Celiac Disease  NOTES  EXAM Description  Also called Gluten-Sensitive Enteropathy.  Is a disease of the small intestine marked by atrophy of the villi and microvilli caused by an immune-mediated inflammatory response to gluten, a protein found in common grains such as wheat, rye, oats, and barley.  The cause is unknown, but genetic, environmental, and immunologic elements maybe involved.  The disease is triggered by surgery, pregnancy, viral infection, or severe emotional distress.  It is most common in young children ages 6 to 24 months but can occur at any age.  Symptoms typically diminish or disappear in adolescence and reappear in early adulthood.  Complications include impaired growth, inability to fight infections, electrolyte imbalance, clotting disturbance, and possible predisposition to malignant lymphoma of the small intestine. Assessment Ages 3 to 9 months 1. Acutely ill; severe diarrhea and vomiting 2. Irritability 3. Possible failure to thrive Ages 9 to 18 months 1. Slackening of weight followed by weight loss 2. Abnormal stools  Pale, soft, bulky  Offensive odor  Greasy (steatorrhea)  May increase in number 3. Abdominal distention 4. Anorexia, discoloration of teeth 5. Muscle wasting: most obvious in buttocks and proximal parts of extremities 6. Hypotonia, seizures 7. Mood changes: ill humor, irritability, temper tantrums, shyness 8. Mild clubbing of fingers 9. Vomiting: usually occurs in the evening 10. Aphthous ulcers, dermatitis Older Child and Adult 1. Signs and symptoms are commonly related to nutritional or secondary deficiencies resulting from disease.  Anemia, vitamin deficiency (A, D, E, K)  Hypoproteinemia with edema  Hypocalcemia, hypokalemia, hypomagnesemia  Hypoprothrombinemia from vitamin K deficiency  Disaccharide (sugar) intolerance  Osteoporosis due to calcium deficiency 2. Anorexia, fatigue, weight loss. 3. May have colicky abdominal pain, distention, flatulence, constipation, and steatorrhea. Diagnostic Evaluation 1. Small bowel biopsy, which demonstrates characteristic abnormal mucosa. 2. Hemoglobin, folic acid, and Vitamin K levels may be reduced. 3. Prothrombin time may be prolonged. 4. Elevated immunoglobulin (Ig) A endomysium antibodies and IgA anti-tissue transglutaminase antibodies. 5. Total protein and albumin may be decreased. 6. 72 hour stool collection for fecal fat is increased. 7. D-xylose absorption test – decreased blood and urine levels. 8. Sweat test and pancreatic function studies may be done to rule out cystic fibrosis in child. Therapeutic Intervention 1. Dietary modifications includes a lifelong gluten-free diet, avoiding all foods containing wheat, rye, barley, and possibly, oats. 2. In some cases, fats maybe reduced. 3. Lactose and sucrose may be eliminated from diet for 6 to 8 weeks, based on reduced disaccharidase activity. The Gluten-free Diet: Some Examples In 2006, the American Dietetic Association updated its recommendations for a gluten-free diet. The following chart is based on the 2006 recommendations. This list is not complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or physician who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten. Allowed Foods amaranth arrowroot buckwheat cassava corn flax Indian rice grass Job’s tears legumes millet nuts potatoes quinoa rice sago seeds sorghum soy tapioca teff wild rice yucca Foods To Avoid wheat   including einkorn, emmer, spelt, kamut wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein barley rye triticale (a cross between wheat and rye) Other Wheat Products bromated flour durum flour enriched flour farina graham flour phosphated flour plain flour self-rising flour semolina white flour Processed Foods that May Contain Wheat, Barley, or Rye* bouillon cubes brown rice syrup candy French fries gravy imitation fish seasoned tortilla chips self-basting turkey soups chips/potato chips cold cuts, hot dogs, salami, sausage communion wafers matzo rice mixes sauces soy sauce vegetables in sauce * Most of these foods can be found gluten-free. When in doubt, check with the food manufacturer. Nursing Intervention 1. Monitor dietary intake, fluid intake and output, weight, serum electrolytes, and hydration status. 2. Make sure that the diet is free from causative agent, but inclusive of essential nutrients, such as protein, fats, vitamins, and minerals. 3. Maintain NPO status during initial treatment of celiac crisis or during diagnostic testing. 4. Provide parenteral nutrition as prescribed. 5. Provide meticulous skin care after each loose stool and apply lubricant to prevent skin breakdown. 6. Encourage small frequent meals, but do not force eating if the child has anorexia. 7. Use meticulous hand washing technique and other procedures to prevent transmission of infection. 8. Assess for fever, cough, irritability, or other signs of infection. 9. Teach the parents to develop awareness of the child’s condition and behavior; recognize changes and care for child accordingly. 10. Explain that the toddler may cling to infantile habits for security. Allow this behavior, it may disappear as physical condition improves. 11. Stress that the disorder is lifelong; however, changes in the mucosal lining of the intestine and in general clinical conditions are reversible when dietary gluten is avoided.