36-year-old woman is seen with complaints of abdominal bloating and gas.

A 36-year-old woman is seen with complaints of abdominal bloating and gas. She says she has been really tired and has noticed sores in her mouth and tingling in her legs. She states her bloating and gas seem to get better when she is fasting.

Critical Thinking Questions

1. What additional questions should you ask the patient and why?
2. What should be included in the physical examination at this visit?
3. What are the possible differential diagnoses at this time?
4. What test should you order and why?
5. How would you manage this patient based on your diagnosis?

Students are expected to

1. Post an initial substantive response
2. References and in-text citations should conform to the APA 6th edition.
3. Respond to at least two other peer/student’s postings with substantive comments
4. The peer postings should be at least one paragraph (approximately 100 words) and include citations and references

Timothy’s Response

A 36-year-old woman is seen with complaints of abdominal bloating and gas. She says she has been really tired and has noticed sores in her mouth and tingling in her legs. She states her bloating and gas seem to get better when she is fasting.

The patient presents with signs of symptoms related to a disease process known as celiac disease. According to Barker and Liu (2008), Celiac disease, also known as “celiac sprue,” is a chronic inflammatory disorder of the small intestine, produced by the ingestion of dietary gluten products in susceptible people. It is a multifactorial disease, including genetic and environmental factors. The environmental trigger is represented by gluten while the genetic predisposition has been identified in the major histocompatibility complex region. Celiac disease is not a rare disorder like previously thought, with a global prevalence of around 1%. The reason of its under-recognition is mainly referable to the fact that about half of affected people do not have the classic gastrointestinal symptoms, but they present nonspecific manifestations of nutritional deficiency or have no symptoms at all.

What additional questions should you ask the patient and why?

According to Schuppan and Dieterich (2016), The patient should be asked questions related to diet, exercise, and more information about abdominal pain. The questions should be about the severity of the abdominal pain, location, onset of pain, alleviating factors, and what make the pain worse. Other questions that should be asked is about how often the pain occurs, the character of the pain, and if the patient’s bowel movements are regular or have they changed. The patient should have questions related to the ulcers in her mouth such as how long has she had them, how often do they occur, and if there are any factors that make them worse or better. The questions can help the clinician in determining what test and procedures will be needed to help treat the patient.

What should be included in the physical examination at this visit?

The clinician will want to know all the past medical information about the patient and her family history related to allergies to medications and food, surgeries in the past, and past medical conditions. The clinician will focus on the abdomen, oral mucosa, and neurological exam of the lower extremities. The clinician will also need to know what type of diet the patient is on and if she can include a history of what type of meals she eats during the week.

What are the possible differential diagnoses at this time?

According to Barker and Liu (2008), the possible differential diagnoses could be Crohn’s disease, IBS, lactose intolerance, and Ulcerative Colitis.

What test should you order and why?

According to Barker and Liu (2008), some of the tests that can be performed for abdominal pain would include a CBC and CMP which can help look for infection and liver functions. Another test would be a UA to help rule out any infections associated with the urinary tract. The patient could give a stool sample, and a stool culture could be ordered to look for parasites, ova, and WBC to rule out anything pathologic in the stool. According to Barker and Liu (2008), the clinician could order a CT of the abdomen and pelvis with PO and IV contrast to look for diverticulitis, diverticulosis, appendix, or any neoplasm of the abdomen.

How would you manage this patient based on your diagnosis?

According to Schuppan and Dieterich (2016), Celiac disease is a condition that impairs your body’s ability to break down certain foods. People who have the disease get sick if they eat bread, pasta, pizza, and cereal. These foods and others contain a protein called “gluten.” Gluten damages the intestines of people with celiac disease. As a result, their bodies can’t absorb nutrients from food. The disease affects children and adults. The best treatment is to stop eating gluten completely. This might be hard to do at first. The patient will need to avoid rye, wheat, barley, and maybe oats. These ingredients appear in many common foods, including bread, pasta, pastries, and cereal, many sauces, spreads, and condiments, and beers, ales, lagers, and malt vinegar. Patients should also avoid milk, cheese, and other dairy foods at first. These foods can be hard to break down. The patient will want to wait to eat these foods until after their intestines have a chance to heal. The clinician could also refer the patient to a gastroenterologist or dietician for further testing and evaluation.

References

Barker, J. M., & Liu, E. (2008). Celiac Disease: Pathophysiology, Clinical Manifestations, and Associated Autoimmune Conditions. Advances in Pediatrics, 55, 349–365. http://doi.org/10.1016/j.yapd.2008.07.001

Schuppan, D., & Dieterich, W. (2016). Pathogenesis, epidemiology, and clinical manifestations of celiac disease in adults. UpToDate. Retrieved from https://www.uptodate.com/contents/pathogenesis-epi…

April’s Response:

Celiac Disease

When reviewing the patient’s presenting complaints, my initial thought is that her symptoms are consistent with Celiac disease; however, a number of differentials must also be considered. Celiac disease is an autoimmune disorder wherein the ingestion of gluten causes the immune system to attack cells in the small intestine. Classic celiac disease includes atrophy of the villi within the small intestine, symptoms of malabsorption, and improvement of mucosal lesions and symptoms when gluten is removed from the diet (Schuppan & Dieterich, 2016).

History and Physical Exam

Common symptoms of Celiac disease include flatulence, bloating, diarrhea, and the presence of malodorous floating stools due to steatorrhea. Failure to thrive, weight loss, anemia, and neurologic disorders from vitamin and mineral deficiencies are often seen in more severe cases. Peripheral neuropathies are experienced by up to half of patients with celiac disease, whereas oral lesions, headaches, fatigue, and skin rashes are also possible When conducting the interview portion of the patient’s visit, it would be important to ask about bowel habits including the frequency, color, odor, and consistency of stool. Using the OLDCARTS pneumonic would be helpful to determine how long she has been having the symptoms, aggravating factors, and severity. Family history should also be explored as celiac disease has a genetic component, with individuals with a first-degree relative with the disease also having a 10-15% chance of having it themselves (Schuppan & Dieterich, 2016).

A full head-to-toe exam should be done on patients suspected of having celiac disease as the disorder can cause both intestinal and extraintestinal symptoms. The abdominal exam may show a distended abdomen with tympanic notes upon percussion. Additionally, patients may present with evidence of muscle wasting or weight loss, skin disruption, peripheral edema, orthostatic hypotension, and peripheral neuropathy (Goebel, 2017).

Differentials and Diagnostic Testing

Common differentials for Celiac disease include irritable bowel syndrome, Crohn’s disease, lactose intolerance, peptic duodenitis, infectious colitis, and ulcerative colitis (Epocrates, 2018). Routine lab work including a CBC with differential, CMP, and iron levels should be done to evaluate for anemia and electrolyte deficiencies (Goebel, 2017). Serologic evaluation to test for the IgA TTG antibody is the most-preferred single test for celiac disease, along with a total IgA level (Kelly, 2018). Genetic testing can also be done to help streamline diagnosis. Barium imaging studies can also be helpful in making a diagnosis. The criterion standard for diagnosis is an upper endoscopy with a minimum of six areas of duodenal biopsy (Goebel, 2017).

Management

The only accepted treatment approach to celiac disease is lifelong adherence to a gluten-free diet. Until the diagnosis is confirmed, I would have the patient trial a gluten-free diet and keep a daily symptom log and food diary. I would send the patient home with printed dietary recommendations, including foods to avoid. Once the diagnosis is confirmed via the above methods, a follow-up visit would be scheduled, during which I would make a referral to a nutritionist for dietary counseling and perhaps a gastroenterologist if needed (Ciclitira, 2017).

References

Ciclitira, P. J. (2017, July 5). Management of celiac disease in adults. Retrieved from https://www.uptodate.com/contents/management-of-celiac-disease-in-adults#H2

Epocrates. (2018).Celiac Disease: Differential Diagnosis. Retrieved from https://online.epocrates.com/diseases/63635/Celiac-disease/Differential-Diagnosis

Goebel, S. U. (2017, January 9). Celiac Disease (Sprue). Retrieved from https://emedicine.medscape.com/article/171805-overview#a1

Kelly, C. P. (2018, March 26). Diagnosis of celiac disease in adults. Retrieved from https://www.uptodate.com/contents/diagnosis-of-celiac-disease-in-adults#H22

Schuppan, D. & Dieterich, W. (2016, November 8). Pathogenesis, epidemiology, and clinical manifestations of celiac disease in adults. Retrieved from https://www.uptodate.com/contents/pathogenesis-epidemiology-and-clinical-manifestations-of-celiac-disease-in-adults#H15