Lewis_Carly_ClinicalCaseStudy
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Transcript of Lewis_Carly_ClinicalCaseStudy
What is Gluten?
A protein found in wheat, rye and barley
Helps foods maintain their shape, acting as a glue that holds food together
Can be found in many types of foods, even ones that would not be expected
http://www.precisionnutrition.com/wordpress/wp-content/uploads/2009/10/gliadin-glutenin-gluten.gif
Common Sources Wheat Varieties and derivatives of wheat such as:
wheatberries durum emmer semolina spelt farina farro graham KAMUT® khorasan wheat einkorn wheat
Rye Barley Triticale Malt in various forms including: malted barley flour, malted milk or
milkshakes, malt extract, malt syrup, malt flavoring, malt vinegar Brewer’s Yeast Wheat Starch that has not been processed to remove the presence of
gluten to below 20ppm and adhere to the FDA Labeling Law*
http://www.livingherbalfarmacy.com/wp-content/uploads/2014/02/gluten-warning.jpg
Labeling Rules
Food and Drug Administration Must meet all requirements:
Contain less than 20 parts per million of gluten
Manufactured in a gluten-free facility
If a food does not have a "gluten-free" claim on the package, check directly with product manufacturers for more information
Ingredients such as modified food starch, malt or soy sauce also contain gluten
What Causes Intolerance?
Possibly, the introduction of gluten-containing grains
Grains introduced 10,000 years ago with new agricultural practices
Represented a "mistake of evolution"
Created conditions for human diseases related to gluten exposure
Best known complications are mediated by the adaptive immune system
Wheat allergy
Celiac disease
Celiac Disease
An autoimmune condition that affects one in 133 people
Releases antibodies that attack the intestinal tract
Difficult to absorb nutrients
Causes unpleasant symptoms
Untreated, celiac can also lead to complications
Managing Celiac Disease
Not just eliminating gluten from your diet
Make sure you get all the vitamins and nutrients you need
Watch weight gain
Non-Celiac Gluten Sensitivity
Non-celiac gluten sensitivity (or NCGS) is believed to be more widespread that celiac
Similarity: involves an immune reaction to gluten
Difference: doesn’t produce damaging antibodies
Currently, the only treatment for celiac disease or NCGS is a gluten free diet
There are no established laboratory markers for non-celiac gluten sensitivity
NCGS
Gluten reactions in which neither allergic nor autoimmune mechanisms are involved
Overall clinical picture is less severe
Not accompanied by the concurrence of tTG autoantibodies or autoimmune disease
Ruled out celiac disease, wheat allergy and other clinically overlapping diseases
Type 1 diabetes
Inflammatory bowel diseases
Helicobacter pylori infection
Symptoms triggered by gluten exposure and alleviated by gluten withdrawal
How is it Diagnosed?
Celiac disease
1. A medical review of symptoms
2. A blood test to look for high levels of certain auto-antibodies
3. A biopsy of tissue from the small intestine
NSGS
1. Rule out Celiac Disease and other related disorders
2. Elimination diet and then a “challenge”
What are the Symptoms?
GERD and irritable bowel syndrome (IBS) like symptoms
Abdominal pain
Bloating
Diarrhea, constipation and alternating bowel symptoms
Extra-intestinal manifestations
“Foggy mind”
Headache
Fatigue
Joint and muscle pain
Leg/arm numbness
Eczema/rash
Depression/anxiety
Anemia
Occur soon after gluten ingestion, rapidly improve after gluten withdrawal and relapse in a few hours or days after gluten challenge
Who has to be Gluten Free?
Currently at least 0.5% of the US population follow a GFD without having a confirmed diagnosis of celiac disease
Even in the absence of celiac disease, gluten is thought to be associated with bloating, diarrhea, abdominal pain, fatigue and nausea
Leading to the definition of a new entity (NCGS)
FODMAPs
In addition to gluten, other triggers involved in NCGS pathogenesis have been recently identified
Wheat proteins (i.e. amylase- and trypsin- inhibitors) and
Fermentable oligo-, di-, mono-saccharides and polyols (FODMAPs)
Note: a GFD leads to a significant reduction of dietary FODMAPs
Which leads to an improvement of the GI symptoms of the patients
FODMAPs
Low FODMAP diet followed
In all participants, GI symptoms consistently and significantly improved during reduced FODMAP intake
Symptoms significantly worsened to a similar degree when their diets included gluten or whey protein
Gut Permeability
The patients who fulfilled the GS diagnostic criteria (see Methods section) experienced symptoms overlapping those presented by CD patients
Their symptoms resolved within a few days after the implementation of the gluten-free diet
They remained symptom-free for the entire follow-up period (up to 4 years)
Those with CD took longer for symptoms to resolve
Symptoms were still present at times even when following GFD
Gluten in the Gut
https://www.stuffed-pepper.com/wp-content/uploads/2015/02/8N76zh30U-tCVoF8H-vffQ.jpg
Immune Responses
Disappearance of anti-gliadin antibodies of IgG after 6 months of GFD
93.2% of non-celiac gluten sensitivity patients
In contrast, 40% of celiac patients displayed the persistence of these antibodies after gluten withdrawal.
In NSGS patients anti-gliadin antibodies IgG persistence after gluten withdrawal was significantly correlated with the low compliance to gluten-free diet and a mild clinical response.
Immune Response
Both adaptive and innate immunity play a major role in Celiac Disease
Only innate immunity has been thought to be activated by gluten proteins in NCGS
Recent research suggests adaptive immunity may play a role in NCGS
CD is a well-recognized autoimmune disease
Whereas NCGS is likely a gluten hypersensitivity without an established involvement of autoimmunity
Gluten Free Diets and Irritable Bowel Disease
Participants with IBD selected
Diagnosis of CD reported by 10 (0.6%)
Diagnosis of NCGS reported by 81 (4.9%)
314 participants (19.1%) reported having previously tried a GFD
135 participants (8.2%) reported current use of GFD
Adherence was in 41.5%
Average in 34.1%
Fair/poor in 24.4%.
GFD with IBD Continued
Excellent adherence to a GFD associated with reduced fatigue
Compared to fair/poor adherence (p<0.03)
Of all clinical symptoms, only fatigue improved significantly with good adherence
Fatigue in the absence of iron deficiency anemia is a leading symptom in many patients with IBD
Iron absorption is inhibited in those with NSGS and CD
Clinical Recommendations
Celiac serologies (tTG or DGP) are an important first step in diagnosis
Those with positive serology are highly likely to have CD
Those with borderline serology can undergo HLA typing to determine the need for biopsy
Those with negative serology who also lack clinical evidence of malabsorption and CD risk factors are highly likely to have NCGS and may not require biopsy
Differentiation of CD and NCGS*Nutrient deficiency is defined as vitamin D, iron, vitamin B12, or Zn deficiency
Clinical Recommendations
Patients/Clients with both Celiac Disease and Non-Celiac Gluten Sensitivity should follow a gluten free diet
Eliminates complications of other conditions
Maximizes ability of the gut to absorb and digest
Reduces fatigue
Each individual has a different threshold
More research needs to be conducted on benefits and downfalls of incorporating gluten into the diet of people with NCGS
Case Study
56 year old male
Worked in IT department
Now off on disability
Declining activity level over 3-6 months
Spends most days in bed
Recent trouble walking at home, too shaky to use his cane
Marital status: boyfriend for 36 years
Symptoms
Increased confusion, trouble ambulation, chills, fever
Progressive coordination issues
Declining executive function over 48hrs
Presenting Diagnosis
Altered mental status, failure to thrive, severe protein malnutrition
Relevant medical history
Chronic hepatitis C
Oral cancer – palliative chemo and radiation
Hemochromatosis
Celiac disease
Smokes 1-1.5 ppd, excessively drinks (sober for 3 weeks)
Clinical Findings
Confusion
Fever, possible aspiration pneumonia
Possible alcohol withdrawal
Sepsis
Severe protein malnutrition
Cachectic limbs
105lbs – BMI 15.6
Poor dentition
Lab Results
ABG for CO2 narcosis
MELD score of 11
3-month mortality rate of 6%
MRI for possible brain abnormality
CBC
? Sign of aspiration pneumonia
Malnutrition
? Liver dysfunction
Recommended Interventions
Encourage increased protein-energy consumption
Some skin breakdown on sacrum
Address vitamin and mineral deficiencies
Speech therapy evaluation for poor dentition and rotting teeth
Promote gradual weight gain
Hospital Course
Cognition improved but then declined again
Admitted to the ICU
PEG placed at brother’s wishes
Patient refed after only eating 10-15% of meals during stay
Dispute over plan of care between family and significant other
Ultimately passed away
Questions?
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References: Ansel, Karen. “Does My Child Need a Gluten Free Diet?” Academy of Nutrition and Dietetics. 21
January 2014. Web.
Biesiekierski, Jessica R., et al. “No Effects of Gluten in Patients With Self-Reported Non-Celiac Gluten Sensitivity After Dietary Reduction of Fermentable, Poorly Absorbed, Short-Chain Carbohydrates”. Gastroenterology (2013) 145: 320-328.
Caio, Giacomo, Umberto Volta, Francesco Tovoli, Roberto DeGiorgio. “Effect of gluten free diet on immune response to gliadin in patients with non-celiac gluten sensitivity.” BMC Med (2014) 14: 26.
Herfarth, Hans H., Christopher F. Martin, Robert S. Sandler, Michael D. Kappelman, Millie D. Long. Prevalence of a gluten free diet and improvement of clinical symptoms in patients with inflammatory bowel diseases.” Inflammatory Bowel Diseases (2014) 7:1194-1197.
Kabbani, Toufic A., et al. “A clinical predictive model for differentiation of celiac disease and non-celiac gluten sensitivity. Gastro Journal.
Lauret, Eugenia, Luis Rodrigo. Celiac disease and autoimmune-associated conditions.” BioMed Research International (2013).
Marcason, Wendy. “Understanding Celiac Disease”. Academy of Nutrition and Dietetics. 23 October 2014. Web.
Sapone, Anna, et al. “Divergence of gut permeability and mucosal immune gene expression in two gluten-associated conditions: Celiac disease and gluten sensitivity.” BMC Med (2011) 9: 23.
“Sources of Gluten.” Celiac Disease Foundation. 2015. Web. <http://celiac.org/live-gluten-free/glutenfreediet/sources-of-gluten/>