Celiac Disease Case Study 12 Jackie Farrall KNH 411 Professor Matuszak November 13, 2012

Patient Description Melissa Gaines 36 years old female; 5’3” Currently 92 lbs UBW is 112 lbs Patient Hx: Chief Complaint: “I have lost a tremendous amount of weight, and I have been having terrible diarrhea for awhile now. I don’t even have the energy to get off the couch” GI issues on mothers side Has been relying on chicken noodle soup, crackers and sprite for the past few days Has a college degree and works as a secretary for a hospital administrator but just gave birth 3 months ago so on maternity leave

Etiology Auto-immune condition which affects an individual for life once there is an onset Usually inherited (associated with the AGA/EMA antibody production) Onset can occur at birth, after surgery, during pregnancy, after infection or any serious trauma Immune response to gluten, a wheat protein which causes damage to the intestinal villi Damaged villus will decrease the area of the intestines in which nutrients are absorbed into the bloodstream

Symptoms for Celiac Disease Direct Abdominal bloating Chronic diarrhea Vomiting Constipation Foul smelling/fatty stool Weight loss Indirect Anemia Fatigue Arthritis Skin rash Osteoporosis Infertility/miscarriage

Patients’ Symptoms Weight loss Foul smelling/fatty stool Chronic diarrhea Anemia Fatigue

Assessment 36 year old female, thin, pale, experiencing fatigue, weakness and diarrhea BMI: 16.3 UBW: 112 lbs Melissa is 82% of her UBW Actual body weight: 92 lbs Avoids eating due to nausea and diarrhea. Has resulted to weight loss

Reasons for Abnormality Chemistry Melissa’s value Normal values Reasons for Abnormality Albumin 2.9 g/dL 3.5-5 g/dL Weight loss, muscle wasting, inadequate protein intake Total Protein 6-8 g/dL 5.5 g/dL Prealbumin 13 g/dL 16-35 g/dL AGA antibodies + Abnormal autoimmune response to gluten EMA antibodies HGB 9.5 g/dL 12-15 g/dL Low absorption of iron HCT 34 g/dL 37-47 g/dL Vitamin B12 21.2 ng/dL 24.4-100 ng/dL Folate 3 mm cubed 5-25 mm cubed Ferritin 12 mg/mL 20-120 mg/mL

Nutrition Requirements Requirements: 1185-1400 kcals per day Increased the kcal by 500 kcal/day because we want Melissa to gain weight Protein: 1.0 g/kg body weight/day (1.0 x 41.8 kg)=42 g/day Which would increase the protein by 63-73 gr/day Receiving: 598 kilocalories 9 gr of protein and fat

PES Statements Involuntary weight loss (NC 3.2) related to inadequate energy intake and untreated Celiac disease as evidence by recent weight loss of 30 lbs and BMI of 16.3 kg/m squared. Altered gastrointestinal function related to secondary malabsorption of nutrients, vitamins and minerals as evidence by reported consumption of gluten containing foods, small bowel biopsy indicating flat mucosa with villous atrophy and hyperplastic crypts, having diarrhea on and off for most of her adult life, and recent weight loss over one month.

Diagnosis Diagnostic Measures 24-hour stool collection 100-g fat diet x 3 days 72- hour fecal fat Sudan Black B fat stain Blood tests Collecting a sample of small intestine for testing CBC, WBC, ESR, CRP, CMP tests Melissa's results revealed flat mucosa with villus atrophy and hyperplastic crypts. Fecal fat tests indicated steatorrhea and malabsorption. As seen in lab values patient was positive for AGA and EMA antigens.

Flat Mucosa

Treatment MNT: Gluten-free diet Medication Nothing containing wheat, rye or barley Words such as stabilizer, starch, flavoring, emulsifier, hydrolyser, plant protein often mean wheat protein is involved Corn, potato, rice, soybean, tapioca, arrowroot, carob, buckwheat, millet, amaranth and quinoa are allowed and good carbohydrate sources Cross contamination Alcohol Medication Steroids and immune suppressants Vitamin supplements Treatment for this condition is non-surgical

Prognosis Education will be important part of recovery With a gluten-free diet regeneration of new epithelial cells in the gut will take place and within 2 years patients intestine will be healed If patient does not stay on gluten-free diet- Increase chances of developing cancer of the intestine Osteoporosis Untreated pregnant women have higher than normal rates of miscarriage and babies born with birth defects, especially neural tube defects, which arise from inadequate amounts of folic acid.

References American Association for Clinical Chemistry. (2009, May 16). Total protein and A/G ratio. Retrieved November 9, 2012, from http://www.labtestsonline.org/understanding/analytes/tp/test.htm American Dietetic Association. (2008). International dietetics and nutrition terminology (IDNT) reference manual: Standardized language for the nutrition care process (2nd ed.) Celiac Disease Foundation. (2011). Celiac disease symptoms. Retrieved November 9, 2012, from http://www.celiac.org/ Celiac Sprue Association. (2008). Symptoms of celiac disease. Retrieved November 7, 2012, from http://www.csaceliacs.org/celiac_symptoms.php Nelms, M. N., Roth, S. L., & Lacey, K. (2009). Medical nutrition therapy: A case study approach (2nd ed.). Belmont, CA: Wadsworth Cengage Learning. USDA Center for Nutrition Policy and Promotion. (2010, September 28). MyPyramid tracker. Retrieved November 9, 2012, from http://www.mypyramid.gov/ The University of Chicago Celiac Disease Center. (n.d.). The University of Chicago celiac disease center. Retrieved November 8, 2012, from http://www.celiacdisease.net/