CELIAC DISEASE

PEDIATRIC CASE

GROUP 2
 01. CASE
INTRODUCTION
JAPSAY & BESA
TABLE OF 02. PAST MEDICAL &
CONTENTS FAMILY HISTORY
ALBANA & ABUAN

03. PEDIATRIC HISTORY

DEPOL & ESTOLAS
04. CLINICAL
PRESENTATION
BERJA, VELADO & BALTAR
 05. TEXTBOOK
DISCUSSION
PANISA & LASALITA
TABLE OF 06. PHYSICAL EXAM
CONTENTS ESTOLAS
07. SHORT-TERM PLAN
CORDERO & BUENAFE
08. LONG-TERM PLAN
LOPEZ & PELAEZ
09. NURSING
MANAGEMENT
DIOSABAN & JAGUIO
 01.
CASE INTRODUCTION

JAPSAY AND BESA

Presenting the case of patient FO 11 y/o, male, presented himself accompanied by his
mother at the emergency room, last April 24, 2021 at 8 am with a chief complaint of
recurrent vomiting, diarrhea, abdominal pain, muscle weakness, and fatigue for the past 3
months. As per mother, the patient had pale, greasy, sticky and a foul odor stool. Patient’s
mother was alarmed because his signs and symptoms worsened two days ago and it
included mouth sores. Patient appeared bloated, pallor, and weak. Patient’s weight upon
assessment was 23.5 kg. (51.7 lb), height of 121 cm or 4 ft., and a BMI of 15.8 (normal BMI
is > 18). His mother noted that his previous weight last 3 months was 29 kg.
He also complained of numbness and tingling of his fingers that radiated up to his
shoulders and from his feet to his hips, marked proximally. Bilateral muscle atrophy (aka
muscle wasting) and weakness, although asymmetrical, on upper and lower limbs was also
noted upon assessment. He also reported that he feels sudden, severe back pain that
worsens when walking. The patient reported he eats bread and drinks milk every morning.
There were also clusters of red, itchy and blistering rash and scabs noted on his elbows and
back. Laboratory tests revealed that his hemoglobin 9.5 g/dL (13.5 to 17.5), Hematocrit 36.4
(38.3 to 48.6 percent), and Calcium 7.5 (8.6-10.2 mg/dl).
 02.
PAST MEDICAL & FAMILY
HISTORY

ALBANA AND ABUAN

Patient FO was delivered through normal spontaneous vaginal delivery (NSVD) at Roxas Memorial Provincial
Hospital. His mother stated that Patient FO underwent newborn screening and results came back negative as she
remembered. He has received Hepatitis B vaccine, BCG vaccine, 3 doses of Pentavalent or 5-in-1, 3 doses of OPV.
It is also noted that patient has not received any dose of Rotavirus vaccine. He also received measles, mumps and
rubella vaccine (AMV2) at the age of 9 months old but missed the second dose when he was 1 year old.

On 2015, Patient FO was hospitalized at Roxas Memorial Hospital due to dengue. During that time he was also
diagnosed with anemia due to reports of frequent bruising and iron deficiency as evidenced by serum iron levels
and CBC. When asked on the management of anemia, the mother stated that there was no management because
they had no money to buy Vitamin B-12 for him.
The mother stated that his abdomen has been distended since he was a toddler. She also noticed that Patient FO
has not gained weight growing up. He also has a history of recurrent diarrhea, vomiting, and abdominal pain in
the left lower quadrant every time he consumes bread, milk, cake, and ice cream. His parents report that he has
had gastrointestinal problems since he was 4 years old, especially every time he eats food mentioned earlier.
However, due to low family income, they did not had the chance to get him checked by a physician.

Mother denies patient allergies of any kind. Patient FO’s mother suffers with type 1 diabetes and dermatitis
herpetiformis (itchy, red blisters and scabs on elbows). While his father’s side has a family history of
hypothyroidism.
 03.
PEDIATRIC
HISTORY

DEPOL & ESTOLAS

Patient FO was born on April 18, 2010 at Roxas Memorial Hospital. He was delivered via NSVD at 36 weeks
AOG. Patient FO was smaller than average when he was delivered. No maternal complications during delivery as
narrated by the mother although she had to monitor her glucose levels during pregnancy because she has Type 1
diabetes. She was also administered immediate acting insulin via IVF since her CBG levels were above 140 mg/dl
during delivery. As far as the mother can remember, a newborn screening test was done to him. Test results came
back negative. The patient’s immunization also solely depended on free vaccines given by the DOH Program. He
has 3 older sisters and 1 younger brother. He is the 4 th child in their family. Mother’s obstetric history is G5P4
T4P1A0L5M0. Patient was breastfed but only in a short period of time (birth up to 4 months).
 Anthropometric
Measurements:

Weight: 2 kg.
Height: 40 cm
Head Circumference: 32 cm
Abdominal/Chest Circumference: 28 cm
APGAR Score:
INDICATOR 0 POINTS 1 POINT 2 POINTS SCORE GIVEN
Appearance (skin Bluish-gray or pale all Normal color (but Normal color all over 2
color) over hands and feet are (hands and feet are
bluish) pink)

Pulse (heart rate) Absent Below 100 beats per Normal (above 100 2
(no pulse) minute beats per minute)

Grimace response Absent (no response Facial movement only Pulls away, sneezes, 1
(reflexes) to stimulation) (grimace) with coughs, or cries with
stimulation stimulation

Activity (muscle tone) No movement, Arms and legs flexed Active, spontaneous 1
“floppy” tone with little movement movement

Respiration (breathing Absent Slow or irregular Normal rate and 1

rate and effort) breathing, weak cry effort, good cry

TOTAL SCORE 7
Patient FO Immunization Chart:
 At 4 years old, the mother started noticing signs of abnormal stools (greasy, bulky, sticky in consistency)
while he had recurrent diarrhea accompanied with nausea and vomiting. As he progressed through child
growth, Patient FO was also experiencing weight loss, bloating, stunted growth, frequent vomiting, tooth
decay and muscle weakness. Muscle wasting on bilateral proximal limbs also started while years passed.

 Patient FO was hospitalized due to Dengue on 2015. He was also transfused with two 350 ml of packed RBC.
During that time, he was also diagnosed with anemia. He gets bruised easily and had iron deficiency as
evidenced by CBC and Serum Iron levels results. However, his anemia was not managed because of their
family status.
 Patient FO has not been physically active and was not able to play with other children because he gets easily
tired and his muscles were weak. He also had difficulty in running and doing strenuous activity as a child.

 As to nutritional status and diet, mother reported that she kept on giving the child milk in the hopes of
making his bones and muscles strong. However, every time he drinks milk and eats bread, cake, and ice
cream symptoms such as diarrhea, vomiting, and abdominal pain occurs. Patient FO is not currently taking
any vitamins but he did take Tiki Tiki Plus from ages 3 – 7 years old. The patient eats all kinds of food. His
favorite is spaghetti and ice cream.
 04.
Clinical presentation

BERJA, VELADO AND BALTAR

 General Appearance:

Patient presented at the emergency room with his mother appearing bloated,
pallor, and weak with a chief complaint of recurrent vomiting, diarrhea,
abdominal pain, muscle weakness, and abnormal weight loss. During the
assessment, the patient was uncomfortable and irritated although he was awake
and oriented of where he is. Facial grimace and abdomen guarding were
observed. Patient has a hunched posture (kyphosis) and needed support when
walking. Visible red bumps and scabs were determined at the elbows and back
 Signs noticed by the examiner:

The patient was pale, weak and irritable. He is malnourished and smaller in weight and height
than average. His range of motion was also limited. Bilateral muscle atrophy on proximal
upper and lower limbs were noted. Presence of mouth sores, rashes on the patient’s elbows and
back, poor skin turgor was observed and has a bloated stomach. Poor and dry skin turgor was
noted. Bruises on legs were also noted. Patient also had decayed teeth. Abdominal pain
worsened prior to admission of patient. Patient needed limited assistance when doing activities
such as walking, going to the bathroom, etc. Patient’s mother described stool as pale, greasy,
sticky and a foul odor stool and thus, was classified as steatorrhea.
 Initial Assessment by Nurse

History of Present Illness

Prior to admission, Patient FO admitted that he ate bread and drank
milk. Presented himself together with a chief complaint of vomiting,
diarrhea, abdominal pain, muscle weakness, and abnormal weight loss.
His complaint also included numbness and tingling of extremities.
 Initial Assessment by Nurse

The symptoms gradually manifested for three months but worsened two days ago while he was
at home playing with his siblings. He had experienced the symptoms ever since he was a child
but the vomiting and diarrhea was already severe. Patient was also very weak and needed
support to walk. Abdominal pain was persistent and did not alleviate. This triggered admission
to emergency department. Vomiting occurred 5 times, non-projectile, yellow in color, and thick
in consistency. Diarrhea occurred 6 times a day, pale, greasy, sticky and a foul odor. The
mother managed the problem by administering oral rehydration solution. He gradually lost
weight throughout the course of 3 months.
Collecting Data Subjective data: The
Nursing Health History
History of Present Health Concern Findings
Abdominal Pain
1. Are you experiencing abdominal pain? If the client answers yes, The patient’s mother stated that he is experiencing abdominal
use COLDSPA to further explore this symptom: pain.
 
a.   Character: Describe the pain  The patient’s mother described the pain as sharp stabbing pain as
  complained by her child.
b.   Onset: When did (does) the pain begin?
  Night before his admission
c.   Location: Point to the area where you have this pain. Does it
move or has it changed from the original location? The patient points the pain in the left lower quadrant and does not
change in location.
d.   Duration: How long does the pain last?
It goes after a few minutes and happens very frequently
e.   Severity: How bad is the pain (severity) on a scale of 1 – 10,
with 10 being the worst? The patient rates the pain 6 out of 10

f.  Pattern: When does the pain occur (timing and relation to
particular events such as eating, exercise, bedtime? What seems to The patient states that the pain occurred after eating specifically
bring on the pain (precipitating factors), or make it better when he eats wheat bread and drinks milk.
(alleviating factors)?

g. Associated factors/How it affects the client: Is the pain The patient’s mother states that the pain is associated with nausea,
associated with any other symptoms such as nausea, vomiting, vomiting, diarrhea, weight loss, and fatigue.
diarrhea, weight loss, fatigue?
2. Do you experience nausea or vomiting? Is it The patient is experiencing nausea and vomiting as
triggered by any particular activities, events, or other reported by the patient's mother and is being triggered
factors (smells, eating certain foods). when he eats food containing gluten.

Appetite The patient’s mother did not notice any increase in his
1. Have you noticed an increase or decrease in your appetite and it affects how much he eats and loses much
appetite? Has this change affected how much you eat or weight
your normal weight?

Bowel Elimination The patient’s mother describes his stool as pale, greasy,
1. Describe your stools (how many a day and sticky and a foul odor. She stated that he defecates 3-4
consistency and color). Have you experienced a change times per day.
in bowel elimination patterns?

2. Have you experienced diarrhea? Describe. Do you The patient’s mother states he experienced diarrhea.
have any associated symptoms?
3. Have you experienced any yellowing of your skin or The patient experienced itchy skin rash as reported by
whites of your eyes, itchy skin, and dark urine (yellow the mother..
brown or tea-colored)?
Anemia When he was 5 years old as stated by the mother.
a. Duration:
When did it start?

b. Onset: Gradual
Was it sudden or gradual?

c. Course: Yes
Is it getting worse?

d. Severity: Yes
Has it affected your daily activities?
2. What’s your diet like? / did you change it? The patient loves to eat bread alongside with milk; he
doesn’t change his diet as reported by the mother.
3. Have you had heavy nosebleeds? The patient’s mother denied that he had heavy
nosebleeds.

4. Have you vomited any blood? He did not vomited any blood as reported by the mother

5. Have you noticed any blood in your urine? The patient’s mother states that she does not notice any
blood in his urine.
6. Have you noticed any bowel motions? Steatorrhea was noted as reported by the patient’s
mother
7. Have you had gastrointestinal problems? The patient’s mother stated that he had gastrointestinal
problems since he was 4 y/o.

8. Did you take any medicines, which ones? He had been taking low dose aspirin to alleviate the
pain as reported by the mother.

9. Did you experienced fever, loss of appetite and The patient experienced fever, loss of appetite and
weight loss? weight loss as reported by the patient.
Muscle Wasting Yes, the mother states that the patients lost 5 kg
1. Do you experience weight changes in the past 6
months? If yes, how many kg did you lose?
2. Have you experienced numbness in the limbs? The patient complained numbness and tingling of his
fingers that radiated up to his shoulders and from his feet
3. Do you have difficulty in maintaining your balance? The mother states that the patient has difficulty
maintaining his balance
4. Is there any part of your body that you can’t move? The patient was experiencing increased muscle wasting,
especially on his right parts of the hand and foot.
5. Have you experienced memory loss? Was it gradual? The patient denied that he have experienced memory loss

6. Have you experienced any changes in vision? The patient’s mother states that he complains about
having blurry vision sometimes

7. Have you experienced loss of consciousness? The patient’s mother states that he never lost his
consciousness
Personal Health History The patient had gastrointestinal problems since he was 4.
Have you ever had any of the following gastrointestinal
problems?
Have you ever had abdominal surgery or trauma to the The patient's mother reported that he has never
abdomen? undergone abdominal surgery or trauma to the abdomen.
What over the counter (OTC) medications do you take? The patient is taking a low dose aspirin as reported by
Is there a history of any of the following diseases or the mother. There were no family histories of colon,
disorders in your family: colon, stomach, pancreatic, stomach, pancreatic, liver, kidney or bladder cancer as
liver, kidney, or bladder cancer; liver disease; gallbladder reported by the patient's mother.
disease; kidney disease?
Nutritional History
Anthropometric Measurement:
a. BMI 15.8
b. Current body weight 23.5 kg
c. Current height 4 ft. or 121 cm
2. Assessment of Eating Habits and Behavior

a. Do you have any concerns related to your child’s Yes, because he has lost so much as stated by the
eating habit? patient’s mother.

b. Do your child follow a special diet related to their None

weight?

c. Do your child have any food allergies or None

intolerance?

d. What is done when your child does not want to eat The patient’s mother states that she did not try to force
all or most of the food that is on his or her plate? him to eat instead she gave him bread as his snack.
3. Food or Beverage Frequency Assessment

a. What meals or snacks does your child eat The patient’s mother states that he often eat wheat bread
and milk

b. How much water does your child drink?

The patient’s mother states that he drinks up to 3-4
glasses of water a day
c. How much milk does your child drink?

The patient’s mother states that he drinks up to 4-5

d. What type of milk does your child usually drink? glasses a day

Sterilized powdered milk

4. Assessment of Activity and Sleep Habits

a. On how many days does your child participate in The patient does not often participate in physical
physical activity for at least 20 minutes where they were activities. He is more engaged in playing mobile game
sweating and breathing hard?

b. How many hours of sleep does your child get each 8-10hrs
night?

 
Admitting Diagnosis
 Celiac disease
Differential Diagnoses:
 r/o Crohn’s disease
 r/o Meckel’s Diverticulum
 r/o Ulcerative Colitis
 r/o Irritable Bowel Syndrome
 05.
TEXTBOOK DISCUSSION

PANISA & LASALITA

 Description
Celiac disease, sometimes called celiac sprue or gluten-sensitive enteropathy, is
an immune reaction to eating gluten, a highly complex protein found in wheat,
barley and rye. Gluten-containing foods trigger an immune response in your
small intestine which damages your small intestine's lining and causes
malabsorption overtime. There is no cure for celiac disease — but for most
people, following a strict gluten-free diet can help manage symptoms and
promote intestinal healing.
 Description
During a microscopic viewing of the small intestine, there will be vast numbers of tiny finger
like projections sticking up from the surface. These are villi and their purpose is to increase
the absorption of nutrients from our diet. In a person with coeliac disease, the villi have been
damaged by inflammation and they will look shorter and stubbier meaning that fewer
nutrients pass into the bloodstream. In more severe cases, they can barely be seen at all so
the lining of the intestine looks quite flat. Doctors call this villous atrophy. Recognizing
villous atrophy is the key to making the diagnosis of coeliac disease. If patients with coeliac
disease stop eating gluten, the villi can recover.
 Classification
 Classical - patients have signs and symptoms of malabsorption

 Non-Classical – mild gastrointestinal disorder but without clear signs of malabsorption or

seemingly unrelated symptoms

 Silent Celiac disease or asymptomatic celiac disease - patients do not complain of any
symptoms, but still experience villous atrophy damage to their small intestine
Children Adults
- abdominal bloating and pain - unexplained iron-deficiency anemia
- chronic diarrhea - fatigue
- vomiting - bone or joint pain
- constipation - arthritis
- pale, foul-smelling, or fatty stool - osteoporosis or osteopenia (bone loss)
- iron-deficiency anemia - Liver and biliary tract disorders (transaminitis,
- weight loss fatty liver, primary sclerosing cholangitis, etc.)
- fatigue - depression or anxiety
- irritability and behavioral issues - peripheral neuropathy (tingling, numbness or
- dental enamel defects of the permanent teeth pain in the hands and feet)
- delayed growth and puberty - seizures or migraines
- short stature - missed menstrual periods
- failure to thrive - infertility or recurrent miscarriage
- Attention Deficit Hyperactivity Disorder - canker sores inside the mouth
(ADHD) - dermatitis herpetiformis (itchy skin rash)
   
 Risk factors (Non-modifiable and Non-Modifiable)

 Non-Modifiable  Modifiable

- Genetic; family members who - Food intake with gluten content

have celiac disease
- Infant-feeding practices (Short Duration of breastfeeding)
- Race: Caucasians and Europeans
- Early exposure and introduction to gluten into the diet of infants
- Gender: Women are more 4-6 months old, but no particular quantity is recommended.
affected than men
- Infection by rotavirus or human intestinal adenovirus
 Diagnosis

 Celiac disease can be difficult to diagnose because it affects people

differently. There are more than 200 known celiac disease symptoms
which may occur in the digestive system or other parts of the body.
Some people develop celiac disease as a child, others as an adult. The
reason for this is still unknown.
 Blood test

Genetic testing (HLA-DQ2 and HLA-DQ8) - looks for antibodies in your blood. Elevated
levels of certain antibody proteins indicate an immune reaction to gluten

Tissue transglutaminase (tTG) immunoglobulin A (IgA) and tTG immunoglobulin G

(IgG) test - preferred celiac disease serologic test for most patients which depends on the
degree of intestinal damage, making the test less sensitive in patients who have mild
celiac disease, however, this test may also be less sensitive in children younger than age
2.
 Blood test

Endomysial antibody (EMA) -IgA test – this test is done after the tTG-IgA
test to help make a diagnosis of celiac disease more certain. This test, on the
other hand, is more expensive and time-consuming to perform than the tTG-
IgA test.

Deamidated gliadin peptide (DGP) -IgA and DGP-IgG tests – this test is less
sensitive and specific than the tTG-IgA test.
 Intestinal (Duodenal) Endoscopy

uses a long tube with a tiny camera that's put into your mouth
and passed down your throat (upper endoscopy). The camera
enables your doctor to view your small intestine and take a
small tissue sample (biopsy) to analyze for damage to the villi.
 Capsule endoscopy

uses a tiny wireless camera to take pictures of your entire small

intestine. The camera sits inside a vitamin-sized capsule, which you
swallow. As the capsule travels through your digestive tract, the
camera takes thousands of pictures that are transmitted to a recorder.
CLINICAL MANIFESTATIONS OF PATIENT FO
S/Sx Patient Family History
 Gastro intestinal  Type 1 diabetes
 Diarrhea  Dermatitis
 Abdominal pain  Herpetiformis
 Muscle weakness  Hypothyroidism
 Fatigue  
 Numbness and tingling of his fingers  
 Visible red bumps and scabs are noted
 Increased muscle wasting
 
 
PATHOPHYSIOLOGY
 CELIAC DISEASE

Risk Factors:
• A family member with celiac
disease or dermatitis
hypetiformis.
• Type 1 diabetes
• Autoimmune thyroid disease
• Down syndrome or Turner
syndrome
 
 
 
 
DISEASE PROCESS:
 Eat gluten (a protein found in wheat, rye and barley), the body mounts an immune response that
attacks the small intestine.
 The attacks leads to damage of the villi.
 Small fingerlike projections that line the small intestine.
 Promotes nutrient absorption.
 

  SIGNS AND SYMPTOMS:

  CELIAC DISEASE SYMPTOMS IN CHILDREN
  CHILDREN WITH CELIAC DISEASE ARE MORE LIKELY
  TO HAVE INTESTINAL PROBLEMS, INCLUDING:

  BLOATING OR BELLY SWELLING

CONSTIPATION
  DIARRHEA
  PALE, FOUL SMELLING POOP
UPSET STOMACH OR VOMITING
 
WEIGHT LOSS
 
 
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