Case Number 11-Inflammatory Bowel Disease: Crohn’s
Please answer the following questions from your lab text on Mr. Sims:
1. What is inflammatory bowel disease? What does current medical literature indicate regarding its
etiology?
It is chronic inflammation of all or part of the digestive tract. The two major types of irritable bowel
diseases are Crohn’s disease and ulcerative colitis. Signs and symptoms associated with IBD include but
are not limited to cramping, irregular bowel habits, weight loss, fever and malaise. The exact etiology of
IBD is unknown but scientific literature points towards family history, stress, diet and immune system
malfunctions as potential risk factors.
2. Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with Crohn’s disease. How
could this happen? What are the similarities and differences between them?
The main difference between ulcerative colitis and Crohn’s disease is how the disease spreads through
the digestive tract, and also its location. Ulcerative colitis is a continuous inflammation of the large
intestine and rectum. Crohn’s disease affects all parts of the digestive system and is segmental.
Futhermore, some shared symptoms include weight loss, diarrhea, and bleeding. Mr. Sims’ was showing
generalized symptoms such as diarrhea and abdominal pain. Consequently, it is possible the initial
diagnosis was made because an exam/endoscopy showed an affected large intestine and rectum, but
further testing showed a mix of healthy and affected bowel which is characteristic of Crohn’s disease.
9. Is Mr. Smith a likely candidate for short bowel syndrome? Define short bowel syndrome, and provide
a rationale for your answer.
Short bowel syndrome is defined as any disease, trauma or injury which leaves 200 cm of viable small
bowel after surgery and leads to an inability to absorb nutrients (MedlinePlus). When upwards of 50% of
the small intestines are removed this leads to malabsorption of nutrients such as fat soluble vitamins
A,D,E,K, fat and cholesterol as well as water soluble vitamins, monosaccharides, amino acids and
important minerals icon, calcium and magnesium. Mr. Smith is not a candidate for short bowel
syndrome because he wasn’t born with a damaged or short small intestine, and hasn’t undergone
surgical resection or removal of any intestines.
10. What type of adaption can the small intestine make after resection?
According to the International Foundation for Functional Gastrointestinal Disorders, twelve to twentyfour months after bowel resection the small intestines begins to adapt. The intestinal villi will grow in
length and thicken which increases surface area. It is also possible for the bowel to increase in
diameter. These adaptations will increase the absorptive capacity of the small intestines.
14. Mr. Sims underwent resection of 200 cm of jejunum and proximal ileum with placement of
jejunostomy. The Ileocecal valve was prepared. 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?
Small intestine = 20 ft
20ft -> 12in/ft-> 240 inches -> 1 inch/2.54 cm-> 609.6 cm
609.6cm- 200 cm = 409.6 cm
409.6cm/609.6cm = 67% of small intestine remains after resection of jejunum.
This is a significant resection because Mr. Sims has lost a little over 1/3 of his small bowel. Although he is
not likely to develop short bowel syndrome, Mr. Sims is likely to suffer from nutrient deficiencies.
According to the International Foundation for Functional Gastrointestinal Disorders, in the first half of
the jejunum is where approximately 90% of nutrient absorption occurs including protein, carbs, vitamins
and minerals.
19. Identify any significant and/or abnormal laboratory measurements from both his hematology and his
chemistry labs.
Protein, albumin and pre-albumin are below normal values. His C-reactive protein is above normal
value. HDL is below what it should be as well. As far as hematology is concerned his hemoglobin and
hematocrit values are below normal. Transferrin and ferritin are also below normal. Lastly, vitamin D, A
and C markers are below what is considered beneficial.
What are Mr. Sims Estimated needs for energy, protein and fluid?
Ht: 5’ 9” = 69 in = 176 cm
Wt: 140# = 63.6 kg
Estimated energy, fluid and protein needs:
@ 30-35 kcal/kg -> 1920-2240 kcal/d
@ 1ml/1 kcal -> 1920-2240 kcal/d
@ 1.3-1.5 g of PRO/kg -> 83-96 g of protein
23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be prevented?
It is a metabolic complication that occurs when nutrition support is given to patients that are severely
malnourished and results in fatal shifts in fluids that can develop into arrhythmias. Mr. Sims is at risk for
refeeding syndrome because although he claims eating normally for the past year, within the last six
months, he has lost a significant amount of weight. Furthermore, Mr. Sims’ Crohn’s has been flaring up
causing severe abdominal pain and diarrhea which make it difficult for him to eat – therefore, it is safe
to assume, his unintentional weight loss will continue as a consequence of fear of abdominal pain and
diarrhea after eating. Studies show the nutrition support of patients at risk for refeeding syndrome
should start @ 10 kcal/kg/d and increased slowly. Also, supplementation of thiamine, vitamin B complex
and multivitamins should be started with refeeding (Mehanna & others).
Information from : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654033/
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.
He doesn’t have a functioning gut because he has been diagnosed with crohn’s, has recently undergone
a resection and his physical exam shows minimal bowel sounds, therefore, enteral nutrition is out of the
question. Overall, Mr. Sims has lost significant amounts of weight (> 16% wt loss in 6 months), has
constant diarrhea, abdominal pain and difficulty eating. For these reasons, I believe Mr. Sims should be
put on PN support.
24. 200g dextrose/L, 42.5 g amino acids/L, and 30 g lipid/L @ 85cc/hr for 24 hrs
CHO, PRO & lipids =
dextrose, amino acids or lipids
________________________
1000 ml
X
x
______________________
2040 ml
CHO: 408 gms-> 4 kcal/gm-> 1387 Kcal
PRO: 86.7 gms -> 4kcal/gm-> 346.8 Kcal
Lipids: 61.2 gms-> 10kcal/gm-> 612 Kcal
SUM: 2346 Kcal
At his rate, Mr. Sims is meeting his estimated energy needs as well as protein needs.
26. Please see article on Blackboard in course documents. What does this information tell you about Mr.
Sims?
Measure
Oxygen consumption(mL/min)
CO2 production (mL/min)
RQ
RMR
Mr. Sims’ data
295
261
.88
2022
The information provided by the indirect calorimetry shows Mr. Sims data is well within the normal
levels for all measurements. This is a promising sign for Mr. Sims’ recovery post-op.
30. 24-hour urine data for 12/20: 18.4 grams. How would you interpret this information? Should you be
concerned? Are there problems with the accuracy of nitrogen balance studies? Explain.
86.7 gms of protein/ 6.25 gm N2= 13.8 gms N2
13.8-18.4+3-4 gms N2 insensible losses= -7.6 gms so, negative nitrogen balance
.Mr. Sims is putting out more than he is taking in.
Downfall: Catabolic effect can be illustrated. Nitrogen is not specific if there is stress or medications
which are creating endogenous nitrogen. Need to wait for stabilization of patient. Look at CRP! It takes
1-2 weeks to progress without complications.
If patient was stable then adding 10 more grams of protein would be advisable. Give them another
week before ask for another UUN
Perfect UNN = +2-4 (ensures promotion of repletion and supporting anabolism)
31. Client Education Material on Blackboard in course documents.
Day 10: Mr. Sims’ reports bowel sounds for the previous 48 hours and has his first bowel movement.
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?
Since Mr. Sims is showing signs of bowel movement then it would be beneficial to wean him of PN
support by introducing small amounts of digestible foods into his diet. It is important for Mr. Sims to get
adequate amounts of liquids. Small frequent meals with low fat, lactose free dairy products and wellcooked, tender protein foods will help Mr. Sims regain weight and recover from surgery. Furthermore, a
chewable multivitamin would be beneficial to normalize levels of vitamin D, A and C. It’s critical to avoid
sugary beverages and high fiber, or high fat foods such as ice cream.
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.
Primary nutrition concern is Mr. Sims’ protein intake must be adequate to move from a
catabolic state to an anabolic state, which will aid him in recovering from surgery and regaining weight.
Furthermore, his hemoglobin, hematocrit and serum ferritin levels are below desires levels and indicate
at risk for developing anemia. Measure these outcomes via reassessment of blood works and values.
The secondary concern is maintaining adequate hydration and electrolyte balance. This requires Mr.
Sims adopt a diet with foods that are least likely to result in bouts of diarrhea and abdominal pain. This
measure can be assessed through a food record .