CASE STUDY Mrs.

Melissa Gaines
Dx: Celiac Disease and secondary malabsorption and anemia

By Lauren Humphrey Fall 2011 NFSC 470

Case Questions

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 the anatomy of the small intestine?
The flat mucosa with atrophied villi indicates the intestinal cells have been significantly damaged, which leads to decreased absorption and digestion(10). The presence of hyperplastic crypts, which are abnormally large tube like depressions in the intestinal lining around the villa, indicates an immune response caused by celiac disease(9).

2.

What is the etiology of celiac disease? Is anything in Mrs. Gainess history typical of patients with celiac disease? Explain.

Celiac disease is an autoimmune disorder marked by damage to the intestinal mucosa leading to flattening of the villa when they are exposed to !-gliadin and other protein components of gluten, which can lead to malabsorption and maldigestion(10). Mrs. Gainess history of diarrhea, weight loss, abdominal pain, and malabsorption are all typical symptoms of celiac disease(12). The onset of celiac disease can be triggered by a pregnancy(10).

3.

How is celiac disease related to the damage to the small intestine that the endoscopy and biopsy results indicate?
Celiac disease elicits an immune response in the body that causes inflammation, damage to the intestinal cells causing the villi to atrophy and eventually flatten against the intestinal wall, and hyperplastic crypts(12)(9).

4.

What are AGA and EMA antibodies? Explain the connection between the presence of antibodies and the etiology of celiac disease.
Anti-gliadin antibody (AGA) and anti-endomysium antibody (EMA) are the antibodies that are released when the body elicits an immune response to !gliadin and other protein components of gluten(12). The inflammatory response causes white blood cells to infiltrate the intestine, producing antibodies that when present in lab analysis are used to diagnose celiac disease(12).

5.

What is a 72-hour fecal fat test? What are the normal results for this test?

The fecal fat test is a fat malabsorption test. The patient consumes 100g of fat a day for 3 days, the stool is then collected and tested for the presence of fat(11). A positive test results is indicated if patient has 6g of fat present in stool after 24 hours(11). A normal result is having less than 6g of fat in stool after 24 hours or at any time.

6.

Mrs. Gaines laboratory report shows that her fecal fat was 11.5 g fat/24 hours. What does this mean?
Mrs. Gainess results show that she has fat malabsorption, thus steatorrha, because 11.5g of fat was present in her stool after 24 hours(11).

7.

Why was the patients placed on a 100-g fat diet when her diet history indicates that her symptoms are much worse with fried foods?
The 100g of fat was given to the patient for the 72-hour fecal fat test, which was needed to see if patient is suffering from fat malabsorption(11).

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 protein composite that contains other protein components like !gliadin(12). Gluten is found in wheat, sometimes oats, barley, rye, and malt(12).

9.

Can patients on a gluten-free diet tolerate oats?

Oats contain a different protein than gluten, but can become contaminated by other wheat, barley or rye products during processing or manufacturing(12). Otherwise, most patients with celiac disease can tolerate oats if they are pure and uncontaminated(12).

10. What sources other than foods might introduce gluten to patient?

Products that can contain gluten include over the counter medications, vitamin and mineral supplements, and beauty products such as lipstick and lip balm, sunscreen, shampoos, soaps, cosmetics, lotions, toothpaste and mouthwash(8). It is also found in the glue on stamps and envelopes, and in the latex on rubber gloves(8).

11. Can patients with celiac disease also be lactose intolerant?

Due to the damage of the intestinal cells from celiac disease, patients can loose the enzyme lactase, which breaks down lactose, and have symptoms common with lactose intolerance, such as diarrhea and abdominal pain(10)(12). It is recommended they avoid lactose while symptoms of celiac disease are present(12). Once the villi destruction has been reversed lactose can typically be re-introduced into the diet(10).

12. Calculate the patients percent UBW and BMI, and explain the nutritional risk associated with each value.
UBW = 112 lbs. (given by patient) % UBW = 92 lbs. / 112 lbs. = 82 % Height = 53 = 63 inch BMI = 92 lbs 63 inch 63inch x 703 = 16.3 (Underweight) Mrs. Gainess is only 82% of her usual body weight and severely underweight. She is at great nutritional risk(10).

13. Calculate this patients total energy and protein needs using the HarrisBenedict equation or Mifflin-St. Jeor equation.
Age = 36yrs Height = 53 = 63 inch x 2.54 = 160 cm Weight = 92 lbs 2.2 = 41.8 kg BEE = 655 + (9.6 x 41.8 kg) + (1.8 x 160 cm) (4.7 x 36 yrs) BEE = 1175 kcals TEE = 1175 kcals x 1.3 (ambulatory) = 1527 kcals 1527 + 300 kcals (for anabolism) = 1827 kcals Protein = 41.8 kg x 1.3 g = 54.3 g of protein/day

14. Evaluate Mrs. Gainess 24-hour recall for adequacy.

Mrs. Gainess is only eating about 503 kcals/day, 9g fat, 33mg cholesterol, 2200mg sodium, 94.1g carbohydrates, 4.5g fiber, 25.4g sugar, 10.5 g protein, 82.9mg calcium, and 109mg potassium(2). She is not getting an adequate amount of any of these macro- or micronutrients. Her total calorie intake is very low and from her food choices it is also evident that she is not getting enough iron, vitamin B12, or folate(13).

15. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term.
Possible nutrition diagnoses include inadequate energy intake (NI-1.4), Inadequate oral food/beverage intake (NI-2.1), Evident protein energy malnutrition (NI-5.2), Inadequate protein-energy intake (NI-5.3).

Possible nutrition diagnoses for the Behavioral-Environmental domain include Food and nutrition-related deficit (NB-1.1), Undesirable food choices (NB-1.7), Poor nutrition quality of life (NB-2.5).

16. Evaluate Mrs. Gainess laboratory measures for nutritional significance. Identify all laboratory values that support a nutrition problem.

Mrs. Gainess albumin levels were 2.9 g/dL and her prealbumin was 13 mg/dL indicating mildly depleted visceral protein stores(10). Her HGB was 9.5 g/dL and HCT was 34%, which are both low and indicated iron-deficiency anemia(10). She also has low Folate, 21.2 ng/dL, and Vitamin B12, 85 mol/mol, possibly indicating macrocytic anemia(10). All lab values indicate that Mrs. Gaines is malnourished(10).

17. Are the abnormalities identified in question 16 related to the consequences of celiac disease? Explain.
Mrs. Gainess low protein levels are related to the malabsorption caused by the damage to the intestinal cells and flattened villi from the immune response of celiac disease(12). Iron deficiency anemia is also a common symptom presented by patients with celiac disease(12).

18. Are any symptoms from Mrs. Gainess physical examination consistent with her laboratory values? Explain.
Mrs. Gainess low albumin and prealbumin levels indicate that she is malnourished and has depleted visceral protein stores, which would be consistent with her thin frame, fatigue and weakness(10). She also has a low H & H, as well as low Vitamin B12 and Iron levels, which indicate anemia(10). This would also cause her to appear pale, and feel tired and weak(10).

19. Evaluate Mrs. Gainess other anthropometric measurements. Interpret this information for nutritional significance.
IBW = 100 + (5 x 3) = 115 lbs. % IBW = (92 lbs 115 lbs.) x 100 = 80% Mrs. Gainess is only 80% of her ideal body weight and has mildly depleted energy stores(10). She is severely underweight and malnourished.

20. From this information gathered within the clinical domain, list possible nutrition problems using the diagnostic term.
Possible nutrition diagnoses include Altered GI function (NC-1.4), Altered nutrition-related lab values (NC-2.2), and Underweight (NC-3.1).

21. Using the VA Nutrition Screening Form, what is this patients nutrition status level?
Mrs. Gainess nutrition status is 3, she is at a moderate nutritional risk.

22. Select two high-priority nutrition problems and complete the PES statement for each.
-

Altered GI function (NC-1.4) related to celiac disease and steatorrhea as evidenced by diarrhea, fat malabsorption, flattened mucosa and atrophied villi, and hyperplastic crypts. Food and nutrition-related knowledge deficit (NB-1.1) related to no prior education on gluten-free, lactose-free, low-fat and low-oxalate diet as evidenced by a new diagnosis of celiac disease and steatorrhea.

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).
Goal: Alleviate symptoms of steatorrhea, such as diarrhea, and reverse damage to intestinal cells caused by celiac disease. Normalize nutritionrelated laboratory values. Intervention: Meals and Snacks (ND-1), change hospital diet to glutenfree, lactose-free and low in fat.

Goal: Demonstrate understanding of basic principles of a gluten-free, lactose-free, and low-oxalate and low-fat diet. Demonstrate ability to identify foods and ingredients that contain gluten, oxalates, and are high in fat. Intervention: Comprehensive Nutrition Education (E-2) on what foods and non-food items may contain gluten as well as foods that have lactose and are high in fat and oxalates.

24. What type of diet would you initially begin when you consider the potential intestinal damage that Mrs. Gaines has?
Mrs. Gaines needs to be on a gluten-free diet as well as a temporary lactosefree, low-fat and low-oxalate diet that also incorporates MCT oil(10). I would also recommend an iron and vitamin B12 supplement for Mrs. Gaines due to her deficiency in these micronutrients.

25. Mrs. Gainess nutritional status is so compromised that she might benefit from high-calorie, high-protein supplementation. What would you recommend?

Mrs. Gaines could benefit from a high-protein supplementation that is low in fat but may contain MCT oil(10). I would recommend the Ensure High Protein drink(4). Some patients with celiac disease have not tolerated ensure products well but can consume Boost products(3). I would then recommend the Boost High Protein Drink(1). Both drinks are high in protein but low in fat(1)(4).

26. Would glutamine supplementation help Mrs. Gaines during the healing process? What form of glutamine supplementation would you recommend?
The amino acid Glutamine, when used as a supplement, can maintain integrity of the gut, translocates bacteria, and immune cells such as lymphocytes and macrophages need it(13). I would recommend a glutamine supplement in a tablet form for Mrs. Gaines. She might tolerate the tablet better than a liquid or powdered since she is suffering from diarrhea and should avoid sugar and milk(5).

27. What result can Mrs. Gaines expect from restricting all foods with gluten? Will she have to follow this diet for very long?

Mrs. Gaines can expect to feel better, stronger, and have more energy. She should eventually have relief from her diarrhea and abdominal pain, and start to gain weight, as the destruction to her villi reverses and her intestinal cells heal(10). She will have a lifelong restriction of gluten and gluten-containing products(12). The lactose-free, low-fat and low-oxalate diet is only temporary and she can begin re-introducing these foods once her intestine has healed(10).

28. Evaluate the following excerpt from Mrs. Gainess food diary. Identify the foods that might be tolerated on a gluten/gliadin free diet. For each food identified, provide an appropriate substitute.
Cornflakes Bologna slices Lean Cuisine Ginger Stir Fry with Chicken Skim Milk Cheddar cheese spread Green bean casserole Gluten-free chex cereal(6) Hormel natural choice cooked deli ham(7) Amys Gluten-free Stir Fry(6)

Coffee Rice crackers Fruit cocktail Sugar Pudding V8 Juice Banana Cola

OK Aged hard cheese(6) Homemade casserole with fresh green beans, onions, mushrooms, and gluten free pasta with goat cheese or other hard cheese and milk(6) OK OK Fresh fruit or canned(6) OK OK OK OK OK, see if tolerated, should be evaluated(6)

Reference list
1. Boost High Protein Drink. Boost Complete Nutritional Drink. 2011. Retrieved from http://www.boost.com/nutritional-drinks/boost-high-protein/boost-high-proteindrink 2. Calorie King. Retrieved from http://www.calorieking.com/foods/calories-in-sodassoft-drinks-sprite_f-ZmlkPTUyNzUz.html 3. Ensure Gluten Free? Celiac Disease and Gluten Free Forum. 2010. Retrieved from http://www.celiac.com/gluten-free/topic/67845-ensure-gluten-free/ 4. Ensure High Protein. Ensure Nutrition in Charge. 2011. Retrieved from http://ensure.com/products/ensure-high-protein 5. Glutamine. University of Maryland Medical Center. http://www.umm.edu/altmed/articles/glutamine-000307.htm 6. Gluten-free diet: Basic diet choices. Celiac Solution. Retrieved from http://www.celiacsolution.com/celiac-diet.html 7. Gluten Free Foods. Hormel Foods. 2011. Retrieved from http://www.hormelfoods.com/brands/glutenfree/default.aspx 8. Hidden Sources of Gluten. Celiac Solution. Retrieved from http://www.celiacsolution.com/hidden-gluten.html 9. Lapid N. Marsh Stage of Celiac Disease. About.com. 2009. Retrieved from http://celiacdisease.about.com/od/diagnosingceliacdisease/ss/MarshScore.htm 10. McCafferty, D. Medical Nutrition Therapy I. Fall 2011. Retrieved from course notes. 11. Nelms M, Sucher KP, Lacey K, Roth SL. Fat Malabsorption. Nutrition Therapy & Pathophysiology 2/e. 2011: 2; 398 12. Nelms M, Sucher KP, Lacey K, Roth SL. Celiac Disease. Nutrition Therapy & Pathophysiology 2/e. 2011: 2; 402 -403 13. Silliman, K. Advanced Human Nutrition. Fall 2011. Retrieved from course notes.