CELIAC DISEASE. Molly Jennings Deb McCafferty MS, RD

Transcription

1 CELIAC DISEASE Molly Jennings Deb McCafferty MS, RD

2 WHAT IS CELIAC DISEASE? In short In this disease, exposure to gluten results in damge to the intestinal mucosa. Immune-mediated disorder Also known as Non-tropical Sprue Gluten-sensitive enteropathy Gluten Intolerance Nelms, 2007

3 WHAT IS CELIAC DISEASE Gluten Ingestion Wheat, rye, barley, oats Gliadin absorbed into lamina propia Binds to receptors stimulating antibody response Cytokines are released destroy micro villi and brush border GLIADIN Compromised sm. intestinal wall poor absorption Malabsorption of essential nutrients Iron def. anemia Early onset osteoporosis Nelms, 2007

4 WHAT IS CELIAC DISEASE

5 PREVALENCE Much more common than previously predicted 1:133 Americans or 2-3 million people in the US! Strong evidence for occurrence in kids with Dermatitis herpetiformis Dental enamel defects Type 1 Diabetes IgA deficiency Down, Turner, or William syndrome 1 st degree relative diagnosed Hill, 2005 Nelms, 2007

6 CAUSES Three factors contribute Genetic predisposition gluten ingestion Immune-mediated response Genetic Predisposition Presence of human leukocyte antigen (HLA) 90% have HLA-DQ2 10% have HLA-DQ8 Wolters, 2008 Nelms, 2007

7 Aafp.org IN THE INTESTINE

8 Celiacdisease.about.com

9 SYMPTOMS Typical Celiac Disease Recurrent abdominal pain Constipation Vomiting Persistent diarrhea Bloating Chronic Fatigue Failure to thrive (in kids)

10 SYMPTOMS Atypical Celiac Disease Osteoporosis Iron Def. anemia Peripheral Neuropathy Dermatitis Herpetiformis 15-25% of people Hill,

11 DIAGNOSIS Test for tissue transglutaminase (TTG) IgA antibodies Deficiency is common in those with celiac disease so test may not show elevated levels Endomysial Antibody (EMA) Antigliadin Antibodies (AGA) IgA, IgG Inferior accuracy, no longer recommended Intestinal (duodenal) Biopsy Required for final diagnosis Hill, 2005

12 DIAGNOSIS

13 MEDICAL NUTRITION THERAPY Low fat, low fiber, lactose free diet For first few days after diagnosis To alleviate diarrhea Gluten Free Diet <50mg gluten/day for treatment Life-long avoidance of gluten Wheat, Rye, Barley, Oats? Oats 30g a day did not cause atrophy Intestinal swelling and cases of diarrhea or constipation were more common Peraaho, 2004 Catassi, 2007 Nelms, 2007

14 NUTRITION CARE PROCESS UNIVERSITY HOSPITAL Meet our Patient: Melissa Gaines

15 MELISSA GAINES Age: 36 Caucasian Female Secretary for hospital administrator Married with 2 sons age 4 and 3 months Height: 5 3 Current Wt: 92lbs

16 CHIEF COMPLAINT Extreme unintentional weight loss along with terrible diarrhea. Very low energy Hard to get off the couch right now

17 PATIENT HISTORY On and off diarrhea throughout adult life Intensified during recent pregnancy Mom and Grandmother have same symptoms Diarrhea is foul smelling no matter what she eats Delivered son 3 months ago Stopped breastfeeding 3 weeks ago because she felt so bad Gained 11 lbs during recent pregnancy and has lost 30 lbs since.

18 PATIENT HISTORY Meds: Prenatal vitamins, Kaopectate Smoker? Yes Father has CAD

19 PHYSICAL EXAM Skin: Pale without lesions Abdomen: Not distended; diminished bowel sounds

20 NUTRITION HISTORY Usual Dietary Intake Likes all foods Generally avoids eating because of subsequent diarrhea 24 Hour Recall Breakfast: Whole Wheat toast 1 tsp butter Hot tea, 2tsp sugar Lunch: 1c chicken noodle soup 2-3 saltine crackers ½ cup applesauce 12oz Sprite + sips 600 kcals total

21 NUTRITION HISTORY Reported Triggers Any food in large amounts Fried foods Meat especially beef Allergy maybe Nutrasweet?

22 PATIENT DIAGNOSIS Celiac Disease with secondary malabsorption and anemia

23 TREATMENT PLAN 24 hour stool collection for visual examination Upper gastrointestinal endoscopy Small bowel biopsy and possible duodenal aspirate Diet: 100-g fat diet for 3 days Result: 11.5g = steatorrhea!!

24 ADIM/E - ASSESSMENT Harris Benedict Equation (9.6*41.8kg) + (1.8*160.02cm) (4.7*36) = 1,176 BEE (1,176)(1.3) = 1,529 kcal + 250kcals (for anabolism) = 1,779 kcals (41.8kg)(1.2) = 50.6g protein/day Usual Wt: 112 Pregnancy Wt: 123 Now: 92lbs 18% unintentional weight loss 92/112 = 82% UBW

25 ADIM/E ASSESSMENT Lab values indicating malnutrition Normal Patient Albumin L Total Protein L Prealbumin L Folate L B L Magnesium L Osmolality L

26 ADIM/E - ASSESSMENT Lab values indicating iron deficiency anemia Normal Patient HGB (women) 9.5 L HCT (women) 34 L MCHC L Ferritin (women) 12 L ZPP

27 ADIM/E - DIAGNOSIS Food and Nutrition related knowledge deficit (NB 1.1) related to no prior education as evidenced by new diagnosis.

28 ADIM/E INTERVENTION Comprehensive Nutrition Education (E 2) of gluten-free diet.

29 ADIM/E - INTERVENTION Encourage whole/enriched grains! Brown and wild rice, quinoa, buckwheat, rice flour Multivitamin with focus on Iron If reduced bone density encourage Ca and Vit D Education of the Gluten Free Diet!!!

30 ADIM/E - INTERVENTION Short-term outcome goals Long-term outcome goals Initiate gluten-free diet Heal villous atrophy Normalize prealbumin No further weight loss Maintain glutenfree diet Normalize hematological ranges Albumin, transferrin Weight gain to UBW

31 SCOPE OF PRACTICE Providing nutrition education about a gluten-free diet. Model/figure from readings

32 ADIM/E MONITOR/EVALUATE Compliance with gluten-free diet Strong correlation between gluten intake (lack of adherence to celiac diet) and intestinal cell damage and atrophy. Antibody levels Cross-Contamination Hidden sources of gluten in foods, medications, and supplements Quality of Life Physical, social, emotional Ciacci, 2002

33 REFERENCES Catassi C. A prospective, double-blind, placebo-controlled trial to establish a safe gluten threshold for patients with celiac disease. Am J Clin Nutr 2007; 85: Ciacci C, Cirillo M, Cavallaro R, Mazzacca G. Long-term follow-up of celiac adults on gluten-free diet: prevalence and correlates of intestinal damage. Digestion 2002; 66(3): PubMed ID: Evidence-based Nutrition Practice Guideline on celiac disease published 2009 at and copyrighted by the American Dietetic Association. Hill ID, Dirks MH, Liptak GS, et al: Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2005; 40: Guideline_for_the_Diagnosis_and_Treatment_of.1.aspx Peraaho M, Kaukinen K, Mustalahti K, Vuolteenaho N, Maki M, Laippala P, Collin P. Effect of an oats-containing gluten-free diet on symptoms and quality of life in celiac disease. A randomized study. Scand J Gastroenterol 2004; 39:27-31.PubMed ID: Wolters VM, Wiimenga C. Genetic background of celiac disease and its clinical implications. Am J Gastroenterol 2008; 103(1): National Digestive Diseases Information Clearinghouse. Dermatitis Herpetiformis: Skin Manifestation of Celiac Disease. Digestive Diseases ddiseases/pubs/dh/index.htm