case study celiac disease answers

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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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• J Community Hosp Intern Med Perspect
• v.9(1); 2019

A case of celiac disease presenting with celiac crisis: rare and life threatening presentation

Rakshya poudyal.

a Department of Internal Medicine, Kathmandu Medical College, Kathmandu, Nepal

Saroj Lohani

b Department of Hospitalist Medicine, Tower Health System, West Reading, PA, USA

William B. Kimmel

c Department of Pathology, Tower Health System, West Reading, PA, USA

A 20 year old male with past medical history of Type 1 Diabetes and Hypothyroidism presented to our hospital with severe hypocalcemia. His calcium was 5.8 mg/dl (normal range 8.6–10.3 mg/dl). He had been complaining of generalized weakness for weeks. Vital signs were within normal limits. Physical exam was significant for positive Chvostek sign. Other labs revealed low magnesium, low potassium, low vitamin D, low albumin, metabolic acidosis and low ferritin. He was started on supplements. Tissue transglutaminase antibody IgG was elevated. Upper gastrointestinal endoscopy showed scalloped and blunted duodenal mucosa. Duodenal biopsy showed villous blunting with intraepithelial lymphocytosis suggestive of celiac disease. He was started on gluten free diet. His symptoms improved and he was discharged home. Celiac disease can present in fulminant form with hemodynamic instability and is called celiac crisis. Celiac crisis is usually manifested by severe gastrointestinal manifestations, hypoproteinemia and metabolic and electrolyte disturbances requiring hospitalization. It is diagnosed by criteria proposed by Jamma et al. Celiac crisis is a rare presentation of celiac disease and is associated with high morbidity and mortality. Most of the cases respond to gluten withdrawal and nutritional suport and few require steroids.

Abbreviation: Type 1 DM -Type 1 Diabetes Mellitus

1. Introduction

Celiac disease is a multiple organ autoimmune disease precipitated by gluten proteins that affects small intestine in genetically predisposed children and adults [ 1 ]. The common manifestations of celiac disease are bulky, foul smelling diarrhea, abdominal distension and consequences of malabsorption such as failure to thrive, weight loss, anemia and osteopenia [ 2 ]. Celiac crisis is a life threatening manifestation of celiac disease especially in children and rarely in adults. Celiac crisis usually presents with severe diarrhea, low protein and severe metabolic and electrolyte derangements that require hospitalization and treatment [ 3 , 4 ]. Celiac crisis is associated with high morbidity and mortality [ 5 ]. It is important to have high index of suspicion of celiac crisis especially in people with undiagnosed celiac disease since it can be the initial presentation of celiac disease as in our case report.

2. Case report

A 20 year old male of mixed European descent with past medical history of Type 1 Diabetes and Hypothyroidism and vitamin D deficiency was called by his endocrinologist and told to go to emergency department after his labs showed severe hypocalcemia. His calcium was 5.8 mg/dl (normal range 8.6–10.3 mg/dl). His corrected calcium was 6.8 mg/dl and ionized calcium was 0.76 mmol/L (normal range 1.15–1.33 mmol/L). He had been complaining of generalized weakness for couple of weeks. Patient and his father reported history of bloating and swelling of feet. He denied any history of seizure like activity, nausea, vomiting, abdominal pain. He reported that his bowel movements were mostly 1–2 times a day light brown and formed. He had been on variable doses of magnesium for the last one year and would get loose bowel movements with high doses of magnesium. He was able to tolerate pasta without any symptoms. He denied history of weight loss, fever, chills. He had been taking calcium, magnesium and vitamin D supplement since his labs showed low calcium, magnesium and vitamin D levels one year ago. He was on insulin for Type 1 diabetes and levothyroxine for hypothyroidism. Family history was positive for hypothyroidism in both parents. Vital signs on admission revealed heart rate of 88/minute, respiratory rate of 18/minute, temperature of 98.4 F and blood pressure of 110/79 mm Hg. Physical exam was significant for 1+ bilateral lower extremity edema and positive Chvostek sign.

Other labs on admission revealed magnesium of 1 mg/dl (normal 1.9–2.7 mg/dl), potassium of 3.1 meq/L (normal 3.5–5.1 meq/L), 25 Hydroxy vitamin D of 10.1 ng/ml (normal >20 ng/ml), parathyroid hormone of 140 pg/ml (normal 12–88 pg/ml), albumin of 2.7 g/dL (normal 3.5–5.7 g/dL), venous PH of 7.314 (normal 7.32–7.43), bicarbonate of 19.8 meq/L (normal 21–31 meq/L), ferritin of 7 ng/ml (normal 27–300 ng/ml), iron of 14 mcg/dL (normal 50–212 mcg/dL), iron sat of 7 (20–50%). His hemoglobin was 8.6 g/dL (14–17.5 g/dL), Mean Corpuscular Volume (MCV) 79 fl (normal 80–99 fl), Mean Cellular Hemoglobin (MCH) 24.8 pg (normal 27–34 pg) and total leucocyte count was 16,600/microL (normal 4800–10,800/microL) . Renal function was normal. Electrocardiogram revealed prolonged QT interval. Computerized Tomography (CT)scan of abdomen revealed diffuse enteritis with reactive mesenteric adenopathy.

He was started on calcium gluconate drip along with oral calcitriol and oral calcium carbonate. He was placed on Lantus 16 U nightly, Humalog 6 units with meals and sliding scale for management of Type 1 Diabetes Mellitus. He was placed on intravenous levothyroxine 75 mcg daily for management of hypothyroidism. When he presented his TSH was very high 383 uIU/ml (normal 0.5–5.3 uIU/ml) with low free T4 0.56 ng/dl (normal 0.58–1.64 ng/dl). He was given 100 mg hydrocortisone in the emergency room due to concern for myxedema and adrenal crisis. Since he was hemodynamically fine and his mental status was intact further doses of hydrocortisone was avoided. Magnesium, potassium and iron was repleted intravenously. Fractional excretion of potassium in urine was 7.34% (normal 4–16%). Fractional excretion for calcium and magnesium from urine were within normal limits. Tissue transglutaminase antibody IgG was elevated at >100 U/ml (normal 0–5 U/ml). He was positive for HLA DQ8 heterozygote. His electrolytes started improving after second day of hospitalization and he was switched to oral replacement. He underwent upper gastrointestinal endoscopy on third day of hospitalization. Findings showed scalloped and mildy blunted duodenal mucosa raising suspicion for celiac disease (see Figure 1 ). Biopsy showed chronic duodenitis with marked villous blunting with intraepithelial lymphocytosis suggestive of celiac disease (see Figure 2 ). Total lymphocyte count at duodenal biopsy was 40/100 epithelial cells. He was started on gluten free diet. His calcium, magnesium and potassium improved to normal range on fourth day of hospitalization. His symptoms improved. He was discharged home on oral calcitriol, calcium carbonate, high dose vitamin D, magnesium oxide and potassium chloride. He was advised to follow up with gastroenterology in 2–3 months with CT abdomen to see if enteritis improved with gluten free diet. His long term care plan was gluten free diet, oral calcium, vitamin D and magnesium supplements. He was advised to follow up regularly with Gastroenterology and Endocrinology in clinic.

Upper GI endoscopy showing scalloped duodenal folds.

Duodenal biopsy image.

3. Discussion

Celiac disease (also called gluten sensitive enteropathy and nontropical sprue) is an immune mediated disease of small intestine characterized by malabsorption symptoms and villous atrophy precipitated by gluten protein [ 6 ]. Originally considered as a rare disease of childhood it now affects people of all age groups [ 6 ]. It was first reported by Samuel Gee in 1888 [ 7 ]. Celiac disease is closely associated with HLA-DQ2 and/or DQ8 gene loci hence it is believed to be caused by immune disorder in genetically susceptible population triggered by gliadin component of gluten [ 8 ]. Celiac disease is diagnosed by serologic evaluation (anti-tissue transglutaminase (TTG) antibody, anti endomysial antibody, anti Deaminated Gliadin Peptide (DGP) antibody), genetic testing for HLA DQ2/DQ8 and small intestinal biopsy [ 8 ]. Histologic findings include intraepithelial lymphocytes, loss of villi, flat mucosa and crypt hyperplasia [ 9 , 10 ].

Type 1 Diabetes and Hypothyroidism are the most common autoimmune diseases associated with celiac disease although there is no specific name for this condition [ 2 ]. Our patient did not have other features (adrenal insufficiency, hypoparathyroidism, candidiasis, hypogonadism) to qualify for autoimmune polyglandular syndrome type 1 or 2.

In most adult cases celiac disease presents as indolent course with gastrointestinal symptoms and nutritional abnormalities. Sometimes celiac disease can present as acute fulminant form called as celiac crisis. The term celiac crisis has been in use since the 1950s [ 11 ]. Celiac crisis is usually manifested by severe gastrointestinal manifestations, hypoproteinemia and metabolic and electrolyte disturbances requiring hospitalization [ 12 ]. Jamma et al. proposed a criteria for diagnosis of celiac disease [ 13 ]. The criteria requires acute onset of progression of gastrointestinal symptoms requiring hospitalization and/or parenteral nutrition with at least 2 of following (hemodynamic instability, neurologic dysfunction, renal dysfunction, metabolic acidosis, hypoproteinemia, electrolyte abnormalities and weight loss) [ 13 ]. In our case rapid onset of enteritis requiring hospitalization along with metabolic acidosis, hypoproteinemia and electrolyte abnormalities was sufficient for diagnosis of celiac crisis.

Only a handful of cases of celiac crisis in adults have been reported in literature [ 13 ]. Jamma et al. reported 12 cases of celiac crisis [ 13 ]. 11 of those patients had positive antibodies and all patients had positive histology findings. 50% of the 12 patients responded to gluten withdrawal and nutritional support and rest of the patients needed steroids [ 13 ]. In our case, the patient improved with gluten withdrawl and nutritional support. Celiac crisis is often precipitated by stress stimulus like surgery, infection or pregnancy [ 14 , 15 ]. In our case no such precipitant could be found.

Celiac crisis is associated with high morbidity and mortality [ 5 ]. In most of the cases celiac crisis presents as the initial manifestation of celiac disease [ 12 ] as in our case. Clinicians should have a high index of suspicion of celiac crisis in someone presenting with gastrointestinal disturbances, hypotension, electrolyte and metabolic derangements after common causes have been ruled out.

Disclosure statement

No potential conflict of interest was reported by the authors. The authors do not have affiliation with or financial involvement with an organization or entity with a financial interest in or financial conflict with subject matter or materials discussed in the manuscript.

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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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