Celiac Disease

1. Celiac Disease Yepraksia Agazaryan, Jocelyn Dang, Polly Lin, Jessica Stier

2. Definition • An autoimmune disease characterized by damage to the small intestinal mucosa from the ingestion of gluten (found in wheat, barley, and rye) in genetically susceptible individuals • AKACeliac sprue and gluten-sensitive enteropathy • Occurs at all ages and has a wide variety of symptoms. • Affects 1% of US population

3. Pathophysiology • T-cell mediated autoimmune injury to intestinal epithelial cells of genetically vulnerable individuals • Specifically with the human leukocyte antigen DQ2 and HLA-DQ8 • Atrophy and flattening of villi and malabsorption of most nutrients in the presence of wheat, rye, and barley • Decrease in surface area causes an entire cascade of events. Ultimately causing a decrease in the three macronutrients, which leads to malnutrition

4. Causes • The exact cause is not known, but both genetics and environmental factors are involved. • Some variations of genes show an increased risk for CD, but these variants don’t guarantee CD. • If your first degree relative has CD, your risk is 1 in 10 for developing the disease. • It is found more often found in people who have other autoimmune diseases like DM, thyroid disease, and rheumatoid arthritis. • It can also be related to gastrointestinal infections and gut bacteria, antibiotic use, rotavirus infection in children. • CD may be triggered or become active after extreme emotional or physical stress such as pregnancy, childbirth, surgery. • Three factors must be present: Genes + Gluten + Trigger = Celiac Disease

5. Signs and Symptoms • Fatigue • Dermatitis herpetiformis - an itchy skin rash with blisters • Headaches • Acid reflux • Painful joints • Osteoporosis/osteomalacia or loss of bone density • Iron deficiency anemia • Reduced spleen function • Neuropathy • Migraine • Deficiency of vitamins A, D, E, & K, infertility, miscarriages, menstrual irregularities, and other problems.

6. Signs and Symptoms Children may experience: • Diarrhea • Failure to thrive • Distended abdomen • Constipation • Irritability • Short stature • Late onset of puberty • Learning disabilities • Muscle wasting • Seizures

7. Diagnostic studies Early diagnosis and treatment can prevent complications. Early screening is highly recommended - patients with close relatives with known disease, young patients with decreased bone density, and certain autoimmune diseases.

8. Diagnostic studies cont. • Histologic evidence of the disease when a biopsy is taken from small intestine • Gold Standard • Symptoms and histologic evidence disappears when person eats gluten-free diet • Must be done before person is placed on gluten-free diet • Confirmed when improvements are seen while on gluten-free diet • Blood tests for gluten antibodies • EMA, TTG, DGP

9. Treatment/Therapies • Most patients recover completely within 3-6 months • Maintain a gluten-free diet for the rest of their lives • Avoid wheat, barley, oats, and rye products • Combination of corticosteroids and gluten-free diet - used to treat individuals with refractory celiac disease who do not respond to a gluten-free diet alone • Lactose intolerance may be present from damage to villi • excluded from diet, but should be resumed after intestine heals • Infants given vitamin D, iron, and folic acid supplements to treat deficiencies • Bone mineral density (BMD) screening required

10. Long-Term Complications If left untreated, chronic inflammation and hyperplasia: *Increased risk of non-Hodgkin’s lymphoma and GI cancers • Iron deficiency anemia • Early onset osteoporosis or osteopenia • Infertility and miscarriage • Central and peripheral nervous system disorders • Pancreatic insufficiency • Gall bladder malfunction • Esophageal carcinoma • Papillary thyroid cancer • Melanoma • Additional autoimmune diseases

11. Food Choices • Foods you can eat: • Eggs • Potatoes • Butter • Cheese, cottage cheese • Yogurt • Fresh fruits • Corn tortillas • Soy products • Peanut butter • Coffee, tea, cocoa • Legumes • Gluten-free breads, crackers, pasta and cereals

12. Food Choices • Foods to avoid: • Wheat, barley, rye • Malts • Triticale • Flour • Baked goods: muffins, cookies, cakes, pies • Bread • Pasta • Pizza • Bagels

13. Reading Labels Very important to always read labels to confirm gluten-free Some products labeled wheat-free are not necessarily gluten-free How to read food label: • A gluten-free label • Check allergen listing • Check for obvious ingredients: wheat, barley, rye, oats

14. Reading Labels cont. Non-food items that must be verified with label reading • Lipstick, lipgloss, lip balm • Herbal and nutrient supplements • Drugs and OTC medications • Vitamins and supplements • Play-dough

15. Patient/Family Education Education on a strict gluten free diet (GFD) is crucial. • Cross-Contamination • Severity of Consequences of Eating Gluten- GI disorder and cancers Strategies for Managing a GFD: • Reading product ingredients • Having snacks on hand at school or work • Bringing gluten-free food to social events • Planning ahead and preparing • Call manufacturers • Find out if restaurants have gluten-free food choices • Make sure vacation destinations have gluten free options

16. Patient/Family Education Cont. Barriers to diet adherence include: • Social Isolation • Gender inequity (women are diagnosed 2-3x more than men) • Misunderstandings about celiac disease Social Support was Identified as the Primary Facilitator of Diet Adherence. • Family and friends- food on different colored plates • School and community • Group support- Social Media • Having friends who are also following a gluten-free diet - Celiac Camp Celiac Disease Foundation

17. Post-Test The healthcare provider is teaching a patient diagnosed with celiac disease about the disease process. Which of the following statements made by the patient would indicate a correct understanding of the teaching? Please choose from one of the following options. • “My immune system reacts to gluten and damages my gut.” • “I’m glad that I can still eat bread made with rye flour.” • “The bacteria in my gut are not able to ferment the gluten.” • “I have an allergy to the proteins that are found in wheat.”

18. Post-Test The healthcare provider is teaching a patient diagnosed with celiac disease about the disease process. Which of the following statements made by the patient would indicate a correct understanding of the teaching? Please choose from one of the following options. • “My immune system reacts to gluten and damages my gut.” • “I’m glad that I can still eat bread made with rye flour.” • “The bacteria in my gut are not able to ferment the gluten.” • “I have an allergy to the proteins that are found in wheat.”

19. Post-Test How is celiac disease treated? • Antibiotics • Surgery • A change in diet • Radiation therapy

20. Post-Test How is celiac disease treated? • Antibiotics • Surgery • A change in diet • Radiation therapy

21. Post Test What is the gold standard for diagnosing Celiac Disease? • Serologic tests • Intestinal biopsy • Genotyping • H & P

22. Post Test What is the gold standard for diagnosing Celiac Disease? • Serologic tests • Intestinal biopsy • Genotyping • H & P

23. Post Test When providing dietary counseling for the parents of a child diagnosed with celiac disease, the healthcare provider should include which of the following information in the teaching plan? • “Instead of breads you may serve pasta products.” • “Avoid starchy vegetables like peas and potatoes.” • “Wheat, corn, and rice should be avoided.” • “Be sure to read all food labels carefully.”

24. Post Test When providing dietary counseling for the parents of a child diagnosed with celiac disease, the healthcare provider should include which of the following information in the teaching plan? • “Instead of breads you may serve pasta products.” • “Avoid starchy vegetables like peas and potatoes.” • “Wheat, corn, and rice should be avoided.” • “Be sure to read all food labels carefully.”

25. Post Test What diet should you recommend for a person who is diagnosed with celiac disease? • Cookies and chips • Pasta and noodles • Rice and corn • Wheat bread and a green salad

26. Post Test What diet should you recommend for a person who is diagnosed with celiac disease? • Cookies and chips • Pasta and noodles • Rice and corn • Wheat bread and a green salad

27. Post Test True or False. Social support is the primary facilitator of a gluten-free diet adherence?

28. Post Test True or False. Social support is the primary facilitator of a gluten-free diet adherence?

29. Post Test The healthcare provider is teaching a patient about celiac disease and malnutrition. Which statement made by the patient would indicate a correct understanding of the teaching? • “The inflammation in my gut uses up all the nutrients.” • “My intestines need to slow down so they can absorb the nutrients they need.” • “Parts of my gut have been damaged so it doesn’t absorb nutrients.” • “My gluten allergy causes an inflammation response that interferes with my digestion process.”

30. Post Test The healthcare provider is teaching a patient about celiac disease and malnutrition. Which statement made by the patient would indicate a correct understanding of the teaching? • “The inflammation in my gut uses up all the nutrients.” • “My intestines need to slow down so they can absorb the nutrients they need.” • “Parts of my gut have been damaged so it doesn’t absorb nutrients.” • “My gluten allergy causes an inflammation response that interferes with my digestion process.”

31. Post Test A patient diagnosed with celiac disease tells the healthcare provider, “I’ve been on a gluten-free diet for 3 months but this week I have had diarrhea, bloating, and gas.” Which response would be most appropriate for the healthcare provider to make? • “We’ll need to take a biopsy of your small intestine to see if your disease is progressing.” • “Try adding more fiber to your daily diet and see if that resolves the problem” • “Let’s sit down and make a list of all the foods you ate this week.” • "You’ll need to be compliant with your diet if you want to avoid these problems.”

32. Post Test A patient diagnosed with celiac disease tells the healthcare provider, “I’ve been on a gluten-free diet for 3 months but this week I have had diarrhea, bloating, and gas.” Which response would be most appropriate for the healthcare provider to make? • “We’ll need to take a biopsy of your small intestine to see if your disease is progressing.” • “Try adding more fiber to your daily diet and see if that resolves the problem” • “Let’s sit down and make a list of all the foods you ate this week.” • "You’ll need to be compliant with your diet if you want to avoid these problems.”

33. Post Test The healthcare provider is teaching a patient diagnosed with celiac disease. Which of the following statements made by the patient would indicate the teaching has been effective? (SELECT ALL THAT APPLY) • “I’ll give up milk and dairy products for a few weeks until my gut heals.” • “I won’t be able to drink beer anymore but I can still have wine.” • “I’ll need periodic monitoring to make sure my bones are not getting thin.” • “It’s possible that I could also develop other diseases like type 1 diabetes.” • “It will be nice when my gut gets better so I can go back to a regular diet.”

34. Post Test The healthcare provider is teaching a patient diagnosed with celiac disease. Which of the following statements made by the patient would indicate the teaching has been effective? (SELECT ALL THAT APPLY) • “I’ll give up milk and dairy products for a few weeks until my gut heals.” • “I won’t be able to drink beer anymore but I can still have wine.” • “I’ll need periodic monitoring to make sure my bones are not getting thin.” • “It will be nice when my gut gets better so I can go back to a regular diet.”

35. Post Test When providing dietary counseling for the parents of a child diagnosed with Celiac Disease, the healthcare provider should stress the importance of avoiding which of the following foods? (SELECT ALL THAT APPLY) • Soft drinks • Oatmeal • Processed meats • Peanut butter • Soy sauce • Eggs • Chocolate malted milkshake

36. Post Test When providing dietary counseling for the parents of a child diagnosed with celiac disease, the healthcare provider should stress the importance of avoiding which of the following foods? (SELECT ALL THAT APPLY) • Soft drinks • Oatmeal • Processed meats • Peanut butter • Soy sauce • Eggs • Chocolate malted milkshake

37. References Bacigalupe, G., & Plocha, A. (2015). Celiac is a social disease: family challenges and strategies. Families, Systems & Health: The Journal Of Collaborative Family Healthcare, 33(1), 46-54. Celiac Disease Foundation (CDF). 1998-2017 What Is Celiac Disease? , n.d. Web. 23 Feb. 2017. https://celiac.org/celiac-disease/understanding-celiac-disease-2/what-is-celiac-disease/ Huether, S.E. and McCance, K.L. (2017). Understanding Pathophysiology. 6th edition Elsevier Mosby Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014). Medical surgical nursing: Assessment and management of clinical problems. (9th ed.). St. Louis, MO: Mosby Elsevier Inc. Mayo Clinic Staff Print. "Celiac Disease." Symptoms and Causes - Celiac Disease - Mayo Clinic. Mayo Foundation for Medical Education and Research (MFMER),17 Aug. 2016. Web. 23 Feb. 2017. Nursing: Assessment and management of clinical problems. (9th ed.). St. Louis, MO: Mosby Elsevier Inc. Rolfes, S., Pinna, K., & Whitney, E. (2014). Understanding Normal and Clinical Nutrition. 10th edition. Belmont, CA. Wadsworth-Cengage Learning.