Celiac Disease

• Also called Gluten-Sensitive Enteropathy.
• Is a disease of the small intestine marked by atrophy of the villi and microvilli caused by an immune-mediated inflammatory response to gluten, a protein found in common grains such as wheat, rye, oats, and barley.
• The cause is unknown, but genetic, environmental, and immunologic elements maybe involved.
• The disease is triggered by surgery, pregnancy, viral infection, or severe emotional distress.
• It is most common in young children ages 6 to 24 months but can occur at any age.
• Symptoms typically diminish or disappear in adolescence and reappear in early adulthood.
• Complications include impaired growth, inability to fight infections, electrolyte imbalance, clotting disturbance, and possible predisposition to malignant lymphoma of the small intestine.

Assessment:

Ages 3 to 9 months

1. Acutely ill; severe diarrhea and vomiting
2. Irritability
3. Possible failure to thrive

Ages 9 to 18 months

1. Slackening of weight followed by weight loss
2. Abnormal stools
   • Pale, soft, bulky
   • Offensive odor
   • Greasy (steatorrhea)
   • May increase in number
3. Abdominal distention
4. Anorexia, discoloration of teeth
5. Muscle wasting: most obvious in buttocks and proximal parts of extremities
6. Hypotonia, seizures
7. Mood changes: ill humor, irritability, temper tantrums, shyness
8. Mild clubbing of fingers
9. Vomiting: usually occurs in the evening
10. Aphthous ulcers, dermatitis

Older Child and Adult

1. Signs and symptoms are commonly related to nutritional or secondary deficiencies resulting from disease.
   • Anemia, vitamin deficiency (A, D, E, K)
   • Hypoproteinemia with edema
   • Hypocalcemia, hypokalemia, hypomagnesemia
   • Hypoprothrombinemia from vitamin K deficiency
   • Disaccharide (sugar) intolerance
   • Osteoporosis due to calcium deficiency
2. Anorexia, fatigue, weight loss.
3. May have colicky abdominal pain, distention, flatulence, constipation, and steatorrhea.

Diagnostic Evaluation:

1. Small bowel biopsy, which demonstrates characteristic abnormal mucosa.
2. Hemoglobin, folic acid, and Vitamin K levels may be reduced.
3. Prothrombin time may be prolonged.
4. Elevated immunoglobulin (Ig) A endomysium antibodies and IgA anti-tissue transglutaminase antibodies.
5. Total protein and albumin may be decreased.
6. 72 hour stool collection for fecal fat is increased.
7. D-xylose absorption test – decreased blood and urine levels.
8. Sweat test and pancreatic function studies may be done to rule out cystic fibrosis in child.

Therapeutic Interventions:

1. Dietary modifications includes a lifelong gluten-free diet, avoiding all foods containing wheat, rye, barley, and possibly, oats.
2. In some cases, fats maybe reduced.
3. Lactose and sucrose may be eliminated from diet for 6 to 8 weeks, based on reduced disaccharidase activity.

Nursing Interventions:

1. Monitor dietary intake, fluid intake and output, weight, serum electrolytes, and hydration status.
2. Make sure that the diet is free from causative agent, but inclusive of essential nutrients, such as protein, fats, vitamins, and minerals.
3. Maintain NPO status during initial treatment of celiac crisis or during diagnostic testing.
4. Provide parenteral nutrition as prescribed.
5. Provide meticulous skin care after each loose stool and apply lubricant to prevent skin breakdown.
6. Encourage small frequent meals, but do not force eating if the child has anorexia.
7. Use meticulous hand washing technique and other procedures to prevent transmission of infection.
8. Assess for fever, cough, irritability, or other signs of infection.
9. Teach the parents to develop awareness of the child’s condition and behavior; recognize changes and care for child accordingly.
10. Explain that the toddler may cling to infantile habits for security. Allow this behavior, it may disappear as physical condition improves.
11. Stress that the disorder is lifelong; however, changes in the mucosal lining of the intestine and in general clinical conditions are reversible when dietary gluten is avoided.

Image by: National Science Foundation

Daisy Jane Antipuesto RN MN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

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