Upper GICara Cruse

West Shore Endoscopy Center

Celiac Disease

● An autoimmune disorder that creates inflammation in the mucosa lining of the

small intestine that may result in atrophy of intestinal villi, malabsorption, and a variety

of clinical symptoms.

● Inflammation occurs after the ingestion of the protein:

Glut

en

Etiology

• Genetic Predisposition• Family History• HLA-DQ Gene Typing

• Exposure to gluten• Breastfeeding

• Environmental trigger• Surgery

• Autoimmune response• Type 1 Diabetes, Down

Syndrome

http://www.healthyhappyft.com/2014/08/dietas-gluten-free/

WHAT IS GLUTEN?!

What’s the difference between celiac disease, gluten intolerance, gluten

sensitivity and wheat allergy?

Gluten Sensitivity●Causes the body to mount a stress response (often GI symptoms).

● Pt should be advised not to follow a gluten free diet without the diagnosis.

Wheat Allergy

● Immune system response

● This immune response is often time-limited and does not cause lasting harm to body tissues.

Prevalence

● Now considered to affect 1 in 133 people in the US.

● Infancy-adulthood

● May be triggered by GI surgery, stress, pregnancy, viral infection.

● 20% of cases dx after age of 60 y/o.

Symptoms

Children

● Diarrhea● Steatorrhea● Malodorous stools● Abdominal bloating● Apathy, Fatigue● Poor wt. gain

* 50% of CD pt has few or no symptoms

Adults* less likely to have digestive symptoms.

● iron-deficiency anemia● Fatigue● bone pain or loss● depression or anxiety● tingling numbness in

the hands and feet● seizures or migraines● missed menstrual

periods● infertility or recurrent

miscarriages● Dermatitis

Herpetiformis

Screening

●Tissue Transglutaminase Antibodies (tTG):● Test will be positive in about

98% of patients with celiac disease who are on a gluten- containing diet.

●Endomysial antibody (EMA): ● Not as sensitive as the tTG-

IgA test. About 5-10% of people with celiac disease do not have a positive EMA test.

http://theconversation.com/everything-you-need-to-know-about-coeliac-disease-and-whether-you-really-have-it-4928

Diagnosis

If blood tests and symptoms suggest celiac disease, a biopsy of the small intestine is

performed to confirm the diagnosis.

http://celiac2051.wordpress.com/cause/

http://celiac2051.wordpress.com/cause/

MNT

● Lifelong, strict adherence to a GF diet is the only known treatment.

● The GF diet greatly diminishes the autoimmune process, allowing the small intestine mucosa to revert to normal or near normal within 2-8 wks.

● Improvements may take months to years depending age, duration of disease and degree of dietary compliance.

Mayo Clinic StudyThe American Journal of Gastroenterology.

Joseph A. Murray, M.D.,

● Studied the effect of a gluten-free diet on mucosal tissue recovery● 241 adults—176 women and 65 men with an average age of

47—with celiac disease. ● confirmed by intestinal biopsy. ● 2 yr mark: about one-third had intestinal villi that had

recovered fully. ● 5 yr mark: about two-thirds had fully recovered intestinal

villi.

● “Good adherence to a gluten-free diet is necessary for mucosal recovery, but doesn’t guarantee mucosal recovery in all adults with celiac disease.”

MNT

If usual food intake shows nutritional inadequacies, the RD should recommend a

daily gluten free and sex specific multivitamin and mineral supplement.

Common deficiencies: ● Ca

●Impaired lactase secretion●Lactose Intolerance

● Iron, folate, niacin, vitamin B12, phosphorus, zinc

● Fat soluble Vitamins (D,A,E,K)

“So, What Can I Eat?”

Safe Grains and Plant Foods:

● Corn

● Soy

● Potato

● Flax

● Beans

● Chia

● Millet

● Nuts

●Nut Flours

●Quinoa

●Rice

●Sorghum

●Tapioca

●Yucca

Avoid!

● Wheat

● Rye

● Barley

● Oats (unless pure, uncontaminated)

● Battered/deep fried foods, noodles, flour tortillas, most baked goods with wheat flour.

Cleaning Your Cabinets of Gluten

-Soy Sauce

-Salad Dressings

-Gravies, Sauces and Marinades

- Soups

-Puddings and Pie Fillings

-Reduced-Fat Products

-Processed Meats

-Ready-Made Meals and Fast Foods

Barriers to Compliance

● Ability to manage emotions – depression, anxiety

● Ability to resist temptation – exercising restraint

● Feelings of deprivation

● Fear generated by inaccurate information!

What We Can Do As RD’s

- Knowledge about the gluten-free diet/CD

- Understand the risk factors and serious

complications that can occur

- Ability to break down big changes into smaller

steps

- Provide positive coping skills

- Build a trusting relationship between client and

dietitian

Gastroesophageal Reflux and Esophagitis

GERDGastroesophageal Reflux Disease

● When gastric content of the stomach refluxs up into the esophagus. ● Heartburn● Burning sensation in

esophagus.● Inflammation with erosion

of the lining of esophagus.

● 20-40% of adults report symptoms of GERD weekly

http://www.webmd.com/digestive-disorders/picture-of-the-esophagus

http://www.lgmpharma.com/blog/tag/erosive-esophagitis/

Pathophysiology

● Reduced LES pressure

● Inadequate esophageal tissue defense

● Direct mucosal irritants

● Increased intraabdominal pressure

● Anti-inflammatory drugs

Symptoms

● Reflux of gastric secretions

● Heartburn

● Difficulty/pain swallowing

● Belching

● Chronic sore throat

● Sour taste

● In children● Vomiting● Dysphasia● Refusal to eat● Abdominal pain

Esophagitis

● inflammation of esophagus● Types● Reflux- GERD- Most common cause● infectious esophagitis- in patients who are

immunocompromised● Radiation esophagitis ● Esophagitis from direct erosive effects of ingested

medication or corrosive agents (Antibiotics, anti-inflammatory drugs)

Causes/Risk Factors

● Pregnancy● Obesity● Scleroderma● Smoking● Certain medications (eg, beta-blockers, NSAIDs,

theophylline, nitrates, alendronate, calcium channel blockers)

● Spinal cord injury● Immunocompromised state● Radiation therapy

Hiatal Hernia

Nutritional Implications

● Side effects that could affect nutritional status- Trouble Swallowing- Impaired ability to consume adequate

diet

● Interfere with sleep, work, social events and quality of life (exercise) .

http://www.zantacsideeffects.net/wp-content/uploads/2013/07/heartburn-effects-300x294.jpg

http://www.webmd.com/heartburn-gerd/ss/slideshow-heartburn-overview

Management

● Antacids● Tums, Rolaids.

● Proton pump inhibitors● Prilosec, Protonix

● Histamine 2 receptor antagonists● Zantac

EAL recommendations

1. Avoid large, high fat meals.

2. Avoid eating 3-4 hours before lying down.

3. Avoid smoking.

4. Avoid alcohol.

5. Avoid caffeine.

6. Stay upright and avoid activity soon after eating.

7. Avoid tight clothes.

8. Consume adequate fiber.

9. Avoid acidic and spicy foods.

10. Lose weight if overweight.

Case Study Assessment ● A 31 y/o man ● Sedentary lifestyle ● 5-6 beers every night● Eats out often● Consumes high fat/ high sodium foods. ● Patient experiences pain as “burning” in the middle of his chest.● Reports trouble swallowing and “food is getting stuck in his throat.” ● Reports frequent regurgitation. ● Family hx of DM, HTN, MI, and wt issues.

• Height: 5 ft 10 in• Weight: 182 lb• Blood pressure: 135/80 mm Hg

At home medications: None

A/D...Abnormal Lab Values• Total cholesterol: 210 mg/dL• Low-density lipoprotein cholesterol: 145 mg/dL• High-density lipoprotein cholesterol: 47 mg/dL• Triglycerides: 160 mg/dL

Diagnosis1. Excessive fat intake (NI-5.6.2) r/t food and nutrition related knowledge

deficit concerning appropriate amount of dietary fat aeb total cholesterol of 210 mg/dL, LDL 145 mg/dL, and TG 160 mg/dL, reports of epigastric pain and frequent high-fat meals.

2. Food and nutrition related knowledge deficit (NV-1.1) r/t lack of prior nutrition related education aeb pt verbalizing unwillingness or disinterest in learning information regarding diet change.

Intervention

Caloric needs: Mifflin-St. Jeor-- (10x95) + (6.25 x 177.8) - (5 x 31) + 5950 + 1111.25- 155 +5

= 1,911 kcalsProtein needs: (1.2-1.5 g/kg) = 89-111 g/kg proFluid: (30-35 mL/kg)= 2.8-3.3LNutrition Education - Content E-1 was provided to help manage symptoms of GERD with lifestyle changes, including low-fat options, food purchasing tips, and physical activity recommendations. Nutrition Counseling (C-1) based on transtheoretical model including MI strategies to help Chuck identify behaviors that may be causing GERD symptoms. Goal setting and self monitoring were used to help client progress

to contemplation stage.

CONTINUED...

Specific goals set by client:1. Reduce alcohol consumption to 2-3 beers per night. 2. Prepare two meals at home this week.

Monitoring/Evaluating Weight, oral intake and lipid panel labs. Pt will complete a

food log to monitor symptom occurrence with intake and time of day. Schedule follow up with client in 1 week.

References

1. Sonia S. Kupfer and Bana Jabri. Celiac Disease Pathophysiology. NIH (online.) Aug 30, 2012. doi: 10.1016/j.giec.2012.07.003. Accessed 10/31/2014.

2. Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P, et al. Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine. 2012;157:808-816. doi:10.7326/0003-4819-157-11-201212040-00008

3. Mahan, L. Kathleen., Sylvia Escott-Stump, Janice L. Raymond, and Marie V. Krause. Krause's Food & the Nutrition Care Process. St. Louis, MO: Elsevier/Saunders, 2012. Print.

4. "CD: EXECUTIVE SUMMARY OF RECOMMENDATIONS (2009)." Eatright.org Evidence Analysis Library. The Academy of Nutrition and Dietetics, 2009. Web.

5. Alberto R, Mussarat R, Jacalyn A. Lahr B, Tsung-Teh W, and Murray J. Mucosal Recovery and Mortality in Adults with Celiac Disease after Treatment with a Gluten-Free Diet. Am J Gastroenterol. Jun 2010; 105(6): 1412–1420. Accessed October 29, 2014.

5. "Celiac Disease Guidelines." Evidence Analysis Library. The Academy of Nutrition and Dietetics, 2009. Web. 13 Oct. 2014.

6. Celiac Disease Foundation. What is Celiac Disease. 2014. Available at http://celiac.org/celiac-disease/what-is-celiac-disease/.

7. Celiac Support Association. How is Celiac Disease Diagnosed. 2013.

8. International Foundation for Functional Gastrointestinal Disorders. Signs and Symptoms of Gerd. February 17, 2014.

9. Mayo Clinic. Diseases and Conditions: Hiatal Hernia. December 8, 2011.

10. Gupta, Puneet, Murray J. Favus, Haikaeli Andrew, and Stefano Guandalini. "Prevalence of Celiac Disease in Patients with Osteoporosis in United States." Gastroenterology 118.4 (2000): A367. Web.