Posted: September 13th, 2015

Non celiac gluten senstivity.

 

Patient CD has experienced intermittent diarrhea, bloating, and diffuse lower abdominal discomfort over the past 7 years, diagnosed with diarrhea-predominant irritable bowel syndrome 5 years ago. She presents with symptoms worsened over the past several months, dermatitis, and c/o fatigue though not limiting her ability to work. Ms. TG is 26 years old.

 

Pt. reports that RAST and PRIST, as well as hydrogen breath test have been performed in the past, with negative results.

 

PMHx: Osteopenia, no hospitalizations, no current medications; iron deficiency anemia refractory to oral iron supplementation; no GI bleeds, no rectal bleeding, gynecologic causes of anemia have been ruled out

FHx: Her father has a history of diabetes type 1, her mother has a history of atherosclerosis with narrowing of the carotid artery, migraine headaches, her siblings have no medical problems

 

Allergies: penicillin, unknown reaction

Medications: none, no herbal remedies, no supplements

 

Physical Examination

Vital signs:

Temp: 37.8°C (100°F),

Pulse: 78 BPM,

RR: 14 BPM,

BP: 118/66

Height: 5’6”, 122 lbs,,

Usual body weight: 122-126lbs.

General: well-developed young woman

Skin: rash in extensor surfaces of elbows and knees, no bruises

Heart: RRR without murmurs or gallops

HEENT:

Eyes: PERRLA, normal fundi

Ears: noncontributory

Nose: noncontributory

Throat: pharynx clear

Chest: CTA

Breasts: no masses

Rectal: no evidence of perianal disease

Neurologic: oriented x 4

Extremities: no edema, pulses full, no bruits, normal strength, sensation and DT

Abdomen: some distention, hyperactive bowel sounds.

 

Assessment: R/o Celiac disease vs. NCGS vs. Inflammatory bowel disease vs. infections

 

Plan:

CBC/Chem 24

ASCA

EMA IgA and IgG

Anti-tTG IgA and IgG

AGA DGP IgA and IgG

HLA DQ2

EGDS (esophagogastroduodenoscopy)

 

Results:

ASCA: negative

EMA IgA and IgG: negative

Anti-tTG IgA and IgG: negative

AGA DGP IgA and IgG: negative

HLA DQ2: positive

EGDS (esophagogastroduodenoscopy): no macroscopic alterations found, histology of the duodenum shows a picture compatible with Marsh-Oberhuber class 1 (>40 intraepithelial lymphocytes per 100 enterocytes but no villous atrophy).

EMA of biopsy supernatants: results doubtful, anti-tTG results of culture supernatants from biopsies were positive

 

Nursing Assessment

(relevant information only)

Abdominal appearance: rounded

Bowel function: continent

Stool color, consistency: light brown, soft to liquid

Urine: clear, yellow

Skin color: pale

Skin turgor: good

 

Lab results

	Reference range	Measured (current date)
Chemistry
Sodium (mEq/L)	136-145	136
Potassium (mEq/L)	3.5-5.5	3.7
Chloride (mEq/L)	95-105	101
Carbon dioxide (mEq/L)	23-30	26
BUN (mg/dL)	7-20	7.0
Creatinine serum (mg/dL)	0.5-1.2	0.9
Glucose (mg/dL)	70-110	82
Phosphate, inorganic (mg/dL)	2.3-4.7	2.9
Magnesium (mg/dL)	1.8-3	1.8
Calcium (mg/dL)	8.5-10.5	7.5
Bilirubin, direct (mg/dL)	<0.3	0.3
Protein, total (g/dL)	6-8	5.5
Albumin (d/dL)	3.6-4.5	3.2
Prealbumin (mg/dL)	16-35	13
Ammonia (µmol/L)	9-33	11
Alkaline phosphatase (U/L)	50-130	48
ALT (U/L)	10-40	81
AST (U/L)	10-40	49
C-reactive protein (mg/dL)	<1.0	1.4
Cholesterol (mg/dL)	120-199	149
HDL-C (mg/dL)	>55 F, >45 M	38
LDL (mg/dL)	<130	111
LDL/HDL ratio	<3.22 F, <3.55 M	2.92
Triglycerides (mg/dL)	35-135 F, 40-160 M	85
T-transglutaminase IgA AB	Neg	Neg
Tissue transglutaminase IgG	Neg	Neg
Total serum IgA		WNL
ASCA	Neg	Neg
Coagulation
PT (s)	12.4-14.4	15
Hematology
WBC (x 103/mm3)	4.8-10.8	5.0
RBC (x106/mm3)	4.2-5.4 F, 4.5-6.2 M	3.85
Hemoglobin (Hgb, g/dL)	12-16 F, 14-17 M	8.6
Hematocrit (Hct, %)	37-47 F, 40-54 M	26.4
Mean cell volume (µm3)	82-94	68.2
Mean cell Hgb (pg)	26-32	30
Mean cell Hgb content (g/dL)	31.5-36	33
Platelet count (x 103/mm3)	150-350	422
Iron (mcg/dL)		56
Transferrin (mg/dL)	250-380 F, 215-365 M	185
Ferritin (mg/mL)	20-120 F, 20-300 M	5
ZPP (µmol/mol)	30-80	85
Cobalamine (ng/dL)	24.4-100	30
Folate (ng/dL)	5-25	6
Zinc, serum (µg/mL)	0.6-1.2	0.5
25-hydroxy-vitamin D (ng/mL)	30-100	22.7
Free retinol (µg/dL)	20-80	17.2
Ascorbic acid (mg/dL)	0.2-2.0	<0.1
Selenium (ng/mL)	70-150	123

 

Nutrition:

Patient reports to have eaten normally for at least seven years. She lost 6 pounds over the past 4 weeks.

 

Usual recent dietary intake:

24-hour Food Recall

Patient states that this is a typical eating pattern during the week:

Breakfast

Bagel (1 plain, 3.5”), cream cheese (2 Tbs), orange juice (6 oz.), banana (1 medium)

Morning snack

Licorice (black, 4 pieces), pretzels, honey wheat (1 oz)

Lunch

Deli turkey breast (6 thin slices, 3oz), whole wheat bread, light (2 slices), low fat mayonnaise (1 Tbs), baby carrots (8), apple (1 medium), oatmeal cookie with raisins (2), bottled water (16 oz)

Afternoon snack

Latte with skim milk (12 oz)

Dinner

Salmon, baked (3 oz), angel hair pasta (2oz dry), marinara sauce, canned, no meat (1/4 cup), green salad (1.5 cup), croutons, plain (2 Tbs), light vinaigrette (2 Tbs.), steamed broccoli (1/2 cup), biscotti, almond, drom bakery (1 pc.), tea, herbal, no sweetener (8 oz.)

 

Current diet order: clear liquids, nutrition consult

 

Helpful sources other than your textbook:

• Textbook of pathophysiology, e.g. Kumar et al.: Robbins &Cotran: Pathologic basis of disease, or trustworthy online sources, e.g. Medscape.com.
• A useful starting point is medicalstudent.com, which leads you to further webpages
• For drugs:
  • Pronksy et al.: Food Medication Interactions. (currently 18^th edition)
  • Medline Plus (.gov)(this is a starting point), http://www.fda.gov/Drugs/default.htm (sometimes helpful), rxlist.com, WebMD, epocrates (requires registration, free, worth the effort in my humble opinion)

 

 

Questions:

1. What are the typical symptoms of a patient with celiac disease or gluten-sensitive enteropathy?

 

2. Explain the acronyms in the initial assessment:
   1. RRR (heart):
   2. PERRLA:
   3. Oriented x 4:

 

3. Explain the following tests: What do they measure and how does this relate to Celiac Disease or to non-celiac gluten-sensitivity (NCGS)?
   1. EMA
   2. tTG
   3. ASCA
   4. AGA DGP IgA and IgG
   5. HLA DQ2

 

4. Another test set performed is done using supernatants of a tissue biopsy. Explain what this test set consists of and, briefly, how and why it is done.

 

5. What micronutrients do you expect to be linked to the patient’s celiac disease?

 

6. The diagnosis made is Celiac Disease. Provide guidelines for MNT for this disease. Be sure to indicate the source.

 

7. The differential diagnosis included non-celiac gluten sensitivity. What is the appropriate MNT for this disease? Be sure to indicate the source.

 

8. Which cereal grains contain gluten? (find a source different from the lecture slides)

 

9. Which foods are safe to eat on a gluten-free diet? (find a source different from the lecture slides)

 

1. How would you modify this patient’s diet (24-hour recall) to provide for relief of symptoms?

 

1. How does a patient identify foods, beverages, dietary and herbal supplements, and medications that contain gluten?

 

2. Evaluate Ms. CD’s % UBW and BMI.

 

3. Calculate Ms. CD’s energy requirements. Be sure to include the formula you use to determine this, including the name of the formula.

 

4. Estimate protein requirements for Ms. CD. Be sure to include the source for your estimate.

 

5. Identify any significant and/or abnormal laboratory measurements from the CBC and chemistry labs.

 

6. Select two nutrition problems and complete the PES statement for each. Use the appropriate NCP terminology.

 

7. You find in the chart that the patient has not consumed anything other than clear liquids for 5 days, due to several test procedures. What diet would you recommend? Provide reasons for your choice.

 

8. For each of the PES statements you have written, establish an ideal goal based on Ms. CD’s signs and symptoms, and an appropriate intervention, based on the etiology. Use the appropriate NCP terminology.

 

9. What parameters will you monitor and evaluate? Use the appropriate terminology from the NCP.

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