Lorena Menutti Renata Rosenberg

ADMITTED TO UNIVERSITY HOSPITAL ON 11/12 WITH FATIGUE, WEAKNESS,AND DIARRHEA

CC: I HAVE LOST TREMENDOUS AMOUNT OF WEIGHT, AND I HAVE BEEN HAVING TERRIBLE DIARRHEA FOR A WHILE NOW. I DONT EVEN HAVE THE ENERGY TO GET OFF THE COUCH RIGHT NOW.
HPI: Diarrhea on and off for most of her adult life She recently delivered a healthy son Gained 11lbs during pregnancy, since lost 30lbs Current weight: 92lbs Greatest non-pregnant weight: 112lbs PMH: 3 pregnancies-2 live births, 1 miscarriage at 22wks Prenatal vitamins, Kaopectate FH: Father has Coronary artery disease (cad) GI problems run on maternal side family

 Celiac

disease: complex, auto-immune disease with genetic, environmental characteristics The body has an abnormal reaction to gluten It can be diagnosed at any age, infancy through old age. Adults: after surgery, viral infection, severe emotional stress, pregnancy or childbirth. Females are more affected than males. Damage of the intestinal mucosa

 Small

intestine is exposed to gliadin (component of gluten) and inflammatory response in height and number of villis appearance of the villis

Toxic

Reduction Flattened Crypts

are elongated, causing mucosal malabsorption.

 Celiac

Disease : other systemic autoimmune disorders related to:

1 Diabetes Mellitus, Thyroid Disease, Systemic Lupus erythematous, William Syndrome, rheumatoidedararthritis. Disease Patient at risk of:

Type

Celiac

Lymphoma,

Osteoporosis, complications of nutrients deficiencies and malnutrition.

 Abdominal

cramping, intestinal gas

Distention
Chronic

and bloating of the stomach

diarrhea or constipation (or both) fatty stools

Steatorrhea

Weight

loss

 Fatigue,

weakness, lack of energy

herpetiformis

Dermatitis Stunted Adults:

growth in children and irritability

depression

Infertility

Anti-tissue transglutaminase antibody (tTG IgA and IgG)

Anti-endomysial antibody (EMA-IgA) Anti-deaminated gliadin peptide (DGP IgA and IgG) Total serum IgA Anti-gliadin antibody (AgA IgG and IgA) Biopsy

Gluten- Free Diet

Critical ill patients:

Immunosuppressant agents: Azathioprine, Cyclosporin A, Intravenous corticosteroid therapy

Research:

Orally active drugs: Bacterial prolylendopeptidase

Drug act by inhibiting activation of T- Cells.

Past Medical History

Patient has had diarrhea most of adult life Family members have funny stomachs Mother and grandmother have diarrhea

Diarrhea became much worse during recent pregnancy

Diarrhea is now debilitating Foul smelling Regardless of what she eats Gained 11lbs during pregnancy, has lost 30lbs since 3 pregnancies-2 live births, 1 miscarriage at 22wks Takes prenatal vitamins and Kaopectate Smoker Father has CAD (coronary artery disease)

Normal Albumin Total Protein Prealbumin Magnesium Osmolality HGB HCT MCHC 3.5-5 6-8 16-35 1.8-3 285-295 12-15 37-47 31.5-36

MG 2.9 g/dL 5.5 g/dL 13 mg/dL 1.6 mg/dL 275 mmol/kg/h2o 9.5 g/dL 34% 30 g/dL

Ferritin
Vitamin B12 Folate AGA antibodies EMA antibodies Fecal Fat

20-120
24.4-100 5-25 -------------------------------------

12 mg/mL
21.2 ng/dL 3 ug/dL positive positive 11.5

Anthropometric Data
Age: 36 Sex: Female Height: 53 (160cm) ABW: 92lbs (41.8kg) UBW: 112lbs (51kg)

%UBW: 82%, has recently lost 30lbs %IDW: 80%

IBW: 115lbs (52kg)

BMI: underweight 16 kg/m2 AMA (arm muscle area): 6.0 = below average (<5 = muscle deficit)

Estimated calorie and protein needs Usual body weight of 112lbs (51kg) Based on 40kcal/kg body weight

(51kg)(40kcal/kg) ~2000kcal/day (51kg)(2g protein/kg) = 102g protein/day (51kg)(30ml/kg)~ 1500ml

Based on 2g of protein/kg body weight

Based on 30ml/kg of fluid

Based on 2000kcal diet

102g Protein= 20% 275g CHO = 55% 70g Fat = 25%

 Usual

dietary intake Likes all foods but avoids eating them because it causes her diarrhea to start

Supplements

Prenatal
Smoker

vitamin and Kaopectate

 Inadequate

protein-energy intake related to malabsorption as evidenced by low lab values of albumin, HGB, HCT, Vitamin B12 and Ferritin. Food and nutrition related knowledge deficit related to consumption of gluten food products as evidenced by fatigue, weakness, diarrhea, malabsorption, and anemia. Inadequate vitamin B12 and folate intake related to malnutrition as evidenced by lab values.

Goal 1: Increase energy intake to promote healthy weight gain

Goal 2: Increase protein intake to counteract anemia and symptoms there of Goal 3: Eliminate all gluten (and temporarily lactose) from diet Goal 4: Educate patient on gluten free diet Goal 5: Recommend standard multivitamin

Recommend energy intake of 2000kcal a day and 102g of protein a day

Suggest Mediterranean diet

Recommend Boost High Protein Drink daily until weight is regained Recommend fluids of 1500ml a day until diarrhea subsides Counsel and educate patient on gluten free foods

What she can eat, including simple recipes What she cannot eat, how to read labels Websites for celiac disease (celiac foundation)

Advise patient on taking a gluten free standard multivitamin

Possibly taking Glutamine supplements

Expect improved lab values, and cessation of diarrhea and anemia with diet compliance
Patient will return to usual body weight within 3 months

Patient will be able to state gluten containing foods to eliminate from diet, and be able to read food labels
Patient will understand that a gluten free diet is lifelong and mandatory in terms of living a healthy life Follow up with patient in 4-6 weeks to see monitor compliance and symptoms

What is the basic treatment for celiac disease? a. Whole Wheat b. Standard multivitamin c. Gluten free diet d. Kaopectate

What is the most commonly used blood test for the screening of celiac disease? a. tTG b. EMA c. AGA d. ARA