Comprehensive Case
Study
Jeff Gibberman
11/23/13
Nathan Littauer Hospital
St. Mary’s Hospital
Preceptors: Kathryn Terry & Judy Yash
1
Contents
Introduction of Patient and Case ...............................................................................................................................3
Etiology and Pathophysiology of Condition ...............................................................................................................4
Medical list of Concerns .............................................................................................................................................5
HTN .........................................................................................................................................................................5
GERD .......................................................................................................................................................................6
Hyperlipidemia........................................................................................................................................................6
Nutrition Practice Guidelines and Current Literature for Diverticulitis Management ...............................................7
Discussion with Impact of the Intervention and Nutrition Care Plan ........................................................................9
Conclusion ............................................................................................................................................................... 12
References ............................................................................................................................................................... 14
Case Study NCP Form .............................................................................................................................................. 15
2
Introduction of Patient and Case
CJ is a 53 year old male that was readmitted for his second acute episode of diverticulitis.
Two weeks prior, CJ was admitted for abdominal pain, rectal bleeding, diarrhea and loss of
appetite. A CT scan revealed acute diverticulitis. On CJ’s first admit, he received antibiotic therapy
and was Nil Per Os (NPO) for 2 days before being allowed a clear liquid diet. After 5 days of
hospital stay and upgrading of the patients diet to full liquid and then soft, the diverticulitis was
resolving and the patient was discharged home. On his first admit, CJ received dietary education
from a registered dietitian (RD) for low fiber diet during diverticulitis with a recommendation to
progress toward a higher fiber diet once diverticulitis is resolved. Between the patients two
hospital admissions it was noted in his dietary recall that he did not thoroughly follow the medical
nutrition therapy (MNT) for the low fiber/residue diet for diverticulitis since his diet recall
included popcorn and steak, both of which are foods that are non-compliant with the low fiber diet
recommendations previously provided by the RD.
Upon CJs readmit, he was ordered peripheral parenteral nutrition (PPN) while receiving a
clear liquid diet. The patients admitting diagnosis was acute diverticulitis, abdominal pain, and a
pelvic abscess. The dietary office at the hospital is consulted anytime PPN or total parenteral
nutrition (TPN) is ordered for a patient. A new nutrition assessment was conducted on the patient
and the medical nutrition supplement ensure clear was prescribed two times per day between
clear liquid meals to add an additional 360 calories and 18 grams of protein (each serving has 200
kcal and 7 g protein) to better meet nutritional needs of the patient. The PPN was providing 1,003
calories and 57 grams of protein to the patient. A note was also placed in the patients chart to the
Dr. recommending that the diet order be progressed to a low fiber diet as medically feasible and
that PPN be discontinued if the patient is able to consume PO.
3
The patient received more antibiotic therapy and a surgery consult for possible colonic
resection or colostomy. The patient’s surgery consult resulted in a recommendation to continue
with antibiotic therapy and that surgery was not necessary at this time. The patient’s acute
diverticulitis resolved and the patient was discharged home on a low fiber diet before a nutrition
follow up assessment was conducted. The patients hospital stay was only four days during his
second admit.
Etiology and Pathophysiology of Condition
Diverticular disease is the herniation of the colon where saclike protrusions of the colon
create a space where potential foodstuff/feces can reside.1 It is believed that a combination of
colon structure, genetics, factors that affect motility and low fiber intake lead to increased
pressure in the colon which results in diverticular disease.1,2 Diverticular disease is more
commonly found in populations with low fiber diets.1,2,3
Diverticulitis is defined by the inflammation of the diverticular saclike protrusions of the
colon which can vary in range of severity.1 When the bacteria, foodstuff/feces or other irritants
are trapped in the diverticula inflammation can occur.2 Diverticulitis severity depends upon level
of inflammation, presence of abscess formation, bowel perforation, obstruction and presence of
sepsis.1 The modified Hinchey classification system in Figure 1 is a system that can be used to
classify the severity of diverticulitis.4
4
Figure 1. Classification of diverticulitis.
About 10% to 25% of people with diverticular disease develop diverticulitis.1 Additionally,
about 25-33% of patients admitted to the hospital with diverticulitis require surgery.1 Surgery for
diverticulitis can include resection of diseased colon or colostomy depending on the severity.1
Medical list of Concerns
The patient has several other medical concerns, including hypertension (HTN), gastro
esophageal reflux disease (GERD), Hyperlipidemia and the patient is a current smoker. According
to the 2004 Surgeon General's Report, smoking harms nearly every organ in the body which puts a
damper on overall health by placing a person at a higher risk for many preventable disease
conditions.5 Notably HTN, GERD, and hyperlipidemia are medical issues closely associated with
poor nutrition and lifestyle choices – this can be genetic as well.
HTN
Hypertension is the persistent increased pressure of blood within the arteries which can
damage the cardiovascular system and is associated with many degenerative diseases if not
treated.1 Hypertension is thought to be associated with genetic predisposition and poor lifestyle
factors like smoking, inactivity, stress, obesity, alcohol intake and diets high in sodium and low in
5
fruits/vegetables (low potassium intake).1 Medical management of hypertension includes drugs
that alter the human physiology to result in decreased blood pressure.1 Drugs used to manage
HTN include diuretics, beta-blockers, alpha-blockers, vasodilators, calcium-channel blockers,
angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers.1 Jansen et al.
conducted a study that found antihypertensive medications to be a risk factor for increased
colonic bleeding as a symptom of diverticular disease.6
GERD
GERD is when stomach acid reaches the tissue in the esophagus and causes inflammation
or tissue damage.1 The esophageal sphincter prevents stomach acid and contents from back flow
during digestion and the mucosa of the stomach prevent stomach acids released for digestion
from damaging the tissues in the stomach.1 When the esophageal sphincter is compromised or
pressure changes occur in the stomach, GERD or “heart burn” is the result.1 Some risk factors for
GERD include alcohol consumption, obesity, and smoking.1 Additionally, El-Serag et al. found that
low dietary fiber intake is associated with an increased risk of GERD in a cross sectional study of
volunteers.7
Hyperlipidemia
Hyperlipidemia/hypercholesterolemia is a major risk factor for atherosclerosis, the
hardening of the arteries.3 Increased levels of cholesterol in the blood increase the development of
fatty streaks along the blood vessels which leads to decreased elasticity of the blood vessels.3
Atherosclerosis and increased presence of fatty streaks which develop into fatty plaques can lead
to disruptions in blood flow which in turn, can cause ischemic tissue damage or even death from a
heart attack.3 Medical management includes drugs that inhibit the body’s own synthesis of
cholesterol (statins) and drugs that sequester bile which is high in cholesterol for removal from
6
the body through the GI tract (bile acid sequestrants).1 Increased soluble dietary fiber is thought
to lower cholesterol levels in the blood by binding to bile and removing it from the GI tract much
like bile acid sequestrant drugs.1 Increased exercise and decreased intake of cholesterol and
saturated fats are also associated with more favorable blood lipid profiles.1
After reviewing the list of these pertinent medical concerns, it is interesting that this
patient is on antihypertensive medication which has been shown to be a risk factor for colonic
bleeding with patients with diverticulosis. Note that CJ has a past medical history including rectal
bleeding. Also, the patient has a few medical conditions where dietary fiber intake can play a
therapeutic or preventative role (hyperlipidemia, diverticulosis, and GERD).1,2
Nutrition Practice Guidelines and Current Literature for Diverticulitis
Management
The current nutrition practice guideline for diverticulitis from the Nutrition Care Manuel
that is set forth by the Academy of Nutrition and Dietetics is presented in Figure 2.8 Medical
nutrition therapy (MNT) for diverticulitis is the avoidance of dietary fiber.8 Medical nutrition
therapy for diverticulosis, the non-inflamed diverticular disease state, is high fiber nutrition
therapy.8 It is recommended that people with diverticulosis consume 6g to 10g of fiber additional
than the standard 20g to 35g per day recommended for healthy adults.8
7
Figure 2. Nutrition therapy for diverticulitis
Previously it was thought that that some particular types of fiber, such as nuts, corn, or
popcorn were associated with increased risk for diverticulitis complications and diverticular
bleeding, however recent research suggests that these previous recommendations are
unfounded.9 It was thought that these foods could easily become lodged in the diverticular
protrusions of the colon and cause irritation.9 A cohort of male health professionals were
prospectively followed up with from 1986 to 2004 with self-administered questionnaires about
medical and dietary information.9 There were 801 incidents of diverticulitis and 383 incidents of
diverticular bleeding that were investigated out of an initial sample population of 47,228 men.9 It
was found that nut, corn, and popcorn consumption did not increase the risk of incident
diverticulitis or diverticular bleeding and that consumptions of these foods may in fact be
beneficial in people that develop diverticular disease .9
Ooteghem et al. conducted a study that observed the role of early initiation of an oral
energetic fiber-free liquid diet in patients with complicated acute colonic diverticulitis.10
Ooteghem et al. noted that complicated acute colonic diverticulitis is usually treated with bowel
rest or parenteral nutrition, both of which increase length of hospital stay and cost of medical
treatment.10 Among 25 patients between February 2008 and October 2011 admitted with
complicated acute colonic diverticulitis that met exclusion criteria, only two patients required
surgery.10 The remaining 23 participants had good recovery and were discharged.10 The results of
this study challenge the indication for bowel rest and use of parenteral nutrition in acute colonic
diverticulitis, both of which potentially increase hospital stay length and thus medical treatment
cost.10
8
According to the American Society for Parenteral and Enteral Nutrition (ASPEN),
parenteral nutrition is only indicated for patients that have been hospitalized without PO intake
for greater than 7 days.11 This recommendation is based off several studies that weigh the risks
associated with parenteral nutrition against the benefits.11 An exception to the recommendation
for starting parenteral nutrition before 7 days without nutrition support is for patients that have
signs of malnutrition.11 According to ASPEN, malnutrition is loosely defined by patients that have
had a recent weight loss of greater than 10%-15% or an actual body weight that is less than 90%
of ideal body weight.11 If sufficient evidence for protein-calorie malnutrition is met, then it is
indicated to initiate parenteral nutrition therapy as soon as possible 11 Correia et al. followed 53
patients receiving PPN to investigate the efficacy and adequacy of peripheral nutrition.12
Parenteral nutrition support that is provided via a venous central catheter carries risks such as
infectious complications such as sepsis.12 Correia et al. findings suggest that PPN can benefit many
patients that are in need of parenteral nutrition support, but without the risks associated with a
venous central catheter.12
Discussion with Impact of the Intervention and Nutrition Care Plan
After a full nutrition assessment, referencing medical nutrition therapy recommendations
for diverticulitis, and consulting a RD for assistance in coming up with a nutrition intervention, a
nutrition care plan was created for CJ. Figure 3 is the nutrition intervention/nutrition prescription
that was prescribed to CJ.
Figure 3. Nutrition intervention
9
The RD consulted was most concerned with the placement of the patient by the doctor on
PPN and a clear liquid diet simultaneously. The RD stated that typically patients are placed on one
or the other, PPN to allow for bowel rest or clear liquids to provide easily digested energy that
leaves no residue in the GI tract. It is routine at Nathan Littauer Hospital (NLH) to supplement
clear liquid diets with Ensure Clear or Gelatein (a gelatin with protein) in patients that are
predicted to have increased needs or a suboptimal nutrition status. Arizona Digestive Health also
indicates that clear liquid protein supplements fall within the scope of a clear liquid diet. 14 This
recommendation for clear protein supplementation of a clear liquid diet is not contraindicated by
the MNT for diverticulitis. Since the doctor is responsible for assessing the severity of diverticulitis
and ordering the patients diet and/or parenteral support, the role of the RD is somewhat limited
in the final recommendations that become implemented to the patients care since any
recommendations made by the RD to the doctor are at the doctor’s discretion.
Guidelines for dietary restrictions in acute diverticulitis are lacking consensus. The
European Association of Endoscopic Surgery, The American Society of Colon and Rectal Surgeons,
and a recent article in the New England Journal of Medicine all have conflicting recommendations
when it comes to dietary restrictions for acute diverticulitis.4 Van de Wall et al. note that to date,
the rationale behind diet restrictions in acute diverticulitis has never been thoroughly studied.4
Additionally, many physicians recommend dietary restrictions under the assumption that a less
active bowel will result in better prognosis and shortened hospitalization time in acute
diverticulitis.4
Van de Wall et al. conducted a retrospective study consisting of 290 patients initially
screened with clinical suspicion of diverticulitis between January 2010 and June 2011.4 256
10
patients met the inclusion criteria of being hospitalized, having diagnostic radiology, and having
received initial conservative treatment for acute diverticulitis with Hinchey 0-Ib severity levels.4
The authors of this study conclude that there is a diversity of diet restrictions being used for
treating hospitalized patients with acute diverticulitis episodes within Hinchey 0-Ib severity levels
and that there is currently no evidence for supporting these dietary restrictions.4 The authors
further argue that these diet restrictions might be unnecessarily increasing the length of hospital
stay for these patients since they noted an inverse relationship between dietary restrictions and
length of hospital stay.4 The authors of this study elude the fact that diet choice may be a more
subjective matter based on old principles, personal preferences, and interpretations of symptoms
by physicians.4
There is a lack of research for indication of both parenteral nutrition and clear liquid diet
therapy simultaneously, but one can reason that the combining of these two types of nutrition
support can help a patient meet their nutritional needs while providing an easily digested diet that
leaves no residue in the GI tract. The lack of a protocol for nutrition therapy or bowel rest for
diverticulosis patients leaves room for inconsistencies in the treatment of such conditions.
Establishing a clinical protocol based on objective information may increase the efficacy of the
treatment and intervention process for patients with diverticulitis.
Patient education was provided to the patient as part of the nutrition care plan. MNT for
low fiber/residue diet for diverticulitis and MNT for transition to a high fiber diet for
diverticulosis were discussed with the patient and handouts from the nutrition care manual were
provided for each diet, low fiber/residue and high fiber respectively. The patient was also
encouraged to attend outpatient nutrition therapy for follow up of nutrition education.
11
After reviewing literature for diverticulitis/diverticulosis management, a study was found
that suggests exercise to play a beneficial role in treatment for these conditions. Strate et al.
conducted a study that observed the role of physical activity on diverticular complications.13
47,230 US males in the Health Professionals Follow-up study cohort who were aged 40-75 years
and free of diverticular disease, gastrointestinal cancer and inflammatory bowel disease served as
the study population.13 It was found that vigorous activity was inversely related to diverticulitis
and diverticular bleeding.13 Although there was no association between physical activity and
uncomplicated diverticulosis, the authors noted that men who spent most hours of the day being
sedentary had a 30% increased risk of developing uncomplicated diverticulosis.13 The results of
this study suggest that physical activity lowers the risk of diverticulitis and diverticular bleeding.13
Exercise recommendations were not made to the patient, but could have been a valuable addition
to the patients nutrition care plan.
Conclusion
From CJ’s first admit until his final discharge spanned a total of almost 3 weeks. The patient
had an acute recurrent episode of diverticulitis shortly after being discharged from his first
hospital stay. It is unknown if the patients acute recurrent episode of diverticulitis was due to his
lack of adherence to the MNT for low fiber/residue diet for diverticulitis or to other factors such as
ineffectiveness of medical therapy. Although there is a lack of research reporting the indication for
both PPN and a clear liquid diet, CJ’s primary care physician prescribed this nutrition support
therapy during the patients readmit. Likely for the purpose of maintaining the patient’s nutritional
status while allowing the gut some level of rest through the clear liquid diet which provides easily
digested energy that leaves no residue in the GI tract.14
12
Upon nutrition intervention, the PPN and clear liquid diet was supplemented with ensure
clear in order to meet the patients nutritional needs. The patient had a favorable clinical course
and was discharged on a low fiber diet before a nutrition follow up was conducted. Estimated
prolonged inadequate fiber intake was a factor for CJ that may have put him at an increased risk
not only for diverticulosis/diverticulitis but also his co-morbidities of HTN, GERD, and
hyperlipidemia.
13
References
1. Mahan LK, Escott-Stump S, Raymond JL. Krause’s Food and the Nutrition Care Process. 13th ed.
St. Louis, MO: Saunders/Elsevier; 2012.
2. Escott-Stump S. Nutrition and Diagnosis-Related Care. 7th ed. Baltimore, MD: Lippincott
Williams & Wilkins; 2012.
3. Kumar V, Abbas AK, Fausto N, Mitchell RN. Robbins Basic Pathology. 8th ed. Philadelphia, PA:
Saunders/Elsevier; 2007.
4. Van de Wall BJ, Draaisma WA, van Iersel JJ, van der Kaaij R, Consten EC, Broeders IA. Dietary
restrictions for acute diverticulitis: evidence-based or expert opinion? International journal of
colorectal disease, 2013; 28:1287–1293.
5. Centers for Disease Control and Prevention. The health consequences of smoking: a report of
the Surgeon General. Available at:
http://www.cdc.gov/tobacco/data_statistics/sgr/2004/index.htm. Accessed November 24,
2013.
6. Jansen A, Harenberg S, Grenda U, Elsing C. Risk factors for colonic diverticular bleeding: a
Westernized community based hospital study. World J Gastroenterol. 2009;15(4): 457.
7. El-Sera HB, Satia JA, Rabeneck L. Dietary intake and the risk of gastro-esophageal reflux disease:
a cross sectional study in volunteers. Gut. 2005;54(1): 11-17.
8. Nutrition Care Manuel. Diverticular Conditions. Available at:
http://nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145209&ncm_t
oc_id=33991&ncm_heading=Nutrition%20Care. Accessed November 30, 2013.
9. Strate L, Liu YL, Syngal S, Aldoori WH, Giovannucci EL. Nut, corn, and popcorn consumption and
the incidence of diverticular disease. JAMA2008;300(8), 907-914.
10. Van Ooteghem G, El-Mourad M, Slimani A, Margos W, El Nawar A, Patris A, et al. Is early enteral
nutrition dangerous in acute non-surgical complicated diverticulitis? About 25 patients fed with
oral fiber free energetic liquid diet. Acta gastro-enterologica Belgica, 2013;76(2), 235-240.
11. American Society for Parenteral and Enteral Nutrition. Guidelines for the Provision and
Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Available at:
http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines/
2009_Clinical_Guidelines_-_When_to_Use_Parenteral_Nutrition. Accessed November 30, 2013.
12. Correia M, Guimaraaaes J, de Mattos L, Gurgel K, Cabral E. Peripheral parenteral nutrition: an
option for patients with an indication for short-term parenteral nutrition. Nutricion
Hospitalaria, 2004;19(1), 14-18.
13. Strate L, Liu Y, Aldoori W, Giovannucci E. Physical activity decreases diverticular complications.
The American journal of gastroenterology, 2009; 104(5), 1221-1230.
14. Arizona Digestive Health. Clear Liquid Diet. Available at:
http://www.arizonadigestivehealth.com/clear-liquid-diet. Accessed December 1, 2013.
14
Case Study NCP Form
Patient: CJ
Referred for: Consult for PPN related to Diverticulitis
NUTRITION ASSESSMENT
Food and Nutrition Related History: Pt reports having a normal appetite and eating schedule prior to first episode of diverticulitis just about 2 weeks
ago. Pts appetite resumed after being discharged from the hospital, and ate “normally” again for a few days before losing his appetite again and
experiencing sx of diverticulitis/abdominal pain. Diet education MNT for diverticulitis/diverticulosis was given to pt last admit. PO intake reported to be
less than 25% of normal per pt for the last 3 days.
Diet recall prior to 10/9, most recent admit:
BFST- Sausage egg and cheese muffin with coffee, LUNCH- 2 slices of pepperoni pizza with diet coke, DINNER- 2 beers with steak and mashed potatoes,
HS SNACK: popcorn.
Anthropometric Measurements
Age: 53
Gender: Male
Ht: 5’7’’
Wt: 190 lbs
Wt Hx: UBW of 218lbs, pt has had recent
weight loss over the last 2 months from
decreased appetite and pt has lost weight
since dx of diverticulitis 2 weeks ago.
% Wt change: 13% weight loss in 2 months,
severe weight loss.
BMI: 29.8, Overweight
Biomedical Data, Medical Tests & Procedures
Labs/Date Albumin
Glucose
eGRF
BUN
Creat
Na+
K+
Hgb
Hct
MCV
Other
10/9/13
3.8 g/dL
93 mg/dL
67
16 mg/dL .85 mg/dL
138 mEq/L
4.9 mEq/L
14.9 g/dL 44%
87 cµ/µm
mL/min/
1.73 m2
Medical Diagnosis/PMH/Relevant Conditions: Current dx- diverticulitis, abdominal pain, pelvic abscess. Pt has PMH of HTN, GERD, hyperlipidemia, rectal
bleeding and is a smoker. Pt is a recent readmit for diverticulitis. Pt was admitted 2 weeks ago for diverticulitis, Diarrhea 3 days prior to admit.
Pertinent Medications:
Home- MVI, Prilosec, lovastatin, Lisinopril and Colace.
Inpatient- Cipro, Flagyl, Zofran, and Morphine.
Skin status:
x Intact □ Pressure Ulcer/Non-healing wound; Comments:
Estimated Nutritional Needs Based on Comparative Standards: Adjusted BW (159lbs) for protein and fluid, actual BW for Calories
Calories: MSJ with illness factor of 1.1 and activity Protein: 1 – 1.2 g/kg = 72 - 86 grams
Fluid: 30-35mls/kg = 2160 - 2520 mL
factor of 1.2 = 2170
Diet Order: PPN and clear liquids,
Feeding Ability
Oral Problems
Intake
PPN 2280mls providing 1003 kcals
x Independent
□ Chewing Problem
□ Good (> 75%)
and 57 grams of protein
□ Limited Assistance
□ Swallowing Problem
□ Fair (approx. 50%)
□ Extensive/Total Assistance
□ Mouth Pain
□ Poor (<50%)
□ N/A
x None of the Above
x Minimal – (<25%)
□ NPO
□ No Nutritional Diagnosis at this time
x Proceed to Nutrition Diagnosis Below
NUTRITION DIAGNOSIS
P (problem) Limited adherence to nutritionrelated recommendations related to:
E (Etiology) as evidenced by: ?lack of understanding
of the importance to follow nutrition MNT for
diverticulitis
15
S (Signs & Symptoms) pt having a diet
recall including foods high in fiber
(popcorn) or not recommended (steak)
for the low fiber/residue diet for
P (problem) Inadequate energy intake related to:
E (Etiology) PPN and clear liquid diet order as
evidenced by:
diverticulosis after diet instruction on
last admit.
S (Signs & Symptoms) PPN only meeting ~
50% of pts energy and ~ 75% of pts
protein needs with clear liquid diet not
adding sufficient calories/protein to
meet pts needs.
INTERVENTION
Nutrition Prescription: Clear liquid diet and ensure clear BID adding an additional 360 kcals and 18 grams of protein to better meet the nutritional needs
of the patient. Recommend discontinuation of PPN and progressing patient’s diet as medically feasible if patient is able to tolerate PO.
Food or Nutrient Delivery: PO
Nutrition education: MNT for low fiber/residue diet for diverticulitis and
MNT for transition to a high fiber diet for diverticulosis. Adherence to
the low fiber/residue diet for diverticulitis was emphasized and the pt
was made aware of the food in his diet recall (popcorn and steak) that
was not recommended for this diet and the possibility that these foods
may have triggered a recurrent acute episode of diverticulitis. Pt was
instructed to wait at least two weeks after his discharge from the
hospital before adding foods high in fiber to his diet.
Nutrition Counseling: N/A
Coordination of Care (refer to): Outpatient nutrition therapy for follow
up of nutrition education.
Goal(s):
1. Medical food supplements: Patient will consume >75% of ensure clear supplement to better meet his needs
2. Collaboration and referral: To monitor patients BM’s, weight and diet advancement.
MONITORING & EVALUATION
Indicators:
1. Diet order progression
2. PPN
3. Weight
4. Bowel Movements
5. PO and supplement intake
Criteria:
1.
2.
3.
4.
5.
16
Patients diet order will be advanced as medically feasible
PPN will be discontinued
Weight will be maintained within ± 5 lbs
Patient will have a BM at least q3days
Patient will consume > 75%