case study celiac disease quizlet

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Case Study – Celiac Disease and Digestion

I designed this digestive system case study for my anatomy class and remote learners. The goal is for students to understand how digestion works and how an autoimmune disease (celiac) interferes with the process. I focused on specific details of the system, like villi and absorption of nutrients across the mucosa.

The case study on celiac disease can be completed independently or in small groups.

To start, this case introduces a person who was diagnosed with celiac disease and links to that person’s blog . I am fairly vague with the opening on this one, and the symptoms can describe anyone with celiac disease. After reading the introduction and symptoms, students answer questions from the text.

At this point, they will not need to look anything up unless they just need to refresh their memory on the sequence of structures in the alimentary canal. I assigned this activity after students learned about the digestive system and completed the digestive system labeling There are several challenging terms in this section, such as chronic disease, gastrointestinal, autoimmune, and malabsorption. I encourage students to use google to look up words they don’t understand.

Diagnosis and Treatment

Next, students examine photos from an endoscopy showing a normal duodenum and one from a person with celiac disease. Students learn that a blood test (serology) can detect the presence of antibodies in the blood that are known to attack tissues of the gut. They learn that a biopsy test can reveal microscopic changes in the lining of the gut. An image shows the progression of the disease and the presence of lymphocytes in the cells, as well as the changes in other cells. Over time, the villi flatten and lose their ability to absorb nutrients.

Each section is followed by questions to assess reading comprehension and understanding of the graphics. Students apply knowledge by analyzing data used to classify different types of celiac disease. On the final page, I tasked them with designing a daily meal plan that does not include gluten. Finally, students write a short summary to explain the basics of the disease to a fictional younger sister.

Shannan Muskopf

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Jane Han and Kara Mead

Celiac Disease Case Study

The following is a scenario of a 19 year-old female, Liz Gavin, who came into the Emergency Department by the ambulance in the morning with complaints of diarrhea and vomiting for a week, abdominal pain, weight loss of 15 pounds in one month, fatigue, dehydration, severe thirst, and paralysis of her lower extremities. She has a family history of Diabetes type 1, Celiac Disease, Rheumatoid Arthritis, and Psoriasis. She has a personal history of Celiac Disease, chronic constipation, weight loss, and abdominal pain associated with her Celiac Disease diagnosis. In the Emergency Department, her labs were taken and she had a hemoglobin of 9, a diagnosis. In the Emergency Department, her labs were taken and she had a hemoglobin of 9, a hematocrit of 32, a potassium of 2.8, a total protein f 5.0, a calcium of 8., a magnesium of 1.0, and metabolic acidosis. Her vitals in the emergency department were heart rate of 103, respiratory rate of 20, blood pressure of 85/50, oxygen saturation of 98%, temperature of 98.7 degrees fahrenheit, and stabbing pain of 8 in her abdomen. Liz was diagnosed with Celiac Crisis. Celiac Crisis is a life threatening form of Celiac Disease that starts with the classic gastrointestinal symptom of diarrhea that leads to dehydration and electrolyte imbalances (Hijaz, Bracken, & Chandratrem, 2014).

She was transferred to the ICU for care. In the ICU she was treated for her dehydration, fluid and electrolyte imbalances, hypotension, nausea/vomiting, and her overall Celiac Crisis. This was done with intravenous lactated ringers, supplements of potassium, magnesium, and calcium. She was also given norepinephrine to increase her blood pressure, Zofran for her nausea, dapsone for her skin rash, and prednisone to treat the overall Celiac Crisis. Upon assessment the primary nurse found that the cause of Liz’s Celiac Crisis was due to nonadherence to her dietary regimen. She is a freshman in college and though she was compliant to her gluten free diet previously, the pressures of fitting into a new school and environment led her to stop her diet. She was educated by the nurse on the signs of Celiac Crisis in the future in order to get help immediately. She was also referred to a dietician, case management, and tele psych in order to help her cope with her disease process and prevent complications in the future.

Discussion Questions

• What are some relevant nursing diagnosis to this patient?
• What are some relevant laboratory results for this patient?
• What is the appropriate treatment for this patient?

Question 1: Risk for imbalanced nutrition, risk of infection, ineffective coping, anxiety, fluid and electrolyte imbalances

Question 2: Potassium, PT and PTT, Hemoglobin and Hematocrit, Magnesium, Calcium, Protein

Question 3: Corticosteroids, gluten-free diet, fluids, support group, vitamins

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• Patient Care & Health Information
• Diseases & Conditions
• Celiac disease

Your small intestine is lined with tiny hairlike projections called villi, which absorb sugars, fats, proteins, vitamins, minerals and other nutrients from the food you eat. Gluten exposure in people with celiac disease damages the villi, making it hard for the body to absorb nutrients necessary for health and growth.

Celiac disease is an illness caused by an immune reaction to eating gluten. Gluten is a protein found in foods containing wheat, barley or rye.

If you have celiac disease, eating gluten triggers an immune response to the gluten protein in your small intestine. Over time, this reaction damages your small intestine's lining and prevents it from absorbing nutrients, a condition called malabsorption.

The intestinal damage often causes symptoms such as diarrhea, fatigue, weight loss, bloating or anemia. It also can lead to serious complications if it is not managed or treated. In children, malabsorption can affect growth and development in addition to gastrointestinal symptoms.

There's no definite cure for celiac disease. But for most people, following a strict gluten-free diet can help manage symptoms and help the intestines heal.

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The symptoms of celiac disease can vary greatly. They also may be different in children and adults. Digestive symptoms for adults include:

• Weight loss.
• Bloating and gas.
• Abdominal pain.
• Nausea and vomiting.
• Constipation.

However, more than half the adults with celiac disease have symptoms that are not related to the digestive system, including:

• Anemia, usually from iron deficiency due to decreased iron absorption.
• Loss of bone density, called osteoporosis, or softening of bones, called osteomalacia.
• Itchy, blistery skin rash, called dermatitis herpetiformis.
• Mouth ulcers.
• Headaches and fatigue.
• Nervous system injury, including numbness and tingling in the feet and hands, possible problems with balance, and cognitive impairment.
• Joint pain.
• Reduced functioning of the spleen, known as hyposplenism.
• Elevated liver enzymes.

Children with celiac disease are more likely than adults to have digestive problems, including:

• Chronic diarrhea.
• Swollen belly.
• Pale, foul-smelling stools.

The inability to absorb nutrients might result in:

• Failure to thrive for infants.
• Damage to tooth enamel.
• Irritability.
• Short stature.
• Delayed puberty.
• Neurological symptoms, including attention-deficit/hyperactivity disorder (ADHD), learning disabilities, headaches, lack of muscle coordination and seizures.

Dermatitis herpetiformis

Gluten intolerance can cause this blistery skin disease. The rash usually occurs on the elbows, knees, torso, scalp or buttocks. This condition is often associated with changes to the lining of the small intestine identical to those of celiac disease, but the skin condition might not cause digestive symptoms.

Health care professionals treat dermatitis herpetiformis with a gluten-free diet or medicine, or both, to control the rash.

When to see a doctor

Consult your health care team if you have diarrhea or digestive discomfort that lasts for more than two weeks. Consult your child's health care team if your child:

• Is irritable.
• Is failing to grow.
• Has a potbelly.
• Has foul-smelling, bulky stools.

Be sure to consult your health care team before trying a gluten-free diet. If you stop or even reduce the amount of gluten you eat before you're tested for celiac disease, you can change the test results.

Celiac disease tends to run in families. If someone in your family has the condition, ask a member of your health care team if you should be tested. Also ask about testing if you or someone in your family has a risk factor for celiac disease, such as type 1 diabetes.

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Your genes, combined with eating foods with gluten and other factors, can contribute to celiac disease. However, the precise cause isn't known. Infant-feeding practices, gastrointestinal infections and gut bacteria may contribute, but these causes have not been proved. Sometimes celiac disease becomes active after surgery, pregnancy, childbirth, viral infection or severe emotional stress.

When the body's immune system overreacts to gluten in food, the reaction damages the tiny, hairlike projections, called villi, that line the small intestine. Villi absorb vitamins, minerals and other nutrients from the food you eat. If your villi are damaged, you can't get enough nutrients, no matter how much you eat.

Risk factors

Celiac disease tends to be more common in people who have:

• A family member with celiac disease or dermatitis herpetiformis.
• Type 1 diabetes.
• Down syndrome, William syndrome or Turner syndrome.
• Autoimmune thyroid disease.
• Microscopic colitis.
• Addison's disease.

Complications

Celiac disease that is not treated can lead to:

• Malnutrition. This occurs if your small intestine can't absorb enough nutrients. Malnutrition can lead to anemia and weight loss. In children, malnutrition can cause slow growth and short stature.
• Bone weakening. In children, malabsorption of calcium and vitamin D can lead to a softening of the bone, called osteomalacia or rickets. In adults, it can lead to a loss of bone density, called osteopenia or osteoporosis.
• Infertility and miscarriage. Malabsorption of calcium and vitamin D can contribute to reproductive issues.
• Lactose intolerance. Damage to your small intestine might cause you abdominal pain and diarrhea after eating or drinking dairy products that contain lactose. Once your intestine has healed, you might be able to tolerate dairy products again.
• Cancer. People with celiac disease who don't maintain a gluten-free diet have a greater risk of developing several forms of cancer, including intestinal lymphoma and small bowel cancer.
• Nervous system conditions. Some people with celiac disease can develop conditions such as seizures or a disease of the nerves to the hands and feet, called peripheral neuropathy.

Nonresponsive celiac disease

Some people with celiac disease don't respond to what they consider to be a gluten-free diet. Nonresponsive celiac disease is often due to contamination of the diet with gluten. Working with a dietitian can help you learn how to avoid all gluten.

People with nonresponsive celiac disease might have:

• Bacterial overgrowth in the small intestine.
• Poor pancreas function, known as pancreatic insufficiency.
• Irritable bowel syndrome.
• Difficulty digesting sugar found in dairy products (lactose), table sugar (sucrose), or a type of sugar found in honey and fruits (fructose).
• Truly refractory celiac disease that is not responding to a gluten-free diet.

Refractory celiac disease

In rare instances, the intestinal injury of celiac disease doesn't respond to a strict gluten-free diet. This is known as refractory celiac disease. If you still have symptoms after following a gluten-free diet for 6 months to 1 year, you should talk to your health care team to see if you need further testing to look for explanations for your symptoms.

Celiac disease care at Mayo Clinic

• Rubio-Tapia A, et al. American College of Gastroenterology guidelines update: Diagnosis and management of celiac disease. American Journal of Gastroenterology. 2023; doi:10.14309/ajg.0000000000002075.
• Catassi C, et al. Coeliac disease. The Lancet. 2022; doi:10.1016/S0140-6736(22)00794-2.
• Singh P, et al. Who to screen and how to screen for celiac disease. World Journal of Gastroenterology. 2022; doi:10.3748/wjg.v28.i32.4493.
• What is celiac disease? Celiac Disease Foundation. https://celiac.org/about-celiac-disease/what-is-celiac-disease/. Accessed April 26, 2023.
• Feldman M, et al., eds. Celiac disease. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed April 26, 2023.
• Celiac disease. National Institute of Diabetes, Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease. Accessed April 26, 2023.
• Ami TR. AllScripts EPSi. Mayo Clinic. March 24, 2023.
• Khanna S (expert opinion). Mayo Clinic. May 12, 2023.

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• Coeliac disease vs gluten intolerance: Mayo Clinic Healthcare expert explains the difference Sept. 26, 2023, 10:00 a.m. CDT

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Celiac Disease NCLEX Practice Questions

This is a quiz that contains NCLEX review questions for Celiac Disease . As a nurse providing care to a patient with Celiac Disease, it is important to know the signs and symptoms, pathophysiology, nursing management, diet education, and complications.

In the previous NCLEX review series , I explained about other GI disorders you may be asked about on the NCLEX exam, so be sure to check out those reviews and quizzes as well.

This quiz will test your knowledge on Celiac Disease in preparation for the NCLEX exam.

B. Globulins

C. Gliadins

D. Glutamate

A. Over exaggerated intestinal villi

B. Ulcerations in the small intestine, specifically the Jejunum

C. Flat intestinal villi

D. Cobble-stone appearance throughout the small intestine

A. Antinuclear antibody (ANA)

B. Tissue Transglutaminase Antibodies (tTG-IgA)

C. IgA Endomysial antibody (EMA)

D. IgA serum

A. Seborrheic Dermatitis

B. Psoriasis

C. Dyshidrotic Eczema

D. Dermatitis Herpetiformis

A. Unexplained Weight loss

B. Jelly-like stools

C. Mouth ulcers

D. Menstrual irregularities

• E. Pain at McBurney's Point

F. Ribbon-like stools

G. Inability to tolerate dairy products

H. Enamel changes

A. Pork barbeque sandwich

B. Steak and steamed broccoli

C. Braised chicken with carrots

D. Vegetables and rice

A. lysine and proline

B. glutamine and cysteine

C. gliadin and gluten

D. proline and glutamine

E. Buckwheat

Celiac Disease NCLEX Questions

1. You’re educating a group of nursing students about the pathophysiology of Celiac Disease. You ask the group to identify the specific protein that plays a role in the immune reaction experienced in Celiac Disease. Which answer is correct?

2. A patient is suspected to be suffering from Celiac Disease. The physician orders an endoscopy. If the patient has Celiac Disease, what finding will be discovered with the endoscopy?

3. Which of the following is not an anti-body blood test ordered by a physician to diagnose Celiac Disease?

4. A patient, who was recently diagnosed with Celiac Disease, has blister type bumps on the elbow and knees. The patient reports it is extremely itchy. As the nurse, you know this is as known as:

5. During an outpatient clinic visit, a female patient reports feeling abdominal bloating/pain, and diarrhea when eating foods that contain wheat or rye. The patient states her mother was diagnosed with Celiac Disease 5 years ago. What other symptoms will you assess the patient for that can be present in Celiac Disease? SELECT-ALL-THAT-APPLY:

E. Pain at McBurney’s Point

6. Your patient was admitted 3 days ago for treatment of severe malnourishment secondary to Celiac Disease. The patient is doing well and will be discharged tomorrow. When you arrive to the patient’s room, the patient’s friends and family are visiting and have brought dinner for the patient. Which food item below should the patient avoid consuming?

7. Gliadin is a wheat prolamin, which is a plant storage protein that is high in the amino acids particularly ____________  and ___________.

8. You’re helping a mother, whose child was recently diagnosed with Celiac Disease, read food labels. Which items below, if listed as the ingredients, should the mother avoid feeding her child?

1. C 2. C 3. A 4. D 5. A, C, D, G, H 6. A 7. D 8. B, C, F More NCLEX Quizzes

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Celiac Disease

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#38563: Celiac Disease

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T is a girl, 7 years of age, who presents to her pediatrician, Dr. G, with complaints of fatigue, abdominal cramping, and diarrhea. T weighed eight pounds, three ounces at birth, and her growth and development have been consistent and appropriate. She has no pre-existing conditions and is current on all of her immunizations.

T is afebrile and her vital signs are within normal limits. A diagnosis of viral gastritis is made. Dr. G advises T's mother (Mrs. H) to limit her daughter's diet to bland foods and give the symptoms time to run their course. Mrs. H is advised to call if symptoms do not improve.

At home, T rests and consumes chicken broth and gelatin. After three days, she is feeling better and ready to return to school. At school the next day, T lunches at 11:30 a.m. on tomato soup, a grilled cheese sandwich, and mixed fruit. T is feeling tired but otherwise well. She consumes all of her soup and fruit, but only a few bites of the sandwich. Around 1:00 p.m., T complains to her teacher of stomach cramping and asks to go to the restroom.

Mrs. H picks T up from school at 3:00 p.m.; T continues to experience stomach cramping and tells her mother that she has had three episodes of diarrhea that day. When she arrives home, T consumes nothing but gelatin and ginger ale and spends the rest of the day in bed. Although T feels better the next morning, Mrs. H keeps her at home and in bed and continues to give T only gelatin, chicken broth, and ginger ale. For the next two weeks, Mrs. H keeps T on a diet of soups and liquids to allow her stomach time to recover. When T appears to be improving, Mrs. H decides to slowly introduce other foods back into her diet.

Within two days, T relapses and experiences diarrhea, bloating, and stomach cramping. Mrs. H schedules a follow-up appointment with Dr. G, who re-evaluates T and discovers that she has lost one pound in body weight and that her stomach is tender to palpation. Dr. G orders additional workup, including blood work, with the following results:

Hemoglobin: 10.8 g/dL (Normal range: 11.5–14.5 g/dL)

Hematocrit: 34% (Normal range: 35% to 42%)

Platelets: 225 (Normal range: 250–500)

Sodium: 127 mEq/L (Normal range: 136–145 mEq/L)

Potassium: 3.3 mEq/L (Normal range: 3.5–5.0 mEq/L)

Calcium: 6.9 mg/dL (Normal range: 9.0–11.0 mg/dL)

Albumin: 2.6 g/dL (Normal range: 3.5–5.5 g/dL)

Mrs. H and T return to Dr. G's office to review the results of the blood work. T has continued to have spells of diarrhea and stomach pains, and she has lost an additional six ounces. Dr. G suspects that T has CD. He schedules further evaluation and an EGD.

Two weeks later, Mrs. H and T return to Dr. G's office for a consultation. Dr. G explains the study results, which revealed atrophy of intestinal villi. He explains that T is experiencing malabsorption of important nutrients, likely due to an intolerance to wheat, rye, or barley products in the foods she is eating. T is referred to a dietitian, Ms. D, who specializes in pediatric nutrition and CD.

T and her parents meet with Ms. D, who explains that CD is an immunologic response to wheat, rye, or barley products that causes destruction of the lining of the small intestine, which in turn causes malabsorption of important nutrients. Ms. D further explains that destruction of the lining leads to diarrhea, fatty stools, weight loss, foul-smelling gas, and iron-deficiency anemia. She reassures the family that, although it sounds frightening, CD is easily controlled with dietary changes and provides the family with a list of foods to avoid as well as sources of "hidden" gluten (e.g., school supplies).

Ms. D works with the family to develop one week's worth of gluten-free meals that T will be willing to eat. They openly and at length discuss challenges that the family may encounter. Ms. D recommends that the family explore a nearby CD support group, which can help them with the adjustments they need to make.

T and her mother return to Dr. G's office for a one-year check-up. T's laboratory tests are normal, and she is slowly gaining weight. Mrs. H reports that T has had some minor episodes of bloating and diarrhea after eating something on the forbidden list when at a friend's house. Dr. G states that T is progressing well and indicates that a few slips in the diet are to be expected, but reminds them that these should not be frequent.

One month later, Mrs. H finds T lying on her bed, crying. Mrs. H asks what is wrong, but T responds that she does not want to talk about it. When Mrs. H persists, T tells her that she was not invited to V's sleepover because V's mother is afraid that T will eat something she should not and get sick. She also reports taunting and feeling left out at school.

Mrs. H calls one of the mothers from the support group to discuss what is happening to T, and the mother provides Mrs. H with some helpful tips. Mrs. H then schedules a meeting with T's teacher to educate him about T's CD and to discuss ways to help lessen the alienation T is feeling. Mrs. H asks him to telephone her if another student's parent plans a celebration so that she can send in a special treat for T. He agrees and promises to be more aware of the way that T is being treated by her classmates.

Later in the week, Mrs. H calls V's mother and invites her to meet for coffee. When they meet the next day, Mrs. H explains what CD is and how it is controlled. She tells V's mother that she is not trying to force her to invite T to her home; she simply wants her to know that CD is nothing to fear. V's mother explains that she was not sure she wanted to take the risk of T becoming ill at her home if she ate something she was not supposed to have. Mrs. H responds that T is very knowledgeable about what she can and cannot eat and explains that small amounts of forbidden foods do not cause a severe reaction in T. That evening, V calls and invites T to the sleepover and apologizes for not having invited her sooner.

After the telephone call, Mr. and Mrs. H discussed some of the misconceptions that the school and their community had about CD. They decide to develop an educational program to present to area schools to increase awareness about CD. Six months later, they have presented the program to local schools and received positive responses and many questions. The next year, prior to the start of the school year, the couple is asked to return and present the information again.

T states that her school days improved greatly after the educational programs were presented.

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Celiac Crisis in an Adult Patient: Case Report and Review of the Literature

* corresponding author(s):.

We report a case of celiac crisis in a previously healthy 51-year-old female presenting with a month’s history of diarrhea, cachexia and an abnormal metabolic panel.The patient’s diarrhea resolved after initiation of a gluten free diet and she gained 4 kilograms during hospitalization. 

Celiac crisis is a very rare presentation of celiac disease in adults but nonetheless should be considered in patients with marked metabolic derangements in the setting of osmotic diarrhea.

Celiac crisis; Celiac disease; Gluten free diet; Hypokalemia; Tissue transglutaminase

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Introduction

Celiac Disease (CD) is an immune mediated inflammation of the small intestine caused by sensitivity to gluten and related proteins. Its prevalence ranges between 1:100 to 1:300 in most countries and manifests with a heterogeneous symptomatology [1]. Typical symptoms include chronic diarrhea and signs of malabsorption [2]. Celiac crisis is a fulminant manifestation of CD that presents with acute symptoms that often require hospitalization. It mainly affects pediatric patients under 2 years of age [3]. Due to its rarity in the adult population, with approximately 40 reported cases in the medical literature, clinicians need a high level of suspicion to recognize this clinical entity.

Case Presentation

A 51 years old woman was presented in the emergency department with a history of one month of diarrhea, accompanied by weight loss of 10 kilograms. The patient reported a frequency of 20 episodes of watery diarrhea per day with the absence of blood, mucus or steatorrhea. There was no history of fever, abdominal pain or recent travel abroad. She, also, denied any episode of night sweats or chills. She did not suffer from chronic illness or used any regular or illicit medication. Her family history was unremarkable. 

At the objective examination she appeared cachectic and fatigued, but with normal awareness. Her skin turgor and jugular venous pressure were decreased and her mucous membranes dry. Auscultation of the lungs and heart was normal with respiratory frequency 15 breaths per minute. Blood pressure was found to be 85/75 mmHg, saturation of oxygen98% and heart rate 105 beats per minute. The rest of the examination was unremarkable. 

Initial investigations revealed severe hypokalemia (K + : 1,8meq/L) and normal anion gap metabolic acidosis (PH: 7,30), consistent with the history of chronic diarrhea. Moreover, her serum sodium was 129 meq/L with urine sodium <5 mmol/L (hypovolemic hyponatraemia). The patient was treated with isotonic fluids and potassium intravenously and was admitted in the internal medicine department for further examination.

Additional laboratory examination indicated hypoalbuminemia (2.7 gr/dl), coagulopathy (INR: 4.4; APTT:55.9 sec) and positive tissue transgtlutaminase IgA antibodies (177U/ml). Stool examination did not suggest infectious etiology; neuroendocrine tumor work-up was negative while Computed Tomography (CT) of the upper and lower abdomen was free of pathological findings. Upper and lower endoscopies were performed and four biopsies were taken (stomach, duodenum and post bulbar duodenum). Histopathological exam describes increased intraepithelial lymphocytes, crypt hyperplasia and villous atrophy (Figure 1). 

The biopsy results together with the positive serological marker of CD are consistent with the diagnosis of CD.

The patient was started on low calorie gluten free diet (500 kcal/day) and received vitamin B complex in order to prevent refeeding syndrome. She showed clinical and laboratory improvement with the episodes of diarrhea limited to 1-2 daily and gained 4 kilograms in 15 days. The patient got referred to the CD clinic of the same hospital.

Celiac crisis is a rare and life-threatening form of CD fist described by Di Sant ‘Agnese in 1953 [4]. In 2010, Jamma and colleagues defined a celiac crisis as an acute presentation or rapid progression of gastrointestinal symptomatology, in CD patients, that requires medical attention [5]. Additionally, at least two of the following criteria have to be met. 

• • Weight loss > 5 kg
• • Neurological symptoms
• • Increased creatinine > 2g/dl
• • Hypoalbuminemia <3.0 g/dl
• • Severe dehydration or shock
• • Metabolic acidosis (PH <7,35)
• • Electrolyte abnormalities 

A recent review of the 42 reported cases described that, as CD, celiac crisis has a female predominance of 2:1. Furthermore, most of the patients (37/42) reported no past history of CD and their mean age of presentation was 50 years of age. Electrolyte imbalances, hypoproteinemia, metabolic acidosis and anemia were the most common abnormalities and the majority of patients indicated positive CD serology and advanced disease specific histopathological lesions (Marsh 3C stage) [6]. 

The present casefulfils five of the proposed criteria; weight loss of 10 kilograms, dehydration, severe hypokalemia/hyponatraemia, metabolic acidosis and hypoalbuminemia. Furthermore, it parallels the reported epidemiology of the disease as our patient was an otherwise healthy female of 51 years. 

Moreover, although, not a part of the diagnostic criteria, bleeding diathesis has been identified in celiac crisis patients [6-7]. We, too, found an abnormal coagulation panel, most probably due to vitamin K malabsorption. This assumption is strengthened with the normalization of the laboratory values after the start of gluten free feeding. 

Lastly, some reports suggest that celiac crisis is triggered by a preceding stimulus, such as surgery or infection [6,8]. In our case none was identified. 

Celiac crisis is an easy to treat but severe presentation of CD. Due to its rarity it often is low or non-existent in the differential diagnosis of diarrhea in adult patients. We suggest that all patients, fulfilling some of the criteria proposed by Jamma and colleagues or having increased levels of CD-related antibodies, should be placed on gluten free diet and undergo to endoscopic examination of the small bowel.

• Gujral N, Freeman HJ, Thomson AB (2021) Celiac disease: prevalence, diagnosis, pathogenesis and treatment. World J Gastroenterol 18: 6036-6059.
• Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA (2013) ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol 108: 656-676.
• Babar MI, Ahmad I, Rao MS, Iqbal R, Asghar S, et al. (2011) Celiac disease and celiac crisis in children. J Coll Physicians Surg Pak 21: 487-490.
• Andersen DH, Di Sant'agnese PA (1953) Idiopathic celiac disease. I. Mode of onset and diagnosis. Pediatrics 11: 207-223.
• Jamma S, Rubio-Tapia A, Kelly CP, Murray J, Najarian R, et al. (2010) Celiac crisis is a rare but serious complication of celiac disease in adults. Clin Gastroenterol Hepatol 8: 587-590.
• Balaban DV, Dima A, Jurcut C, Popp A, Jinga M (2019) Celiac crisis, a rare occurrence in adult celiac disease: A systematic review. World J Clin Cases 7: 311-319.
• MagroR, Pullicino E (2012) Coeliac crisis with severe hypokalemia in an adult. Malta Medical Journal 24: 36-39.
• Hammami S, Aref HL, Khalfa M, Kochtalli I, Hammami M (2018) Refeeding syndrome in adults with celiac crisis: a case report. J Med Case Rep 12: 22.

Citation:  Katsifis-Nezis D, Papazafiropoulou A, Vrakas S, Kampourogiani D, Kourkoulis P, et al. (2021) Celiac Crisis in an Adult Patient: Case Report and Review of the Literature. J Clin Stud Med Case Rep 8: 0116.

Copyright: © 2021  Dimitrios Katsifis-Nezis, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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• J Athl Train
• v.40(4); Oct-Dec 2005

Celiac Disease Symptoms in a Female Collegiate Tennis Player: A Case Report

James e leone.

*Southern Illinois University Carbondale, Carbondale, IL;

Kimberly A Gray

John e massie, jennifer m rossi.

†Deltona, FL

Objective: To present the case of a collegiate tennis player with celiac disease symptoms.

Background: Celiac disease is a common intestinal disorder that is often confused with other conditions. It causes severe intestinal damage manifested by several uncomfortable signs and symptoms. Failure by the sports medicine staff to recognize symptoms consistent with celiac disease and treat them appropriately can have deleterious consequences for the athlete.

Differential Diagnosis: Irritable bowel syndrome, Crohn disease, Addison disease, lupus erythematosus, juvenile rheumatoid arthritis, lactose intolerance, herpes zoster, psychogenic disorder (depression), fibromyalgia, complex regional pain syndrome, hyperthyroidism, anemia, type I diabetes.

Treatment: The athlete underwent a series of blood and allergen tests to confirm or refute a diagnosis of celiac disease. When celiac disease was suspected, dietary modifications were made to eliminate all wheat-based and gluten-based products from the athlete's diet.

Uniqueness: The athlete was able to fully compete in a competitive National Collegiate Athletic Association Division I tennis program while experiencing the debilitating effects associated with celiac disease. The immediacy of symptom onset was notable because the athlete had no history of similar complaints.

Conclusions: Celiac disease is a potentially life-threatening condition that affects more people than reported. A properly educated sports medicine staff can help to identify symptoms consistent with celiac disease early, so damage to the intestine is minimized. Prompt recognition and appropriate management allow the athlete to adjust the diet accordingly, compete at a high-caliber level, and enjoy a healthier quality of life.

Our purpose in developing this communication on celiac disease is fourfold: (1) to present the physical manifestations experienced by our patient, (2) to discuss celiac disease in general, (3) to explain why the disease is important to athletic trainers, and (4) to alert athletic trainers about the diagnosis and prognosis of celiac disease and prepare them to help the athlete once he or she is diagnosed.

Celiac disease is a hereditary hypersensitivity disorder causing malabsorption within the gastrointestinal tract, 1 which some experts believe is triggered by a virus. A hereditary hypersensitivity disorder results in the body's overreacting to a foreign substance. In celiac disease, this substance is an antigen ingested as gluten or gliadin-containing foods. The immune system of a susceptible person responds to the ingestion of gluten or gliadin by damaging the small intestinal mucosa, resulting in a reduced ability to absorb nutrients. 1 The disease itself has many interchangeable and descriptive names, including celiac sprue, nontropical sprue, gluten-sensitive enteropathy, celiac syndrome, and simply gluten intolerance. 1 The clinical presentation of the disease is vague at best because of the wide variety of symptoms with which it may be associated. These symptoms are numerous, varied, and potentially debilitating, ranging from physical ailments such as arthralgia, myalgia, chronic diarrhea, abdominal pain, and cramping to cognitive and behavioral changes. 2

Two schools of thought exist regarding the origin of the disease: genetic and viral. 3 Celiac disease is on the rise globally and particularly in the United States. 4 Whatever the origin, the incidence and failure to diagnose the condition can result in harmful consequences for the affected individual. Celiac disease is not a disease athletic trainers commonly deal with, and so we hope that presenting this case will increase awareness among athletic trainers and other health care professionals. By being familiar with this disease and considering the diagnosis in patients with suspicious symptoms, the athletic trainer can be of great benefit to both undiagnosed and established celiac disease patients.

CASE REPORT

A 20-year-old female collegiate tennis player presented in the athletic medicine facility on October 14, 2001, complaining of diffuse myalgia centered in her midback. Her height was 162.5 cm and her mass was 58.2 kg. Her father's height was 182.9 cm; her mother's, 172.2 cm; and her sister's, 175.3 cm. Vital signs were temperature of 98.2°F, respirations of 13 per minute, and blood pressure of 118/76 mm Hg. The subject had severe eczema in 1996 and mononucleosis in 2000. In April 2001, she developed arthralgia, myalgia, chronic diarrhea, and profound fatigue. She saw her pediatrician in May 2001 and was referred to an allergist, who found negative reactions to a multitude of substances. Because of her symptom severity and persistence, the athlete was referred for further, more specific testing. An enzyme-linked immunosorbent assay test was conducted in July 2001. This assay tests the patient's blood for antibodies to specific substances (antigens). The patient showed positive reactions to gluten, spelt (a member of the same grain family as wheat and oats but an entirely different species), albumin, lactose, barley, and rye, as well as other wheat-based substances ( Figure 1 ).

Celiac disease was considered at this point, but a firm diagnosis was not made. The athlete and her mother both experienced symptoms of celiac disease; therefore, an effort to find a diagnosis for their joint symptoms was undertaken. The athlete's symptoms may have been caused by leaving home for college, where she was subjected to a “regular” diet. The diet she followed at home may have evolved to minimize the foods that tended to bring on the symptoms.

The athlete reported typical gastrointestinal distress (nausea, diarrhea, black and tarry stools, and intestinal cramping), arthralgia, lack of attentional focus, back spasms, and general feelings of malaise. She also had a history of lactose intolerance and suspicious skin rashes and family history of a “wheat allergy” diagnosed in her maternal grandfather at age 90. The athlete's symptoms started in August 2000, when she began college. Her outward physical appearances were judged normal by the athletic trainers in the athletic medicine facility, aside from a slight painful rash on her back that consisted of reddened papules without drainage.

Interestingly, the athlete was able to fully participate in a competitive National Collegiate Athletic Association Division I women's tennis program and lost virtually no time from competition or practice because of her condition. After the tentative diagnosis, the athlete was allowed to continue competing fully as tolerated.

The differential diagnosis included irritable bowel syndrome, Crohn disease, Addison disease, lupus erythematosus, juvenile rheumatoid arthritis, lactose intolerance, herpes zoster, psychogenic disorder (depression), fibromyalgia, complex regional pain syndrome, hyperthyroidism, anemia, type I diabetes, and celiac disease. The athlete was tested for diabetes and lupus with negative results.

During the course of testing, we treated the spasms of her back muscles with physical modalities, (ice, massage, and electric stimulation) and nonsteroidal anti-inflammatory drugs. Treatment was continued for approximately 3 weeks, yielding minimal improvement of her back spasms. We initiated an aggressive stretching and strengthening program because of the lack of response to other treatments. The focus was on improving scapular stability and postural control. Two weeks of treatment produced short-term reduction of her back pain and spasms. However, because of her persistent gastrointestinal, cognitive, and systemic complaints, further consultation with the athlete's physicians and the school physician was deemed necessary. The physicians disagreed about the possible diagnosis of celiac disease and, therefore, the insurance company declined to cover a jejunal mucosal biopsy. The patient was advised to follow a gluten-free and wheat-free diet to see whether her symptoms improved.

The athlete and her mother chose to try a wheat-free diet to eliminate most sources of wheat and gluten after learning the results of the enzyme-linked immunosorbant assay. The diet resulted in a marked decrease in symptoms such as myalgia, arthralgia, flatulence, and fatigue in both, reinforcing the likelihood that the symptoms were celiac in nature.

The Gastrointestinal Tract: Absorption and Celiac Disease

General overview.

The digestive tract includes the mouth, teeth, pharynx, esophagus, stomach, and intestines, as well as exocrine glands such as the liver, pancreas, and salivary glands. The primary function of the gastrointestinal tract is to aid in the digestion and absorption of nutrients. Nutrients within this canal are not considered to be within the body until they are absorbed via the intestines. This absorption and secretion occurs at the inner layers of the gastrointestinal tract, the gastrointestinal mucosa. The mechanical process of breaking food down into its constituents is digestion. As the smaller food molecules pass through the mucosal cells of the small intestine into the blood and lymphatic system, absorption occurs. 5–8

The Small Intestine

The intestine is a series of convoluted tubes with 3 distinct subdivisions: the duodenum, the jejunum, and the ileum. 5, 6, 8 The duodenum receives partially digested food from the stomach and begins the absorption of nutrients, whereas the jejunum and ileum move the food further along while absorbing nutrients. The coils of the small intestine dominate the abdominal cavity, averaging 6 to 7 m in length. 7, 8 The small intestine absorbs digested molecules of food into the bloodstream and lymphatic system via the gastrointestinal mucosa. 5 Typically, all products of carbohydrate, lipid, and protein digestion, as well as most ingested electrolytes and vitamins, are absorbed by the small intestine, with little absorption occurring in the duodenum and jejunum. 5

Finger-like projections, villi are present in the small intestinal mucosa to increase the absorptive surface area. The movement of the villi during the digestive process is made possible by a slip of smooth muscle that extends into the core of each villus. These muscular motions enhance absorption. 6, 7 The surface area is further increased by the infolding of epithelium between the bases of the villi, forming tubular intestinal glands, or crypts of Lieberkühn. 5–7 Villi are considered very effective structures in that they increase absorption by 600 times. 5

Diagnosing Celiac Disease

The “gold standard” for diagnosing celiac disease is through a jejunal mucosal biopsy sample to measure the extent of the damage. 2, 4, 9, 11 However, subjective findings with minimal objective evidence often lead to an inconclusive diagnosis, as was the case with this athlete. Another method is the enzyme-linked immunosorbant assay (ELISA). Both procedures are costly, 4, 9 but the potential for harm exists if the proper diagnosis is not made. Therefore, the cost and discomfort of more invasive procedures need to be weighed against the possible harm caused by not diagnosing celiac disease. If the definitive test is not possible, either because of cost or patient reluctance, dietary modifications with significant improvement may suggest a celiac diagnosis, even without definitive proof.

Celiac disease is very damaging to the small intestine and can create many other problems, such as electrolyte imbalances, cardiac arrhythmias, villus atrophy, and short stature because of the diminished ability to properly absorb nutrients ( Table 1 ). 11, 13–15 Celiac disease also causes many problems for the body, and healing the damage requires a great deal of time.

Many signs and symptoms associated with celiac disease are characteristic of other conditions ( Table 2 ). As a result, diagnosing this condition can be very challenging for the sports medicine team and frustrating for the athlete.

Celiac disease can be an incapacitating condition if it goes undiagnosed or is mismanaged. The condition usually manifests in childhood, but it can present at any time during adulthood. Our patient's presentation was unusual in that no single traumatic life event appeared to trigger the disease.

The signs and symptoms of celiac disease are usually easily addressed. For example, if wheat or gluten has been ingested, the athlete may develop a rash (hives). This reaction, dermatitis herpetiformis, is typical of celiac disease and can be effectively managed with oral Dapsone (Jacobus Pharmaceutical Co, Inc, Princeton, NJ). 2, 3, 9–11 Other treatments include supportive nutrition such as supplemental iron, vitamin B 12 , and folic acid. Dehydration can be managed with electrolyte drinks or, in more severe cases, intravenous fluids. 4, 10, 12–15

Celiac disease patients cannot tolerate gluten, a protein found in the grains wheat, rye, and barley. In order to preserve their gastrointestinal integrity, people with celiac disease need to take extra precaution when selecting foods. 13, 15–18 It is challenging to avoid all forms of food that may contain the gluten or gliadin offending agents. Table 3 lists some common and less obvious foods that contain gluten or gliadin and should be eliminated from the diet for more successful treatment of celiac disease. Today, the only known treatment is to eliminate these agents from the diet and to carefully monitor pro-gress. 1–4, 11, 14, 15, 19 Therefore, a gliadin-free and gluten-free diet must be a lifelong commitment for the patient with this condition.

The sports medicine team can play a crucial role in helping a person with celiac disease deal with dietary restrictions. Athletic trainers, other health care professionals, and coaches all contribute to the athlete's choices. The athletic trainer can help by referring the patient to the most appropriate health care professional. 20 This could be the institution's physician, his or her own family physician when the initial symptoms occur, or a specialist. If psychological issues from the frustrations of dealing with the disease are affecting performance, a sport psychologist can be consulted. Finally, the athletic trainer can refer the athlete to a nutritionist or dietitian to help manage the diet. Coaches can stay involved by learning more about the disease in order to make better choices of restaurants with gliadin-free and gluten-free options during team traveling.

Currently, there is no cure for celiac disease. Therefore, it is important for athletic trainers to be aware of the symptoms (see Table 2 ) and the adverse effects of celiac disease. Ideally, science, through research and alternative therapies, will allow the celiac patient to achieve a better quality of life. Until then, heightening the public's awareness of the condition will allow for the person with celiac disease to be more appropriately accommodated. For now, the athlete needs to take precautionary measures to maintain a healthy body and lifestyle.

Statistically, celiac disease is on the rise in the United States. 4 It is estimated that 1 in every 200 to 500 people have celiac disease. Of this number, only 1 in every 4700 is accurately diagnosed. 3, 4, 11 The “iceberg” model proposed by Feighery 3 ( Figure 2 ) provides a pictorial representation of this point, reflecting the fact that celiac disease is more prevalent than people think. The damage that can occur because symptoms associated with this condition are not recognized can lead to negative consequences for the athlete and even death in some instances.

Athletic populations are just as susceptible to celiac disease as other populations. Sports medicine professionals interact with a variety of populations from clinical settings, including physical therapy clinics and traditional athletic venues such as colleges and universities. This places the “team” in a critical role in helping the diagnosed athlete receive proper treatment. The misdiagnosis and mismanagement of celiac disease can lead to severe consequences for the athlete. Quality of life can be achieved by following a strict gliadin-free and gluten-free diet, but the commitment has to be present on the part of both the athlete and the clinician. Depending on the severity and stage of the disease, symptoms can usually be managed quite effectively, and the athlete can continue to participate and remain active and competitive with minimal complications. Because athletes place enormous physical and psychological stresses on their bodies on a regular basis, celiac disease in this population may produce more profound effects than in the general population.

Acknowledgments

We thank Dr. Rollin Perkins of Southern Illinois University Student Health Programs. His insightful comments on this topic added to our knowledge of the subject as well as the quality of the manuscript. We also thank E. Jay Sedory, ATC, for his feedback on the project and review of the manuscript.

James E. Leone, MS, LAT, ATC, CSCS; Kimberly A. Gray, MS, ATC, CSCS; John E. Massie, PhD, LAT, ATC; and Jennifer M. Rossi, MS, LAT, ATC, contributed to conception and design; analysis and interpretation of the data; and drafting, critical revision, and final approval of the article.

Address correspondence to James E. Leone, MS, LAT, ATC, CSCS, Department of Physical Education, Southern Illinois University at Carbondale, 1075 S. Normal Avenue, Carbondale, IL 62901-4310. Address e-mail to ude.uis@enoelJ .

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