemia due to depleted iron stores. 13. Calculate this patients total energy and protein needs using the HarrisBenedict equation or Mifflin- St. Jeor equation. 665 + (9.6 x 41.8 kg) + (1.8 x 160 cm) (4.7 x 36) 665+ 401.28+ 288- 169.2 BEE= 1185 kcals TEE= 1185 x 1.3 x 1.1= 1695 Protein= 1.0 x 41.8 kg= 42 g per day 14. Evaluate Mrs. Gaines 24-hour recall for adequacy. Mrs. Gaines is eating much less than she needs in order to meet her energy, macronutrient and micronutrient intakes. An analysis of her recall showed that she consumed only 452 kilocalories of the 2000 kilocalories that are recommended. Of the calories she does consume, 258 of them are empty calories meaning about half of her caloric intake arent nutrient dense foods (USDA, 2013). Of the food groups that included grains, vegetables, fruits, dairy, and protein, she had an inadequate intake. She consumed 2 oz. out of the recommended 6 oz., 0 cups of vegetables and only a half a cup of fruit out of the recommended 2 cups. 0 out of the recommended

3 cups were consumed and she consumed zero protein (USDA, 2013). She also is not consuming dinner. The grains she is consuming is wheat toast, which is damaging her intestine further because of her celiac disease. Below is a chart displaying her intake with the purple bar representing her protein.

15. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term. NI-1.4 Inadequate energy intake NI-2.1 Inadequate oral intake NI-5.2 Malnutrition NI-5.3 Inadequate protein-energy intake NI-5.6.1 Inadequate fat intake NI-5.7.1 Inadequate protein intake (IDNT reference manual, 2013) 16. Evaluate Mrs. Gaines Laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition value. The patients values for albumin, prealbumin and transferrin were all low (2.9 g/dL, 13 mg/dL, and 350 mg/dL,) and can indicate liver disease or malnutrition. This may be low in those with celiac disease because they cannot absorb or digest protein properly due to the damage villi. She tested positive for AGA and EMA antibodies indicating she may be sensitive to gluten. The fecal test came out high indicating she has steatorrhea and fat malabsorption. The lab results showed low B12 and folate levels which can lead to anemia, however we cannot assume the patient is deficient based on these results. Her low H&H of 9.5 g/dL and 34 % is an indicator that the patient might be iron deficient.. Ferritin levels were low (13 mg/L). Low ferritin levels indicate that the patients iron stores are low. Also, her mean cell hemoglobin concentration (30g/dL) was low which is common for individuals with iron deficiency anemia. The combination of these three lab results combined, support the diagnosis of her anemia.

Her diet is not providing adequate of nutrients which is why she has levels lower than normal in multiple nutrients. She has low levels in folate (3) and vitamin B12 (21.2) even though she is taking prenatal supplements. 17. Are the abnormalities identified in question 16 related to the consequences of celiac disease? The abnormalities are most likely related to the celiac disease consequences. The patient has instant diarrhea with other symptoms of fatigue and cramping after eating. This has led the patient to avoid eating because she fears the onset of the celiac disease symptoms. Since the patient has not been eating properly, she has become malnourished in a variety of nutrients. Her current diet of sprite, salted crackers, and chicken noodle soups does not meet her nutritional needs. 18. Are any symptoms from Mrs. Gaines physical examination consistent with her laboratory values? Explain. Her physical examination states she is pale and thin. This is most likely due to her depleted nutrients and calories. She complains of fatigue and diarrhea and has recently lost 30 pounds due to the celiac disease. Her diarrhea is caused by her malabsorption. Her fatigue, weight loss and weakness are directly related to vitamin and mineral deficiencies. Mrs. Gaines low intake of all nutrients, due to severe diarrhea and discomfort with eating, also contributed to low lab values. 19. Evaluate Mrs. Gaines other anthropometric measurements. Using the available data, calculate her arm muscle area. MAC= 180 mm (18 cm) TSF= 7.5 mm (.75 cm) AMA (Muscle deficit) =244.6/12.57= 19.46 cm2 Percentile rank is <5th percentile 20. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term. NI-1.3 breastfeeding difficulty NI-1.4 altered GI function NI-2.1 impaired nutrient utilization NI-3.1 underweight NI-3.2 unintended weight loss

IV Nutrition Diagnosis
21. Using the VA Nutrition Screening Form, what is the patients nutrition status level? 3, patient has poor nutrition status.

22. Select two high priority nutrition problems and complete the PES statement for each. 1. Altered GI function (NI-1.4) related to celiac disease as evidenced by secondary malabsorption, steatorrhea, weight loss, and flat mucosa with villous atrophy and hyperplastic crypts. 2. Inadequate oral intake(NI-2.1) related to diarrhea as evidenced by low albumin, low hematocrit, low folate, low B12, and weight loss.

V Nutrition Intervention
23. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). 1. reverse destruction of villi by put patient on lactose-free initially, and replacing gluten-containing foods with gluten free items. 2. provide nutrition education on gluten-free diet 24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has? Mrs. Gaines needs to eliminate all gluten in her diet if she wants to prevent further damage to her small intestine. Foods and products that contain gluten should not be ingested. Lactose should be limited when there is a presence of flare-ups. Until her symptoms start going away should she gradually start adding lactose back into her diet. Her gluten free diet is permanent and is a lifelong diet. To treat the malabsorption and steatorrhea, I would recommend she limits her fat and eat small frequent meals. She should also increase her consumption of fat-soluble vitamins for they can be absorbed without fat (Nelms, Sucher, & Roth, 2010). 25.Mrs. Gainess nutritional status is so compromised that she might benefit from high calorie, high protein supplementation. What would you recommend? I would recommend the Magnacal formula. The patient is depleted of nutrients and has high calorie needs. This formula is a concentrated formula with high amount of calories and protein as well. 26.Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend? Her body has been put under a lot of stress due to the injury celiac disease has caused. Glutamine helps to protect the lining of the gastrointestinal tract known as the mucosa. Glutamine supplementation would be beneficial so it can help build and heal the mucosa. There are two forms of glutamine, L-glutamine and glutamine peptide. L-glutamine is recommended because of its free form of amino acids. Glutamine peptide comes from wheat, which can cause a reaction so try to avoid glutamine peptide (University of Maryland Medical Center, 2013).

27.What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet very long? This is a lifelong diet. Mrs. Gaines can expect her symptoms to alleviate and her body should begin to heal once the gluten has been removed. Diarrhea should start to go away and she should be able to start absorbing nutrients properly again. She should also be able to start gaining weight back now that she will not have to fear the symptoms from celiac disease. 28. Evaluate the following excerpt from Mrs. Gainess food diary. Identify the foods that might not be tolerated on a gluten/gliadin-free diet. For each food identified, provide an appropriate substitution. Food Cornflakes Tolerated/ not tolerated Not tolerated; substitute with Chex Gluten free cereal Not tolerated; substitute with turkey or chicken Not tolerated; substitute with Amys Thai stir fry or Asian noodle stir-fry Limit lactose products; substitute with almond milk May be tolerate; May be tolerated; substitute with real cheese May be tolerated if you make with gluten free mushroom soup; for quick and easy meal substitute with Amys broccoli and cheddar bake or Mexican casserole Sources http://www.chex.com/Recipes/GlutenFree.aspx

Bologna slices Lean cuisine

http://www.amys.com/products/productcategories/gluten-free

Skim milk

http://almondbreeze.com, http://silk.com/products/learn-more/aboutalmondmilk

Cheddar cheese spread Green bean casserole

http://www.amys.com/products/productcategories/gluten-free

Coffee Rice crackers Fruit cocktail Sugar Pudding

Tolerated, limit intake Tolerated Tolerated Tolerated May be tolerated; check brand, may have food starch from gluten Tolerated Tolerated Not tolerated; substitute with sparkling water http://www.jello.com/product/pudding-moussedesserts/chocolate

V8 juice Banana Cola

*reminder: with all items, read food labels thoroughly to avoid contamination of gluten

Works Cited
American Association for Clinical Chemistry. (2013, September 16). Celiac Disease Tests. Retrieved May 3, 2011, from Lab Tests Online: http://labtestsonline.org/understanding/analytes/celiac-disease/tab/sample Celiac Sprue Association. (2013). Celiacs helping celiacs. Retrieved from Celiac Sprue Association: http://www.csaceliacs.info/diagnosis_of_celiac_disease.jsp Cleavland Clinic. (2013, March). Celiac disease and conditions. Retrieved March 12, 2013, from Cleavland Clinic: http://my.clevelandclinic.org/disorders/celiac_disease/hic_celiac_disease.aspx David C. Dugdale, I. M. (2012, september 2). Medline Plus. (American Accreditation HealthCare Commission) Retrieved from Fecal Fat: http://www.nlm.nih.gov/medlineplus/ency/article/003588.htm National Digestive Diseases Information Clearinghouse. (2012, January 27). Celiac Disease. Retrieved from NDDIC: http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/ Nelms, M., Sucher, K., & Roth, S. L. (2010). Nutrition Therapy and Pathophysiology (Second ed.). Belmont, CA: Wadsworth Cengage Learning. University of Chicago Celiac Disease Center. (n.d.). Antibodie blood tests. Retrieved from University of Chicago Celiac Disease Center: http://www.uchospitals.edu/pdf/uch_007935.pdf

University of Maryland Medical Center. (2013, May 7). Glutamine. Retrieved from University of Maryland Medical Center: http://umm.edu/health/medical/altmed/supplement/glutamine USDA. (2013). MyPlate Supertracker. Retrieved from Supertracker: https://www.supertracker.usda.gov/foodtracker.aspx?CatgoryID=1&FoodDescription=1+slice+whole+wheat+toast