Pathophysiology

Gastrointestinal Symptoms in Teen

Case Study

Patient Profile

Name: Jacob Thompson

Age: 16

Gender: male

History of Present Illness

J.T. is a 16-year-old boy who presents with abdominal pain, distension, and bilious vomiting over the past two days. He reports that the pain has worsened and is constant, with no bowel movement in 48 hours.

Past Medical History

  • Frequent abdominal pain over the past year, often postprandial.
  • Intermittent foul-smelling and uncontrolled diarrhea and significant weight loss (approximately 15 lbs over six months).
  • Occasional bloating and persistent fatigue.

Family History

  • Mother with Irritable Bowel Syndrome (IBS), father with Hashimoto’s Disease and hypertension.
  • Paternal grandmother with rheumatoid arthritis.

Social History

  • High school student, volleyball player.
  • Nonsmoker, no alcohol or drug use, not sexually active.
  • Previously active in school sports, current participation decreased due to fatigue.

Physical Assessment

Vitals

    • Blood pressure: 110/70 mm Hg
    • Heart rate: 95 bpm
    • Respiratory rate: 22 bpm
    • Temperature: 98.2°F
    • Height: 5 ft 6 in
    • Weight: 122 lbs

General Survey

  • General Appearance:  Pale, appears in distress due to abdominal pain.
  • Abdomen:
    • Distended abdomen with hyperactive bowel sounds.
    • Diffuse tenderness, particularly lower abdomen.
    • Rebound tenderness and guarding present.
  • Skin:
    • No rashes or lesions.
  • Neurological:
    • Alert and oriented, no focal deficits.

Diagnostic Testing

  • Serology:
    • Complete Blood Count (CBC):
      • Hemoglobin (Hgb): 10.5 g/dL (Normal range: 13.8-17.2 g/dL for males)
      • Hematocrit (Hct): 32% (Normal range: 40.7-50.3% for males)
      • Mean Corpuscular Volume (MCV): 75 fL (Normal range: 80-100 fL) – indicating microcytic anemia
      • Red Blood Cell Count (RBC): 4.2 million cells/mcL (Normal range: 4.7-6.1 million cells/mcL for males)
      • White Blood Cell Count (WBC): 6,000 cells/mcL (Normal range: 4,500-11,000 cells/mcL)
      • Platelet Count: 250,000 cells/mcL (Normal range: 150,000-450,000 cells/mcL)
    • Antitissue Transglutaminase (anti-tTG) IgA Antibodies: 150 U/mL (Normal range: <20 U/mL)
    • Normal total IgA levels
  • Imaging:
    • Abdominal X-ray shows dilated loops of small bowel with air-fluid levels.
    • CT scan: No enlargement or inflammation of the appendix, distal small bowel obstruction detected with evidence of inflammation and possible stricture.
  • Endoscopy:
    • Biopsy shows villous atrophy consistent with celiac disease.

Activity: Pathophysiology of Celiac Disease

Fill in the blanks with the correct terms: gluten, lactose, autoimmune, allergic, diarrhea, weight gain, weight loss, intestinal cancers, Barrett’s esophagus, retinal deterioration.

Celiac disease is an _______________ condition where ingestion of _______________ leads to an inappropriate immune response and damage to the small intestine’s villi. This damage impairs nutrient absorption and can cause symptoms like _______________, abdominal pain, and fatigue. The key immune response targets peptides from gluten, leading to villous atrophy. This condition is influenced by both genetic and environmental factors, with certain viral infections potentially acting as triggers in genetically predisposed individuals. If left untreated, it can lead to nutrient deficiencies, _______________, and an increased risk of _______________.

Activity: Small Bowel Obstruction (SBO)

Fill in the blanks with the correct terms: ischemia, overgrowth, cancer,  hyperactive, sepsis, hypoactive, elongation, villous atrophy.

A blockage in the small intestine may be partial or complete. The most common cause is mechanical blockage from adhesions, hernias, tumors, strictures, or volvulus (twisting of the intestines).  In this case, the SBO may be due to inflammation or strictures from untreated celiac disease. SBO can also be functional when the bowel fails to propel its contents due to dysmotility, such as paralytic ileus.  Fluid and gas accumulate proximal to the blockage, increasing intraluminal pressure.  Obstruction leads to symptoms like severe abdominal pain, vomiting (often bilious), and constipation. The obstruction can cause distension and compromise blood flow, risking _______________ ischemia, necrosis, perforation, and peritonitis.  It also prevents normal absorption and movement of fluids and electrolytes, leading to their accumulation in the bowel lumen.  Fluids sequestered in the bowel or lost through vomiting can produce dehydration and electrolyte imbalances.  Stagnation of intestinal contents can lead to bacterial _______________, increasing the risk of translocation across the intestinal wall into the bloodstream, which can result in _______________. Patients typically have _______________ bowel sounds in the early stages, but these sounds may diminish as the bowel becomes fatigued and unable to overcome the obstruction.

Activity: Iron Deficiency Anemia

Fill in the blanks with the correct terms: small, large, villous atrophy, cancer, hypertrophy, iron, vitamin B12.

Iron deficiency anemia in celiac disease is primarily due to impaired iron absorption in the _______________ intestine. Iron is primarily absorbed in the proximal part of the small intestine, particularly in the duodenum and the upper jejunum. In celiac disease, inflammation and subsequent _______________ in these areas reduce the surface area available for absorption, leading to decreased iron uptake. Additionally, the damage to the intestinal lining impacts the absorption of other nutrients, such as folate and vitamin B12, which can further contribute to anemia. However, _______________ deficiency remains the most common cause of anemia in patients with celiac disease. Some individuals may also experience gastrointestinal bleeding due to inflammation, which can further contribute to iron deficiency. During periods of growth, such as adolescence, the body’s demand for iron increases. If celiac disease goes undiagnosed or untreated during these times, the risk of developing iron deficiency anemia heightens due to both increased demand and impaired absorption.

Treatment Plan

1. Immediate Management:

  • Nasogastric tube insertion for stomach decompression.
  • Intravenous fluids for hydration and electrolyte balance.
  • NPO (nothing by mouth) status until obstruction resolution.

2. Long-term Management:

  • Initiate a strict gluten-free diet to manage celiac disease and prevent further intestinal damage.
  • Nutritional assessment and supplementation prn (iron, Ca, vitamin D).
  • Follow up with a gastroenterologist for ongoing management.

3. Surgical Consultation:

  • If no improvement with conservative management or evidence of complete obstruction.

4. Developmental Concerns:

  • Nutritional deficiencies: Due to malabsorption, Jacob may experience deficiencies in essential nutrients, impacting growth and development. This can lead to delayed puberty, stunted growth, and anemia.
  • Psychosocial impact: The need for a strict gluten-free diet can affect social interactions, as eating is a significant part of social activities for teenagers. This can lead to feelings of isolation or anxiety about eating in social settings. The chronic nature of celiac disease and the acute episodes of bowel obstruction can lead to stress, anxiety, or depression. Regular screening and support from mental health professionals may be beneficial.
  • Academic performance: Chronic fatigue and abdominal pain can affect concentration and school performance. Frequent medical appointments and potential hospitalizations may also disrupt his education. Parents may wish to advocate for a 504 plan with medical documentation provided.
  • Physical activity: Reduced participation in sports due to fatigue and pain can affect physical fitness and social connections through team activities. Support participation as tolerated. School sports and activities can be supported through a 504 plan and coach awareness.

Review Questions

Click the arrow to expand the section and view the correct answers.

  1. When the nurse practitioner is assessing Jacob, which of the following findings during the physical exam would be an early sign of a small bowel obstruction?
    1. Hypoactive bowel sounds.
    2. Hyperactive bowel sounds.
    3. Absence of bowel sounds.
    4. Normal bowel sounds.
Answer:

B) Hyperactive bowel sounds.

Feedback: Hyperactive bowel sounds are often present in the early stages of bowel obstruction as the intestines attempt to push contents past the obstruction.

  1. When discussing dietary changes with Jacob, who has been diagnosed with celiac disease, what advice should the nurse practitioner provide?
    1. Limit gluten intake to once a week.
    2. Follow a strict gluten-free diet.
    3. Gradually reintroduce gluten over time.
    4. Consume gluten only with meals.
Answer:

B) Follow a strict gluten-free diet.

Feedback: Celiac disease requires a strict gluten-free diet to prevent intestinal damage and associated symptoms.

  1. During a follow-up appointment, Jacob expresses concern about fatigue and decreased performance in sports. What developmental issue related to celiac disease might be contributing to these symptoms?
    1. Hormonal imbalance.
    2. Nutritional deficiencies.
    3. Decreased muscle mass.
    4. Neurological deficits.
Answer:

B) Nutritional deficiencies.

Feedback: Nutritional deficiencies, especially iron and vitamin B12, are common in untreated celiac disease and can contribute to fatigue and decreased physical performance.

  1. As Jacob’s nurse practitioner, you are considering a dietary supplement. Which supplement might Jacob require due to his celiac disease?
    1. Vitamin C
    2. Vitamin D
    3. Vitamin A
    4. Vitamin K
Answer:

B) Vitamin D

Feedback: Individuals with celiac disease may have malabsorption of fat-soluble vitamins, including vitamin D, requiring supplementation.

  1. What developmental concern is most relevant for a teenager like Jacob with undiagnosed celiac disease?
    1. Accelerated growth.
    2. Delayed puberty.
    3. Increased muscle mass.
    4. Advanced cognitive development.
Answer:

B) Delayed puberty.

Feedback: Nutritional deficiencies due to malabsorption in celiac disease can lead to delayed puberty and other growth-related issues.

  1. In the context of celiac disease, what is the significance of dense intra-epithelial lymphocytes and villous atrophy observed in a biopsy?
    1. It indicates the intestines have healed.
    2. It is evidence of damage to the intestinal lining due to repeated gluten exposure and an autoimmune response.
    3. It suggests bacterial overgrowth.
    4. It shows normal nutrient absorption.
Answer:

B) It is evidence of damage to the intestinal lining due to repeated gluten exposure and an autoimmune response.

Feedback: Villous atrophy is a hallmark finding in celiac disease, indicating damage to the intestinal lining. Intra-epithelial lymphocytes are the WBCs found in the immune system that act as a barrier. The presence of many indicates a significant immune response.

  1. What is the most likely cause of Jacob’s microcytic anemia, as seen in his laboratory results?
    1. Acute blood loss.
    2. Iron deficiency due to malabsorption.
    3. Vitamin B12 deficiency.
    4. Hemolysis
Answer:

B) Iron deficiency due to malabsorption.

Feedback: In celiac disease, villous atrophy of the small intestine impairs the absorption of iron, leading to iron deficiency anemia.

  1. What long-term complication is Jacob at risk for if his celiac disease remains untreated?
    1. Esophageal stricture.
    2. Crohn’s disease.
    3. Small bowel adenocarcinoma.
    4. Pancreatitis
Answer:

C) Small bowel adenocarcinoma.

Feedback: Untreated celiac disease increases the risk of certain malignancies, including small bowel cancer.

  1. Which of Jacob’s symptoms is most directly related to the malabsorption seen in celiac disease?
    1. Bilious vomiting
    2. Fatigue
    3. Abdominal distension
    4. Constipation
Answer:

B) Fatigue

Feedback: Fatigue is commonly due to anemia and nutritional deficiencies resulting from malabsorption in celiac disease.

  1. Jacob’s family history includes several autoimmune conditions. Which of the following statements best explains this pattern in the context of celiac disease?
    1. Autoimmune diseases are all caused by gluten ingestion.
    2. Genetic predisposition to autoimmune disorders can manifest in various forms in family members.
    3. Autoimmune diseases are primarily a result of infectious agents.
    4. There is no link between different autoimmune conditions.
Answer:

B) Genetic predisposition to autoimmune disorders can manifest in various forms in family members.

Feedback: Celiac disease, like other autoimmune diseases, often has a genetic component, leading to a higher prevalence in families.

  1. What immediate management step is crucial for Jacob’s small bowel obstruction upon presentation?
    1. Administering oral laxatives.
    2. Initiating a gluten-free diet immediately.
    3. Nasogastric tube insertion for decompression.
    4. Starting high-dose corticosteroids.
Answer:

C) Nasogastric tube insertion for decompression.

Feedback: This helps relieve pressure and symptoms from the obstruction.

  1. In Jacob’s condition, what do anti-tTG IgA antibodies indicate?
    1. They directly cause intestinal damage.
    2. They are a marker of ongoing gluten ingestion in celiac disease.
    3. They indicate the presence of bacterial infection.
    4. They have no relevance to celiac disease.
Answer:

B) They are a marker of ongoing gluten ingestion in celiac disease.

Feedback: High levels of anti-tTG IgA antibodies indicate an autoimmune response triggered by gluten ingestion.

  1. Explain how Jacob’s family history impacts his risk for the development of celiac disease.
Answer:

Answers will vary. For example, Jacob’s family history impacts his risk of developing celiac disease due to the genetic predisposition associated with the condition. Celiac disease is an autoimmune disorder strongly linked to specific genetic markers, particularly the HLA-DQ2 and HLA-DQ8 haplotypes. These genetic markers are inherited, meaning that if a family member has celiac disease or other autoimmune conditions, the likelihood of carrying these genetic markers increases. In Jacob’s case, his family history includes autoimmune conditions such as Hashimoto’s disease in his father and rheumatoid arthritis in his paternal grandmother. These conditions suggest a familial tendency toward autoimmune disorders, which can increase Jacob’s risk of developing celiac disease. First-degree relatives of individuals with celiac disease also have a significantly higher risk (about 1 in 22) of developing the disease themselves. This familial risk underscores the importance of genetic factors in the development of celiac disease, alongside environmental triggers such as viruses and gluten exposure. Jacob’s family history of autoimmune diseases suggests a genetic predisposition that could contribute to his risk of developing an autoimmune condition like celiac disease.

References

Heavey, E. (2024). Lecture on the pathophysiology of the GI system. [Transcript].

Lebwohl, B., Ludvigsson, J. F., & Green, P. H. (2014). The unfolding story of celiac disease risk factors. Clinical gastroenterology and hepatology, 12(4), 632–635. https://doi.org/10.1016/j.cgh.2013.10.031

OpenAI. (2023). GPT 4 [Large language model]. https://www.openai.com/research/gpt

You.com. (2024). https://www/you.com

Tkacs, N. (Ed.). (2020). Advanced physiology and pathophysiology: Essentials for clinical practice. Springer Publishing Company.

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Be Prepared for Your Nurse Practitioner Clinical Readiness Exam Copyright © 2026 by Elizabeth Heavey, Renee Biedlingmaier, Colleen Burgoyne and Carnel C. Jackson is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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