1. 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

2. 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

3. 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.

4. 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 RangePatient Value Reason for Deviation
Patients Value Normal Range Probable reason for variance
Glucose 115 mg/dl Less than 140 mg/dl Normal
BUN 10 mg/dl 7 to 20 mg/dl Normal
Na+ 140 mEq/L 135 to 145 mEq/L Normal
K+ 3.8 mEq/L 3.5 to 5.0 mEq/L Normal
Cl- 102 mEq/L 96 to 106 mEq/L Normal
AST 10 U/L 10 to 34 U/L Normal
Hgb 10.8 g/dl 13.5 to 17.5 g/dl Lower than normal. Anemia
caused by CD
Hct 32.1 % 38.8 to 50 % Lower than normal. Anemia
caused by CD
Serum albumin 3.8 g/dl 3.5-5g/dl Normal
WBC 5 x 109
/L
4.5 to 11 *10^9/L Normal
RBC 4x10^3/L
3.9 to 5.03*10^6/mm^3 Normal
MCV 101 um3
80 to 100 um3
Higher than normal,
Macrocytic anemia
Creatinine 0.6mg/dl 0.7 to 1.3 mg/dl Lower than normal,
malnutrition, diarrhea
GGT 18U/L 8 to 65 U/L Normal
Cholesterol 115mg/dl Less than 200 mg/dl Normal
ALT 12U/L 7 to 35 U/L Normal
Ferritin 18 ng/dl 12 to 150 ng/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.

5. 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.

6. 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.