PANCE Blueprint GI and Nutrition (9%)

Patient with celiac disease will present as → a 34-year-old male presents to the clinic with a six-month history of chronic diarrhea, weight loss, and generalized weakness. He reports frequent abdominal pain and bloating after meals. He has also noticed a blistering, itchy rash on his elbows and knees. His medical history is significant for iron deficiency anemia. Physical examination reveals pallor, a distended abdomen, and a rash consistent with dermatitis herpetiformis. Laboratory tests show low hemoglobin and hematocrit levels, elevated transaminases, and a positive tissue transglutaminase (tTG) IgA antibody. Given his clinical presentation and positive serologic test for celiac disease, the patient is diagnosed with celiac disease. Upper endoscopy with a biopsy of the small intestine is scheduled to confirm villous atrophy. He is started on a strict gluten-free diet and referred to a dietitian for comprehensive dietary education and management. He is also advised to avoid foods that may contain hidden sources of gluten and to be aware of cross-contamination. Follow-up is planned to monitor his response to the gluten-free diet, check for improvement in symptoms, and reassess his nutritional status.

Patient with non-celiac gluten intolerance will present as → a 28-year-old female presents to the clinic with a one-year history of recurrent abdominal bloating, diarrhea, and fatigue. She notes that her symptoms tend to worsen after consuming foods containing gluten, such as bread, pasta, and pastries, but she does not experience any symptoms when she avoids gluten. She has tried a gluten-free diet for several weeks, which seemed to improve her symptoms. Her medical history is unremarkable, and she denies any weight loss, anemia, or skin rashes. Physical examination and routine laboratory tests, including a celiac panel, are all normal. Based on her history of symptoms improving with a gluten-free diet and the absence of diagnostic markers for celiac disease, the patient is diagnosed with non-celiac gluten intolerance. She is advised to continue a gluten-free diet and to monitor her symptoms closely. She is also educated on reading food labels and avoiding cross-contamination. A referral to a dietitian is made to ensure she maintains a balanced and nutritious diet while avoiding gluten. Follow-up appointments are scheduled to monitor her symptoms and nutritional status.

To watch this and all of Joe-Gilboy PA-C's video lessons you must be a member. Members can log in here or join now.

Celiac Disease: An autoimmune disorder where gluten intake damages the small intestine, leading to nutrient absorption issues and symptoms like diarrhea, abdominal pain, and fatigue. Diagnosis is through blood tests and intestinal biopsy. Treatment requires a strict, lifelong gluten-free diet.

Celiac disease is characterized by inflammation of the small bowel secondary to the ingestion of gluten-containing foods such as wheat, rye, and barley, leading to malabsorption.

• Celiac disease is an autoimmune disorder
• Celiac disease runs in families
  • People with a first-degree relative with celiac disease (parent, child, sibling) have a 1 in 10 risk of developing celiac disease. 
    • 1:300 in southwest Ireland.
    • > 1:5000 in North America.

Clinical presentation is variable and may lead to a delay in diagnosis in milder cases

• Diarrhea, steatorrhea, flatulence, weight loss, weakness, and abdominal distension are common
• Infants and children may present with failure to thrive

Non-Celiac Gluten Sensitivity (NCGS): A condition causing symptoms similar to celiac disease, such as bloating and abdominal pain, WITHOUT the autoimmune intestinal damage. Diagnosed by ruling out celiac disease and wheat allergy, and observing symptom improvement on a gluten-free diet. Gluten sensitivity levels vary, and some individuals may tolerate minimal gluten.

• NCGS does not involve autoimmune damage to the intestine
• Normal serum biomarkers - NCGS is diagnosed by ruling out celiac disease and wheat allergy and observing symptom improvement on a gluten-free diet.
• Individuals with NCGS may have varying levels of sensitivity and may be able to tolerate small amounts of gluten.

Celiac Disease and Non-Celiac Gluten Sensitivity/Intolerance (NCGS):

IgA endomysial antibody (EMA) and anti-tissue transglutaminase (anti-tTG) antibodies. If the serologic tests are positive, an upper endoscopy with a small bowel biopsy is performed to confirm the diagnosis. Testing for celiac disease should ideally be performed while patients are on a gluten-containing diet.

• Tissue Transglutaminase Antibodies (tTG-IgA): The tTG-IgA test will be positive in about 98% of patients with celiac disease who are on a gluten-containing diet.
• IgA Endomysial antibody (EMA-IgA): The EMA test has a specificity of almost 100% but is not as sensitive as the TTG-IgA test. About 5-10% of people with celiac disease do not have a positive EMA test.

"Endoscopic intestinal mucosal biopsy of the proximal duodenum (bulb) and distal duodenum is the standard method for confirmation of the diagnosis in patients with a positive serologic test (IgA endomysial antibody) for celiac disease."

Treat celiac disease with a gluten-free diet. Supplementation may be needed to correct nutritional deficiencies in iron, vitamin B12, folic acid, calcium, and vitamin D.

• Patients are encouraged to consult a dietitian and join a celiac support group such as Beyond Celiac or the Celiac Disease Foundation.

Non-Celiac Gluten Sensitivity (NCGS) is also treated with a gluten-free diet, but sensitivity levels vary; some individuals may tolerate small amounts of gluten.