Topic 1 Celiac disease: a case study
General information of the case
- Name: Raul Moreno
- Gender: male
- Age: 7 years and 4 months
- Raul and his mother attend the Nutrition Unit.
- Symptoms:
Raul’s mother reports low weight and height for his age, since always. Abdominal pain, flatulence abdominal distension, and feeling of early satiety. She considers that Raul does not eat too much small since he rejects some foods on occasions and does not finish the preparations. He manifest chronic tiredness that does not stop after vacation period. He is very tired at the end of the day and he cannot finish dinner for many days. He shows a decreased appetite in some seasons. He has come to use a dietary supplement. He has irregular bowel movements and periods of 1 stool/day of normal consistency and periods of diarrheal stools (5-8 a day).
Anthropometric data
- Weight: 19 kg
- Size: 116 cm
- Head circumference: 52 cm
Energy evaluation data
- BMR WHO: 926 Kcal/day
- Moderate activity
- TEE WHO: 1482 Kcal/day
Psychosocial data
- Raul lives with both parents at home.
- He has a 10 year old brother.
- Both parents work.
- He attends the school to the corresponding course and with average academic results an, usually, eats in the school dinning room.
Other Clinical Data
- There are no relevant data on previous illnesses, hospital admissions or surgical interventions.
Physical activity
- He does physical education at school 2 days a week.
- He plays soccer and he trains 2 days a week in the afternoons.
- In the afternoons, weather permitting, he goes to he park with his brother.
- Weekends are usually quite sedentary.
- The have dinner almost every day as a family.
- Weekend don´t change diet habits much. Maybe you don’t have midmorning every day because you get up and eat breakfast later.
- Drink water regularly with meals. About 3 glasses of water a day.
- Have some commercial juice some days.
- At home, they usually cook with virgin olive oil.
- Take in general from all fook groups.
- He rejects certain foods, but not an entire group in general.
- His favorite dishes are the potato omelette and burgers.
- Foods he does not eat because he does not like them: cauliflower, broccoli, spinach and chickpeas. He reports that he is eating less bread because sometime he feels heavy after eating it.
- No known allergies or intolerances.
The following 3 tables represent the Raul’s diet during 2 working days and 1 weekend day
| Day 1 (business day) | |
| Breakfast | Glass or whole cow´s milk with 2 teaspoons of cocoa (takes half) |
| 2 assorted cookies with chocolat coating | |
| Midmorning | 30 g sandwich white bread with 20 g serrano ham |
| 200 ml commercial orange juice. | |
| Meal | Green bean with potato |
| Breaded chicken breast fillet | |
| Peach | |
| 10 g white bread | |
| Afternoon snack | Whole fruit flavored yogurt |
| Dinner | Broth pasta soup |
| 1 egg cheese omelette (takes halt) | |
| No dessert | |
| No bread | |
| Day 2 (business day) | |
| Breakfast | Glass or whole cow´s milk with 2 teaspoons of cocoa (takes half) |
| 2 assorted cookies with chocolat coating | |
| Midmorning | Apple |
| 3 maria type cookies | |
| Meal | Lentils with rice |
| Baked hake slice with lemon | |
| Sweetened plain yogur | |
| No bread | |
| Afternoon snack | 30 g sandwich white bread wich chocolat |
| Dinner | Tomato in salad |
| 1 Wheel of pork loin in sauce | |
| No dessert | |
| No bread | |
| Day 3 (weekend or holiday) | |
| Breakfast | Glass of whole cow´s milk with 2 teaspoons of cocoa (takes half) |
| 1 commercial sponge cake | |
| Meal | Paella with vegetables and prawns |
| Ice cream | |
| No bread | |
| Afternoon snack | Banana |
| Small bag of corn chips | |
| Dinner | Sandwich with 2 slices of sliced bread and 1 slice of cooked ham and 1 slice of cheese |
| Apricot | |
| No bread | |
(DIAL dietary calibration program)
| Fact | Amount | Fact | Amount | Fact | Amount |
| Energy | 1091 | Cholesterol | 285 | Vitamin B2 | 0,8 |
| Protein | 37 | Calcium | 456 | Vitamin B3 | 15 |
| % Proteins | 14 | Iron | 6,7 | Vitamin B6 | 0,7 |
| Carbohydrates | 107 | Iodine | 54 | Folic acid | 108 |
| % Carbohydrates | 39 | Magnesium | 129 | Biotin | 16 |
| Sugars | 57 | Zinc | 4 | Pantothenic acid | 2,2 |
| Fiber | 8 | Selenium | 41 | Vitamin B12 | 1,8 |
| Fats | 57 | Sodium | 753 | Vitamin C | 51 |
| % Fats | 47 | Potassium | 1324 | Vitamin A | 306 |
| SFA | 17 | Phosphorus | 675 | Vitamin D | 0,4 |
| MUFA | 26 | Fluorine | 117 | Vitamin E | 4 |
| PUFA | 4 | Vitamin B1 | 0,7 | Vitamin K | 48 |
How is celiac disease diagnosed?
An intestinal biopsy is necessary in all cases to confirm the diagnosis.
In the 2020 Guide os the European Society for Pediatric, Gastroenterology, Hepatology and Nutrition (ESPGHAN) there are some news regarding the diagnosis criteria for celiac disease in children and adolescents. It is established that a person is celiac if they present symtoms compatible with the disease or, without presenting symptoms, they have these two factors:
- Positive IgA antitranglutaminase antibodies in blood with values 10 times higher than the normal value.
- Positive anti-endomysial IgA antibodies in blood (in different blood simple).
The more specific symtoms, although many times they do not appear, are malabsorption that leads to growth failure, weight loss and chronic diarrea. In parallel, diarrea, chronic constipation, iron deficiency or dental enamel hypoplasia imply an increased risk of celiac disease. Pain, bloating or dyspepsia may be present, but are more nonspecific.
In these cases, it would not be necessary to perform an intestinal biopsy or genetic study.
Histological study (biopsy)
- In cases where the diagnosis requires an upper gastrointesintal endoscopy with intestinal biopsies for evaluation, it is recommended to take at least 1 simple from the bulb and at least 4 samples from the distal duodenum, and it is considered that the mucosa it is damaged when the villus: crypt ratio is less tan 2, which corresponds to Marsh type 2 (crypt hiperplasia) and Marsh tupe 3 (villus atrophy) lesions.
Genetic study (HLA)
- HLA genetic testing is not necessary to reinforce a diagnosis. It is used to rule out disease due to its high negative predictive alue, when there is no associated HLA protein variant (DQ2, DG8 or one of the alleles of the DQ2 protein: DQA1*05 or DQB1*02.
Questions on the case study
QUESTION 1: Whith which tool is the adequacy of weight and size in pediatric age?
QUESTION 2: According to Raul´s initial dietary assessment, what modifications can be introduced to improve the diet by adapting to current circumstances?
QUESTION 3: How is celiac disease defined?
QUESTION 4: What foods in Raul´s diet of day 1 have gluten by nature?
QUESTION 5: In Raul´s diet of day 2, what are gluten-free foods by nature?
Celiac disease and non-celiac gluten sensitivity are the same disease.
People with non-celiac gluten sensitivity cannot be diagnosed as celiac because they do not meet the criteria for it. However, by removing gluten from their diet, the symptoms they suffer from are noticeably improved.
One of the fundamental differences is found the symptomatology picture. In the case of celiac disease, the symptoms are very wide and distributed practically by all the organs and body systems. On the other hand, in the case of non-celiac gluten sensitivity, the symptoms are concentrated in the digestive tract with abdominal pain, flatulence, diarrea or constipation, a sensation of slow and heavy digestion as the main complications associated with gluten intake.
Thus, non-celiac gluten sensitivity is not an inmune disease and has no genetic component.
However, there is still much to investigate in this pathology.
