Case 11: Inflammatory Bowel Disease: Crohn’s Disease
Lynne Roller
KNH 411
September 17, 2013
Understanding the Disease and Pathophysiology
1. What is inflammatory bowel disease? What does current medical literature indicate
regarding its etiology?
Inflammatory bowel disease is an autoimmune, chronic condition of the gastrointestinal
tract. The two specific diagnoses within IBD are ulcerative colitis, and Crohn’s disease. The
etiology behind IBD is currently unknown, but some of the factors that might lead to these
diseases can be identified. Some of these include, smoking, infectious agents, intestinal flora, and
family history (Nelms 417).
2. Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with
Crohn’s. How could this happen? What are the similarities and differences between
Crohn’s disease and ulcerative colitis?
Ulcerative colitis and Crohn’s disease are both diseases under Inflammatory Bowel
Disease. They both trigger an abnormal immune response, which causes inflammatory damage to
the gastrointestinal mucosa. A lot of the symptoms are similar, such as: fever, weight loss,
abdominal pain/cramping, and. diarrhea. Mr. Sims might have been diagnosed originally with
ulcerative colitis because he displayed these cross-over symptoms, and maybe because Crohn’s
disease typically occurs in patients in their teens to their twenties, whereas ulcerative colitis and
onset in ages 20-30. Since Mr. Sims was 32 years old when he was diagnosed, there was a
greater possibility of the disease being Ulcerative Colitis. However, there are definitely
differences between the two diseases. Within patients with Ulcerative Colitis, the GI tract is
unable to distinguish foreign from self-antigens and the symptoms are more specific to bloody
diarrhea with mucus, constipation, rectal spasm, arthritis, dermatological changes, and ocular
manifestations. In patients with Crohn’s disease, there is inflammation of the bowel mucosa,
which progresses through the bowel wall. Specific symptoms include chronic diarrhea, anorexia,
malnutrition, and delayed growth in adolescents (Nelms 416).
3. A CT scan indicated bowel obstruction and the Crohn’s disease was classified as
severe-fulminant disease. CDAI score of 400. What does a CDAI score of 400
indicate? What does a classification of severe-fulminant disease indicate?
CDAI scores show the stages of Crohn’s disease. Mr. Sims score of 400, puts him under
the Moderate-Severe Disease stage. This indicates that he has failed to respond to treatment for
mild-moderate disease, or he has had some of the major symptoms of fevers, significant weight
loss, abdominal pain, nausea, vomiting, or significant anemia (Nelms 419).
4. What did you find in Mr. Sims’ history and physical that is consistent with his
diagnosis of Crohn’s? Explain.
During his initial hospitalization when diagnosed, Mr. Sims’ had lost 25 pounds. Patients
with Inflammatory Bowel Disease are often shown to lose large amounts of weight. He also has
consistent soft to liquid stool. He also had a fever of 101.5, and his abdomen is rounded and
soft.
5. Crohn’s patients often have extraintestinal symptoms of the disease. What are some
examples of these symptoms? Is there evidence of these in his history and physical?
Other organs besides the bowel can be affected by this disease, such as the bones, joints,
skin, eyes, hepatobilary system, lungs, and kidneys. In Mr. Sims’ physical we see that his skin
has turned pale.
6. Mr. Sims has been treated previously with corticosteroids and mesalamine. His
physician had planned to start Humira prior to this admission. Explain the
mechanism for each of these medications in the treatment of Crohn’s.
Corticosteroids have been shown to help for the first 6-17 weeks, but they have not been
shown to help in the maintenance of long-term remission. Corticosteroids have also been shown
to cause dependence and toxic-side effects (Corticosteroids). Mesalamine can inhibit
inflammatory cell function, kill cell activity, and produce plasma cell antibodies. Humira
(Adalimumab) can be used to treat rheumatoid arthritis, psoriatic arthritis, and snkylosing
spondylitis (Adalimumab).
7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease?
Identify and explain these values.
His protein levels are lower than normal, which could be he is not consuming enough
protein to counteract the loss from his inflamed GI tract. His iron levels are also low, which
could be due to malabsorption from his Crohn’s’. He also has low vitamin D levels, which can
be linked to his decreased dairy intake due to intolerance.
8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why he
may be at risk for vitamin and mineral deficiencies.
It is important that Mr. Sims is taking a multivitamin daily, because he is at higher risk
for deficiencies of vitamin B12, and iron since his small intestine cannot absorb nutrients
normally. It is also recommended that patients with Crohn’s disease take a calcium, magnesium,
zinc, and copper supplement because these minerals are at high risk for deficiency (Nelms 422).
9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel
syndrome, and provide a rationale for your answer.
Short bowel Syndrome results from a large resection of the small intestine, with extensive
loss of surface area of the small intestine and colon. Mr. Sims’ may be at risk because his
Crohn’s disease could lead to the need for surgical resection.
10. What type of adaptation can the small intestine make after resection?
Several months following surgery, the remaining bowel makes adaption, including
increased blood flow, secretions, and mucosal cell growth. Also, the lumen on the small intestine
will increase in length and increase in villous height (Nelms 425).
11. For what classic symptoms of short bowel syndrome should Mr. Sim’s health care
team monitor?
Multiple resections from Crohn’s disease, inability to maintain protein-energy, fluid,
electrolyte, or micronutrient balance (Nelms 426.
12. Mr. Sims is being evaluated for participation in a clinical trial using high-dose
immunosuppressant and autologous peripheral blood stem cell transplantation
(autoPBSCT). How might this treatment help Mr. Sims?
Since 10% of patients with Crohn’s disease do not respond to conventional treatment,
autoPBSCT has been shown to induce remission. Although it has not been proven to help every
patient, there are still some that gain progress. This treatment could have the potential to induce
remission for Mr. Sims (Hasselblatt).
13. What are the potential nutritional consequences of Crohn’s disease?
Depending on the extent of medications and surgeries that Mr. Sims could endure, the
degree to which nutrition intervention plays on his body may increase. For example, during
exacerbations of Crohn’s disease, enteral nutrition plays the largest role in treatment. However,
in some cases, medicine can reduce enough of the inflammation in order for the patient to
manage. In Mr. Sims’ case, he is experiencing acute exacerbations of the disease, and should be
treated with enteral nutrition. Energy needs and proteins needs are very specific and based on the
amount of lean body mass. If steatorrhea is present, fat should be reduced in the diet and fiber
should also be reduced in the diet.
14. Mr. Sims underwent resection of 200cm of jejunum and proximal ileum with
placement of jejunostomy. The ileocecal valve was preserved. Mr. Sims did not have
an ileostomy, and his entire colon remains intact. How long is the small intestine,
and how significant is this resection?
The average small intestine is approximately 400cm long, and after resection, Mr. Sims’
is 200cm long. This surgery was important because normal absorptive processes were not
functioning correctly.
15. What nutrients are normally digested and absorbed in the portion of the small
intestine that has been resected?
B12 absorption and reabsorption of bile salts usually take place in the small intestine. Fat
is also absorbed in the small intestine, and when it is not being absorbed correctly, it leads to the
inability to absorb vitamins A, D, E, and K.
16. Evaluate Mr. Sims’ % UBW and BMI..
% UBW: actual wt/usual body weight x 100
140/167 X100 = 83.8%
This puts Mr. Sims in a moderate malnutrition category.
BMI: weight (kg)/height (m)^2
140lbs./2.2= 63.5kg
69inches/1.75m
63.5/(1.75)^2= 21.2
A BMI of 21.2 is in the normal body weight range. However, it is close to being underweight.
17. Calculate Mr. Sim’s energy requirements
EER for Males 19 and older= 662-9.53 X age + PA X (15.91 X weight +539.6 X height)
PA=1.11 for low active
662-9.52 X 35 + 1.11 X (15.91 X 63.5 + 539.6 X 1.75)
= 2497.5 kcal
18. What would you estimate Mr. Sim’s protein requirements to be?
1.5g protein/kg -1.75 protein/kg
63.5kg X 1.5g-1.75g = 95.25g = 95g – 111g protein/day
(Nelms 421).
19. Identify any significant and/or abnormal laboratory measurements from both his
hematology and his chemistry labs.
Mr. Sims has low hemoglobin and hematocrit levels. He also has low Transferrin and
Ferritin levels, and high Zinc levels in his blood. All of these numbers are only slightly above
average, but they are still a concern for Mr. Sims.
20. Select two nutrition problems and complete the PES statement for each.
-
Malnutrition related to abdominal pain, diarrhea, and lack of nutrition education, as
evidence by 24-hour dietary recall and lab results.
-
Involuntary weight loss related to excessive diarrhea and lack of appetite as evidence
by recent weight loss of 25lbs, and decreased BMI.
21. The surgeon notes Mr. Sims probably will not resume eating by mouth for at least 710 days. What information would the nutrition support team evaluate in deciding
the route for nutrition support?
Since Mr. Sims will have to receive parenteral nutrition, it is important to base his
therapy on his energy, protein, and micronutrient requirements. The first items given should be
sugar-free, isotonic clear liquids and then low-fat, lactose-free, and low-oxalate foods will be
gradually inserted into his diet. Insoluble fiber will not be given, but soluble fiber could assist in
increasing mucosal health. In order to ensure tolerance, each food item should be inserted into
the diet one at a time (Nelms 426).
22. The members of the nutrition support team note his serum phosphorus and serum
magnesium are at the low end of the normal range. Why might that be of concern?
It is important that both serum phosphorus and serum magnesium levels are at a normal
range since Mr. Sims needs the protein to stay out of metabolic stress, which could lead to
refeeding syndrome (Parrish).
23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be
prevented?
Refeeding syndrome refers to the metabolic events caused by certain nutrients. These
events could consist of fluid retention, micronutrient deficiencies, cardiac and neuromuscular
dysfunction. Prolonged fasting puts patients at risk because vital organs begin to lose function
and introducing foods back into the body can create metabolic distress. Mr. Sims is at slight risk,
because of chronic malnutrition. This can be prevented by introducing foods very slowly back
into the diet (Parrish).
24. Mr. Sims was placed on parenteral nutrition support immediately postoperatively,
and a nutrition support consult was ordered. Initially he was prescribed to receive
200 g dextrose/L, 42.5 g amino acids/L, and 30 g lipid/L. His parenteral nutrition
was initiated at 50 cc/hr with a goal rate of 85 cc/hr. Do you agree with the team’s
decision to initiate parenteral nutrition? Will this meet his estimated nutritional
needs? Explain. Calculate: pro (g); CHO (g); lipid (g); and total kcal from his PN.
I think it is wise the Mr. Sims received parenteral nutrition so that foods are introduced
slowly and the proper nutrient amounts are regulated and observed closely.
Protein: RDI recommends 0.8g/kg of body weight  ~%10 of kcal from protein. For parenteral
nutrition, use 1.5g/kg of protein.
1.5g protein/kg -1.75 protein/kg
63.5kg X 1.5g-1.75g = 95.25g = 95g – 111g protein/day
Carbohydrates: ~50-60% daily intake
(2497 kcal X 0.50)/4g = 312g/day-375g/day
Lipid: ~ 20% of totally intake
(2497 kcal X .20)/9 = 55g/day
25. For each of the PES statements you have written, establish an ideal goal (based on
the signs and symptoms) and an appropriate intervention (based on the etiology).
-
Educate Mr. Sims on proper dietary choices in order to improve his knowledge of
foods to avoid. Maintain appropriate intake levels of the main nutrients: protein,
carbohydrates, and lipids.
-
Continue to monitor weight and proper energy intake.
26. Indirect Calorimetry revealed the following information:
Measure
Mr. Sims’ Data
Oxygen consumption (mL/min)
295
CO2 production (mL/min)
261
RQ
0.88
RMR
2022
What does this information tell you about Mr. Sims?
This information tells us his resting levels, such as the amount of oxygen he consumes versus
carbon dioxide he produces. It also shows his basal metabolic rate, or the energy he burns while
resting. These numbers are important because you can gauge his progress as he ages.
27. Would you make any changes to his prescribed nutrition support? What should be
monitored to ensure adequacy of his nutrition support?
The TPN diet should be monitored in order to ensure proper nutrition intake. The process
of introducing food items should also be monitored closely so that the progress is slow (Nelms
426).
28. What should be nutrition support team monitor daily? What should be monitored
weekly? Explain.
They should monitor the energy intake, and specific nutrient intakes daily. They should
monitor his weight weekly.
29. Mr. Sims’ serum glucose increased to 145 mg/dL. Why do you think this level is now
abnormal? What should be done about it?
This number could be high because he was introduced to certain carbohydrates too
quickly, which shocked his metabolism. Items, specifically carbohydrates, should be introduced
very slowly making sure his metabolism can handle the food.
30. Evaluate the following 24-hour urine data: 24-hour urinary nitrogen for 12/20: 18.4
grams. By using the daily input/output record for 12/20 that records the amount of
PN received, calculate Mr. Sims’ nitrogen balance on postoperative day 4. How
would you interpret this information? Should you be concerned? Are there
problems with the accuracy of nitrogen balance studies? Explain.
N2 Balance= Dietary protein intake/6.25 – urine urea nitrogen -4
= -13.6g showing a negative nitrogen balance.
This loss could be through fecal excretion, skin breakdown, or wound drainage. Sometimes the
measurements can be inaccurate based on failure to account for renal impairment and inability to
measure the actual amount loss through diarrhea and vomiting. This number is probably not
useful for Mr. Sims’ because he does suffer from chronic loose stools and diarrhea (Nelms 54).
31. On post-op day 10, Mr. Sims’ team notes he has had bowel sounds for the previous
48 hours and had the first bowel movement. The nutrition support team
recommends consideration of an oral diet. What should Mr. Sims be allowed to try
first? What would you monitor for tolerance? If successful, when can the parenteral
nutrition be weaned?
He should first be allowed to eat sugar-free isotonic clear liquids and then be slowly
introduced to low-fat, lactose-free, low-oxalate foods. It is important to monitor his tolerance to
fiber. Parenteral nutrition can be weaned once all food categories are introduced back into the
diet. However, this could take up to 6 months (Nelms 426).
32. What would be the primary nutrition concerns as Mr. Sims prepares for
rehabilitation after his discharge? Be sure to address his need for supplementation
of any vitamins and minerals. Identify two nutritional outcomes with specific
measures for evaluation.
It is a concern to monitor his tolerance to foods and to not consume certain foods such as
caffeine and alcohol. It is important for Mr. Sims to take his multivitamin in order to continue
getting B12, magnesium, zinc, and vitamins A and D in order to help with food absorption and
reduce inflammation. Mr. Sims should have his weight monitored weekly in order to gauge is
progression in weight gain. He should also be evaluated and monitored in the amount of
macronutrients he is consuming so that he takes in enough energy to counteract malnutrition.
Works Cited
“Adalimumab in Crohn’s disease.” December 1, 2007.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721293/
Hasselblatt P; Potthoff K. “Remission of refractory Crohn’s disease by high-dose
cyclophosphaamind and autologous peripheral blood stem cell
transplantation.”
“Mesalamine Safe?” November 2, 2007.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104151/
Parrish, Carol; McCray, Stacey; Walker, Sherrie. “Much Ado About Refeeding.”
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions /digestivehealth/nutrition-support-team/nutrition-
articles/McCrayArticle.pdf.
Nelms, Marcia; Sucher, Kathrn; Lacey, Karen; Roth, Sara Long. Nutrition Therapy and
Pathophysiology. 2/e.
Yang, Yu-Xiao; Lichtenstein, Gary R. “Corticosteroids in Crohn’s disease.”
http://jessig.mit.edu/Beh214/IBD%20pdfs/YuXiao.pdf
Nitrogen Balance=Nitrogen intake-nitrogen losses
Intake=protein intake(g)/6.25
Nitrogen losses=urinary urea nitrogen (g)+ 4g
UUN is determined from a 24 hour urine collection
Positive NB = anabolic state with overall gain in body protein. Negative= catabolic
state net loss of protein with adequate feeding.