Case Study 11—Inflammatory Bowel Disease: Crohn’s Disease
KNH411
Mary Allison Geibel
I. Understanding the Disease and Pathophysiology
[1] What is inflammatory bowel disease? What does current medical literature
indicate regarding its etiology?
Inflammatory bowel disease, Crohn’s disease, and ulcerative colitis, are all
interrelated conditions that can be attributed to the gastrointestinal tract.
Inflammatory bowel disease is the overarching condition of inflammation of the GI
tract, which can be divided into either Crohn’s disease or ulcerative colitis (Nelms,
415). Ulcerative colitis involves inflammation strictly in the colon and the rectum.
The inflammation is assigned primarily to the mucosa of the colon. This
autoimmune disorder, pertaining to Crohn’s disease, involves the inflammation of
the lining of the stomach from the oropharynx to the perianal region, producing
incredulous abdominal pain and discomfort in digestion and bowel movements.
The most common region target to inflammation is the ileocecal region and the
terminal ileum (Hendrickson, 2002). IBD and its related disorders often cause very
distinct nutrient deficiencies and may result in severe malnutrition.
The etiology of inflammatory bowel disease as a whole is decently
ambiguous currently, but different risk factors can contribute to ulcerative colitis
and Crohn’s. Some of these factors include but are not limited to “smoking,
infectious agents, intestinal flora, and physiological changes in the small intestine,”
(Nelms, 415). All of these contributions can elicit an inflammatory response within
the GI tract. Current medical research has been able to utilize animal models in
detecting certain genomic patterns that link the condition of IBD to the human
genome. One influential finding that arose was the participation of T cells in the
development of Crohn’s Disease. Th1-cell over-activity in the intestinal mucosa was
proposed to have a direct correlation to the incidence of Crohn’s disease
(Hendrickson, 2002). Ultimately there are several genetic as well as lifestyleinfluenced risk factors that can cause the development of inflammatory bowel
disease as well as its related disorders.
Sources: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy
and Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
Hendrickson, B.A., Gokhale, R., Cho, J.H. (2002). Clinical Aspects and
Pathophysiology of Inflammatory Bowel Disease. American Society for Microbiology:
Clinical Microbiology Reviews, 15(1), 79-94. doi: 10.1128/CMR.15.1.79-94.2002.
[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?
This misdiagnosis is not entirely uncommon because both of these disorders
fall under the category of inflammatory bowel disease. Though ulcerative colitis and
Crohn’s disease are both inflammations of the gastrointestinal tract, they contain
very distinct differences. For starters, both disorders require similar medical
processes for diagnosis including MRI, CT scans, abdominal ultrasounds, antiglycan
antibodies, and indicative calprotectin, lactoferrin, and polymorphonuclear
neutrophil elastase. Both disorders contain the same etiology in particular,
inflammation of the gastrointestinal mucosa, a history of smoking, and genetic
disposition. Both disorders also share some symptoms that could lead to confusion
in diagnosis such as abnormal diarrhea, abdominal pain, weight loss, and fevers.
The distinctions between these disorders reside in the disease pathology and
the complications the patient endures. Some characteristic pathology with
ulcerative colitis includes the abnormal inflammation of the colonic mucosa caused
by GI tract confusion with foreign antigens. The location that this disorder resides
in is typically restricted to the colon but my also include the rectum. Some
complications contained only within ulcerative colitis include sever bleeding, toxic
colitis and megacolon, strictures, perforation, dysplasia, and carcinoma (Nelms,
416). Crohn’s Disease is characterized as inflammation in the bowel mucosa and
inner lining and can be amplified to the GI tract in general. Some complications
found only in Crohn’s Disease include malabsorption, malnutrition, abdominal
fistula formation, intestinal obstruction, gallstones, kidney stones, UTI,
thromboembolic complications, and neoplasia (Nelms, 416).
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[3] A CT scan indicated bowel obstruction and Crohn’s disease was classified as severefulminant disease. CDAI score of 400. What does a CDAI score of 400 indicate? What
does a classification of severe-fulminant disease indicate?
CDAI is a medical quantification score that allows for characterization of the
intensity of Crohn’s disease. The range of CDAI includes 150 at the low end to
anywhere greater than 450 for the most severe of cases. A CDAI score of 400
classifies the Crohn’s disease as moderate to severe and can be defined as major
symptoms including fevers, weight loss, abdominal pain, nausea, and extreme
anemia. Thoguh not in the most severe characterization, this CDAI score indicates
that the patient is enduring severe exacerbation of Crohn’s (Nelms, 419). The CDAI
can also be assigned based on calprotectin and lactoferrin levels present in the stool.
Classification of severe-fulminant indicates that the symptoms have been
persistent and unmanageable with steroids. This state of the disease involves a
CDAI score of >450, the uppermost level attained. The symptoms upheld in this
classification include elevated temperature, intestinal obstruction causing
persistent vomiting, cachexia, and abscess (Nelms, 419).
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[4] What did you find in Mr. Sims’ history and physical that is consistent with his
diagnosis of Crohn’s? Explain.
All of the above signs and symptoms mentioned eliciting a diagnosis of
Crohn’s disease and can be found in patient history, recalls, laboratory values, and
hematology reports. Mr. Sim’s mention of his incessant abdominal pain and
distension is a very qualitative sign that he is inflicted with Crohn’s disease. The site
of his inflammation resides within the last 5-7 cm of jejunum and first 5 cm of the
ileum. This aligns directly with the assigned areas of the GI tract that Crohn’s can
inflame. Mr. Sim’s extreme weight loss by 16-17% of his usual body weight shows
extreme signs of malnutrition and his lab values indicated nutrient deficiencies in
protein, HDL-C, Vitamin D< retinol, and ascorbic acid. The depleted levels of the
fecal markers, Transferrin and Ferritin, are direct indicators of Crohn’s disease and
are commonly utilized for diagnosis. Mr. Sim’s describes his painful diarrhea and
how it inhibits his hunger. With his pale skin color and abnormal stool consistency,
it is clear that Mr. Sim’s is experiencing Crohn’s inflicted malnutrition. All of these
recorded symptoms lead to consistency with the diagnosis of Crohn’s disease.
[5] Crohn’s patients often have extra intestinal symptoms of the disease. What are
some examples of these symptoms? Is there evidence of these in his history and
physical?
Crohn’s disease can often mask itself in extra intestinal symptoms that may
be assumed as extraneous. Some of these symptomatic conditions include
osteoporosis, osteopenia, dermatitis, ankylosing spondylitis, ocular symptoms, and
hepatobiliary complications (Nelms, 418). All of these conditions are found outside
the intestinal region, so it is of upmost importance to survey patient history and
physical examinations to conclude the presence of these symptoms. From Mr. Sim’s
medical history and physical examinations, it is clear he does not have any of these
extra intestinal symptoms of Crohn’s Disease.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[6] Mr. Sims has been treated previously with corticosteroids and mesalamine. His
physician has planned to start Humira prior to this admission. Explain the mechanism
for each of these medications in the treatment of Crohn’s.
Medication
Corticosteroids
Mesalamine
Humira
Crohn’s Treatment Mechanism
Inhibit inflammatory response and are typically utilized in
the most severe CDAI score or in acute exacerbations of
Crohn’s. These are immune-suppressors that can cause
steroid dependence.
A form of aminosalicylate medications involved in the ileum
and the colon. They work to decrease inflammation of the GI
tract lining as well as prevent relapses of Crohn’s.
A form of TNF blockers (tumor necrosis factor), which is a
protein involved in the immune system. Humira blocks TNF
as it is found to promote inflammation in tissues.
Sources: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy
and Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
Crohn’s Disease Medication Options. Crohn’s & Colitis Foundation of America: What
are Crohn’s and Colitis. Retrieved on 14 Sept 2014 from http://www.ccfa.org/whatare-crohns-and-colitis/what-is-crohns-disease/crohns-medication.html.
Crohn’s Disease Treatment. Humira. Retrieved on 14 Sept 2014 from
https://www.humira.com/crohns/treatment
[7] Which laboratory values are consistent with an exacerbation of his Crohn’s
disease? Identify and explain these values.
Mr. Sim’s laboratory values could provide direct indication of an
exacerbation of Crohn’s disease. Some prominent areas include his low protein and
albumin levels, which indicate the progression of malnutrition often caused by
severe abdominal pain and excessive diarrhea. Another source for measurement
would be his significantly lower values for fecal markers such as Transferrin and
Ferritin, which are used in CDAI score assignment. Mr. Sim’s hematological report
showed evidence of anemia, another symptom of Crohn’s disease, with his under
standard levels of Hemoglobin and Hematocrit. Aside from these indicators, Mr.
Sim’s also exhibits nutrient deficiencies with Vitamin D, ascorbic acid, and retinol.
All of these lab values allow for consistent diagnosis of Mr. Sim’s recent Crohn’s
exacerbation.
[8] Mr. Sims is currently on several vitamin and mineral supplements. Explain why he
may be at risk for vitamin and mineral deficiencies.
Though vitamin and mineral supplementation is typically a very effective
procedure for returning to healthy nutrient levels, patients inflicted with Crohn’s
disease endure alternative complications that make the absorption of these
supplements unlikely. Water-soluble vitamins are less absorbed after
implementation of a surgical resection of the ileum, which removes the terminal
portion (Nelms, 420). This terminal section of the ileum is responsible for receptive
absorption of B12 and Iron. Fat-soluble supplementation can be restricted due to
steatorrhea, which is easily observed as excess fat present in the stool (Klapproth,
2012). High incidence of diarrhea also has considerable influence on mineral
deficiencies because of lack of desire to eat, abdominal pain, as well as overall loss of
fluids and nutrients from the body. Crohn’s patients are also characteristic for
malnutrition and anorexia, which directly causes these deficiencies.
Sources: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy
and Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
Klapproth, J.M., Yang, V.W. (5 Jan 2012). Malabsorption. Medscape: Drugs and
Diseases. Retrieved on 13 Sept 2014 from http://emedicine.medscape.com/articl
e/180785-overview
[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 is an aftermath syndrome of the surgical procedure of
resectioning the small intestine. The overall theme of short bowel syndrome is
inadequate absorption of fluids, proteins, and micronutrients due to this alteration
of the small intestine. The loss of surface area of the small intestine after resection
is at blame for these malabsorption symptoms of deficiencies. From Mr. Sim’s
medical history, it is apparent that he has received intestinal resection surgery to
treat his Crohn’s, including him to be diagnosed with short bowel syndrome. Mr.
Sim’s does exhibit the symptoms of malnutrition and malabsorption based on his
protein and micronutrient levels as well as his significant weight loss, which also
may be simply attributed to his persistent diarrhea, abdominal pain, and lack of
desire to eat.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[10] What type of adaptation can the small intestine make after resection?
There are several phases post-operative intestinal resection that exhibit a
variety of characteritics. After several months, there are occurrences of fluid and
electrolyte losses, reduced diarrhea incidences and volume, and reintroduction of
enteral nutrition. In the third phase, the intestine begins its physiological adaptions.
This phase happens after several months and even years post-surgery and can
involve increased mucosal cell growth in the intestine as well as equilibrium
secretions and blood flow (Nelms, 425). The general interpretation of this adaption
is increased surface area of the small intestine, signifying a return to more normal
intestinal function and GI health.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[11] For what classic symptoms of short bowel syndrome should Mr. Sims’ health care
team monitor?
Since Mr. Sim’s would be classified in the first phase of short bowel
syndrome, the most pertinent symptoms to be monitored would come from
excessive diarrhea. The symptoms associated would be extensive loss of fluids and
electrolytes. In order to remediate this symptom, Mr. Sim’s health care team should
monitor his fluid and electrolyte levels to assure serious malnutrition and
dehydration does not result. In terms of the absorptions in the ileum that are
inhibited, B12 has a significant effect on fat absorption, which would cause even
further weight loss. Vitamin losses are central to short bowel syndrome and it is a
spiraling affect that once fat absorption is inhibited, vitamin deficiency furthers
mostly including vitamins A, D, E, and K. Sodium, magnesium, iron, zinc, selenium,
and calcium are also lost in excess in the diarrhea. With proper supplementation
and diarrhea suppression, Mr. Sim’s will be able to avoid severe nutrient
deficiencies brought about by short bowel syndrome.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[12] Mr. Sims is being evaluated for participation in a clinical trial using high-dose
immunosuppression and autologous peripheral blood stem cell transplantation
(autoPBSCT). How might this treatment help Mr. Sims?
For about 10% of patients, conventional Crohn’s Disease treatments are
inadequate to suppress the symptoms of this disorder. Recent research has
promoted the use of autologous peripheral blood stem cell transplantation to
prevent reoccurrence. This method claims to revive the immune system by
producing more regulatory T cells through cloning (Hasselblatt, 2012). The goal of
this method is to use cellular remission to prevent the necessity of medical
treatment. Evaluation of the efficacy of this treatment lies in mucosal healing,
endoscopy, and incidence of relapse. All of these factors seemed to improve greatly
when cell transplantation was utilized.
Source: Hasselblatt, P., Drognitz, K., Potthoff, K., Bertz, H., Kruis, W., Schmidt, C., & ...
Kreisel, W. (2012). Remission of refractory Crohn's disease by high-dose
cyclophosphamide and autologous peripheral blood stem cell transplantation.
Alimentary Pharmacology & Therapeutics, 36(8), 725-735. doi: 10.1111/apt.12032
II. Understanding the Nutrition Therapy
[13] What are the potential nutritional consequences of Crohn’s disease?
Crohn’s disease consists of a variety of nutritional consequences, most
frequently defined as severe nutritional deficiencies. The most notable deficiencies
include, caloric intake, protein, fluids, Iron, Magnesium/Zinc, Calcium/vitamin D,
B12, Folate, water-soluble vitamins, and fat-soluble vitamins (Nelms, 420). Deficient
caloric intake is associated with malnutrition and inflated energy requirements that
aren’t being met. Protein and albumin levels are typically under standards because
there is such an increased necessity of protein due to inflammatory GI tract losses
and catabolic effects. Fluid deficiencies can be ensued by short bowel syndrome and
excessive fluid loss through diarrhea. Iron deficiency is most commonly observed
through blood loss and poor absorption. Crohn’s patients are classified with many
nutrient deficiencies such as Magnesium and Zinc, which are depleted by intestinal
losses due to short bowel syndrome and consistent diarrhea. Calcium and Vitamin
D can be up for discretion is dairy intake is not plentiful enough. B12 deficiencies can
be caused through surgical procedures that resection the stomach and terminal
ileum. Folate deficiencies are commonly resulted from medications that are
employed for treating Inflammatory Bowel Disease. Water and fat-soluble vitamins
are incapable of being absorbed due to surgical resections and steatorrhea (Nelms,
420). Ultimately, the consequences of suffering from IBD as well as the surgical and
post-operative procedures of the disease inflict several nutritional deficiencies
within the body.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[14] Mr. Sims underwent resection of 200 cm 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 small intestine has a very functional structure that relies on surface area
for appropriate absorption and secretion, enabling sufficient digestion. With this
extreme functionality comes great adaptability, allowing for 50% removal before its
functions are inhibited. A standard adult small intestine is 460-690 cm. A 200 cm
resection of the small intestine is typically less than 50%, allowing for digestion and
absorption to function properly. The three main components of the small intestine
include the duodenum (0.5m), the ileum (3-4m), and the jejunum (2-3m). Mr. Sim’s
resection was located between the jejunum and the ileum, without disturbing the
duodenum. Mr. Sim’s resection did not interfere too extensively with the ileum of
the small intestine, which helps to preserve several necessary functions. Though
much of the jejunum surface area was lost, functionality can still persist due to the
ileum and the saving of his colon. This resection is not too significant that his small
intestine cannot perform its previous capabilities.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[15] What nutrients are normally digested and absorbed in the portion of the small
intestine that has been resected?
The jejunum and ileum are located towards the end of the small intestine and
contain many nutrients to digest and absorb during the process of digestion.
Absorption is promoted in the jejunum and ileum through microfibers called villi.
Most nutrients are primarily absorbed in the jejunum. The main componenets
digested and absorbed in the jejunum consist of proteins, carbohydrates, watersoluble vitamins, and fats upon exit of the stomach and duodenum. Pancreatic
enzymes aid in the break down of these structures into amino acids, sugars, and
fatty acids. Vitamin B12 and bile salts are the main nutrients absorbed in the ileum
and more specifically absorbed in the terminal ileum. Vitamin B12 is sequentially
transferred to the blood capillaries. Bile salts are primarily absorbed in the ileum
due to its inherently porous nature that allows for recycling of bile salts to the liver.
Fat-soluble vitamins are also preferentially absorbed in the ileum as well as
cholesterol, sodium, and potassium alcohol.
Sources: Sieroslawska, A. The Small Intestine. KenHub. Retrieved on 14 Sept 2014
from https://www.kenhub.com/en/library/anatomy/the-small-intestine
Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
III. Nutrition Assessment
[16] Evaluate Mr. Sims’ % UBW and BMI.
[%UBW = (100 x Actual Weight)/Usual body weight]
%UBW= (140lb/166lb) * 100= 84%
%UBW= (140lb/168lb) * 100= 83%
Weight change = 100%-84%, 100%-83% = 16-17%
[BMI = (weight (kg)/ (height2 (m2))]
Weight = 140 lbs. * (0.4536 kg/lb.) = 63.5 kg
Height = 69 in. * (2.54 cm/in) * (1m/100cm) = 1.75 m
BMI = (63.5 kg/(1.75 m)2) = 20.67 kg/m2
Mr. Sim’s calculated BMI was 20.67 kg/m2, which is only the low range for a
normal BMI, which is 18.5-24.9 kg/m2 (CDC value). This can be directly attributed
to his weight deficiency. Another measure of his quantitative weight deficiency is
his %UBW. These values indicate that Mr. Sim’s currently weighs 83-84% of his
usual body weight, which illustrates a significant weight loss.
[17] Calculate Mr. Sims’ energy requirements.
Mifflin-St. Jeor for Men
[10*weight (kg) + 6.25*height (cm) – 5*age (years) + 5] * stress factor
[(10)(63.5 kg) + (6.25)(175.26 cm) – (5)(35 yr.) + 5] (1.5) = 2340 kcal
Mr. Sim’s calculated energy requirements based on his height, weight, age,
and stress factor was measured to be 2340 kcal/day. The stress factor was assigned
based on Mr. Sim’s drastic weight loss and therefore increased energy requirements
for replenishment to equilibrium (Nelms, 421).
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[18] What would you estimate Mr. Sims’ protein requirements to be?
The standard deduction for protein requirements is 1.5-1.75 g protein/kg
body weight. Mr. Sim’s laboratory values indicate incredibly reduced protein levels
as seen in his total protein level (5.5 g/dL), albumin (3.2 g/dL), and pre-albumin (11
mg/dL). For that extreme of a deficiency, I would recommend that Mr. Sim’s protein
requirements aim to the 1.75 g protein/kg body weight standard.
(63.5 kg) (1.5, 1.75 g protein/ kg) = 95.4 – 111.3 g protein/day
[19] Identify any significant and/or abnormal laboratory measurements from both his
hematology and his chemistry labs.
Laboratory Measurement
Total Protein (g/dL)
Albumin (g/dL)
Standard Range
6-8
3.5-5
Patient Value
5.5
3.2
Pre-Albumin (mg/dL)
C-reactive Protein (mg/dL)
HDL-C
ASCA
PT (sec)
Hemoglobin (g/dL)
Hematocrit (%)
Transferrin (mg/dL)
Ferritin (mg/mL)
ZPP (umol/mol)
Vit D 25 hydroxy (ng/mL)
Free retinol (ug/dL)
Ascorbic Acid (mg/dL)
16-35
<1.0
>45
12.4-14.4
14-17
40-54
215-365
20-300
30-80
30-100
20-80
0.2-2.0
11
2.8
38
+
15
12.9
38
180
16
85
22.7
17.2
<0.1
Listed above are all of Mr. Sim’s concerning laboratory and hematology
values that were collected.
IV. Nutrition Diagnosis
[20] Select two nutrition problems and complete the PES statement for each.
Unintended Weight Loss NI-3.2
Excessive weight loss related to malnourishment and anorexia included with
diagnosis of Crohn’s Disease as evidenced by 83-84% usual body weight and
incapability to return to normal body weight after diagnosis of inflammatory bowel
disease and Crohn’s Disease.
Inadequate Protein Intake NI-5.7.1
Inadequate protein intake related to diagnosed Crohn’s Disease, which involves
elevated protein requirements as evidenced by insufficient laboratory values
collected for total protein, albumin, and pre-albumin as well as patient history of
Crohn’s Disease and incidence of diarrhea.
V. Nutrition Intervention
[21] The surgeon notes Mr. Sims probably will not resume eating by mouth for at least
7-10 days. What information would the nutrition support team evaluate in deciding
the route for nutrition support?
The treatment for post-operative nutrition involves a three-phase treatment
plan. For the first 7-10 days after surgery, Mr. Sim’s nutrition support team would
need to very closely monitor his electrolyte and fluid levels. They will deplete
significantly due to excessive losses through diarrhea. In order to replenish these
deficiencies, Mr. Sim’s will need to be restricted to parenteral nutrition, which
excludes the GI tract. Proper supplementation of fluids and electrolytes would be
imperative to preventing post surgical malnutrition. After a couple of months, as
long as his diarrhea has suppressed, enteral nutrition can be reintroduced due to
better bowel function. This next stage should only be entered if intestinal
reconstruction is concluded which would allow for proper electrolyte, fluid, and
nutrient absorption.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[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?
Phosphorus is an incredibly prevalent mineral in the body, ranking in at #2.
Levels of 2.7-4.5 mg/dL are required for adequacy, which can be measured through
secretion and absorption in the body. There are several risk factors for
hypophosphatemia including malnutrition, vitamin D deficiency, secretory diarrhea,
vomiting, fluid therapy, and post-operative state (Parrish). All of these risk factors
will be present for the patient post-op. Magnesium deficiencies are also important
to monitor because deficiencies can cause further intestinal inflammation, which
would be a detriment to his recovery (Smith, 2008). Low magnesium levels could
also inflict refeeding syndrome in the patient recovering from intestinal resection.
Both magnesium and phosphorus levels can be decreased extensively from the
parenteral nutrition plan as well as the excessive diarrhea losses.
Sources: Parrish, C.R. Low Serum Phosphorus Got You Down? (2013). Nutrition
Issues in Gastroenterology 120, 26-36. Retrieved on 14 Sept 2014 from
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/diges
tive-health/nutrition-support-team/nutrition-articles/Parrish_Glassman_August_13
Smith, A., Morimoto, M., Chmielinska, J.J. Intestinal Inflammation Caused By
Magnesium Deficiency Alters Basal and Oxidative Stress-induced Intestinal
Function. (2008). Molecular and Cellular Biochemistry 306(1-2), 56-69.
DOI: 10.1007/s11010-007-9554-y.
[23] What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be
prevented?
Refeeding syndrome is characterized as the aftermath of malnutrition and
prolonged starving that results in cardiac failure once nourishment is regained.
When carbohydrate intake is suppressed in starving, insulin secretion is
correspondingly decreased. Fat and protein banks within the body are tapped into
for expenditure of energy in the forms of ketone bodies and metabolism as a whole
declines. The reintroduction of carbohydrates through parenteral nutrition in Mr.
Sim’s case, utilizes glucose metabolism as a source of energy. The metabolic process
requires hefty amounts of magnesium, phosphorus, potassium, and thiamin in
transition from ketone bodies to glucose(Nelms, 92-93). Hypomagnesaemia and
hypokalemia can cause several detrimental health affects including cardiac
impairment, tremor, muscle twitching, and potential death. The monitoring of these
electrolytes is imperative to preventing refeeding syndrome from occurring in Mr.
Sim after he begins his parenteral diet. Other methods to avoid this syndrome
include slowly paced introduction of feeding as well as adequate supplementation to
avoid nutrient deficiencies.
Sources: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy
and Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
Hearing, S.D. Refeeding Syndrome. (2004). British Medical Journal 328(7445), 908909. Retrieved on 14 Sept 2014 from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC390152
[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.
50 cc/hr (24 hr)= 1,200 cc/day (1.2L/day)
Carbohydrates—1.2 L (200 g dextrose/L)= 240 g/day
Protein — > 240g (3.4kcal/g) = 816 kcal
1.2L (42.5 g amino acids/L)= 51 g/day
Lipids— > 51g (4 kcal/g)= 204 kcal
1.2L (30g lipid/L)= 36 g/day
Total calories— > 36g (9 kcal/g)= 324 kcal Total kcal/day= 1,344
85cc/hr (24 hr)= 2,040 cc/day (2.04L/day)
Carbohydrates—2.04L (200 g dextrose/L)= 408 g/day
Protein — > 480 g (3.4 kcal/g)= 1,632 kcal
2.04 L (42.5 g amino acids/L)= 86.7 g/day
Lipids— > 86.7g (4 kcal/g)= 346 kcal
2.04 L (30 g lipid/L)= 61.2 g/day
Total calories— > 61.2 g (9kcal/g)= 550 kcal Total kcal/day= 2,528
I do agree with the decision to place Mr. Sim’s on parenteral nutrition after
his intestinal resection. Post-operation, copious amounts of restrictions must be
implemented to prevent malnutrition, dehydration, and deficiencies and to promote
restorative healing of the intestinal tract. The sensitivity and gradual allocation of
electrolytes and fluid make the parenteral nutrition plan a good option for
reintroduction to the oral diet. Short bowel syndrome requires parenteral nutrition
as the primary form of nutrient intake after surgery. The protein requirements are
slightly lower than the estimated needs for the patient. All other criteria are met
through the parenteral nutrition plan.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[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).
After Mr. Sim’s intestinal resection, his diarrhea will worsen and losing fluid
and electrolytes will become of his main concern. I think regaining his usual body
weight is an ideal goal once he reaches phase 2 of his post-operative treatment,
when his diarrhea ceases and he begins enteral nutrition again. Once his
gastrointestinal tract has returned to higher functionality, I would recommend Mr.
Sim’s increase his caloric consumption by about 500 kcal/week so he gains 1
lb/week until he returns to his usual body weight of 166 lbs. In replenishing his
caloric intake, it is important that Mr. Sim’s is consuming nutrients necessary for his
healing provided by his nutrition care team. This would include returning his
protein and albumin levels up to standard, as well as the electrolytes that were
previously deficient.
Crohn’s disease is characteristic for low protein levels due to malnutrition
and severe losses through the feces. Mr. Sim’s needs to regain his protein to its
standard requirement at 95.4-111.3 g/day. At his current state, he is receiving 86.7
g/day through parenteral nutrition. Once he is able to orally consume foods, I
would increase his protein intake by 2 g/day, as to reach the ideal goal but in a
gradual manner to prevent his body to feel overwhelmed into refeeding syndrome.
VI. Nutrition Monitoring and Evaluation
[26] Indirect calorimetry revealed the following information:
Measure
Oxygen Consumption (mL/min)
CO2 production (mL/min)
RQ
RMR
Mr. Sim’s Data
295
261
0.88
2022
What does this information tell you about Mr. Sim’s?
Indirect calorimetry is a method used after a patient is in states of
malnutrition that observes the metabolic changes occurring within the body and
monitors energy expenditure. If overfeeding is occurring, the CO2 levels will
elevate, making respiration a difficult and straining process. Shown in the table
above are Mr. Sim’s O2 consumption, CO2 production, respiratory quotient (CO2:O2),
and his resting metabolic rate. From the respiratory quotient value and the table
below, it seems that Mr. Sim’s is experiencing mixed substrate oxidation, but mostly
consistent with protein oxidation. This conclusion directly correlates to his low
protein and albumin levels collected from his lab.
Source: Siobal, M.S., Baltz, J.E. A Guide to the Nutritional Assessment and Treatment
of the Critically Ill Patient. (2013). American Association for Respiratory Care, 27-37.
Retrieved on 14 Sept 2014 from https://www.aarc.org/education/nutrition_guide/
[27] Would you make any changes to his prescribed nutrition support? What should be
monitored to ensure adequacy of his nutrition support? Explain.
In order to pursue proper rehabilitation from the surgical resection, it is very
important that the patient maintains elevated fluid and electrolyte levels to prevent
severe deficiencies and malnutrition. Laboratory values could be collected to
ensure that Mr. Sim’s is receiving appropriate amounts to prevent malnutrition in
concert with gradual supplementation to also prevent refeeding syndrome. It is also
imperative to reduce fecal losses and suppress diarrhea. For the tenderness f the
post-operative intestine, non-obstructive foods would promote healing. Once oral
feeding is attainable, it would be beneficial to regiment 4-6 small meals per day and
supply foods that are easily digestible (Nelms, 424). This would involve avoiding
fibrous meats and fruits and vegetables that have especially tough skin and
excessive seeds. Should fecal output increase during the nutrition care, insoluble
fiber should be retracted from the meal plan as well as foods that cause flatulence.
Due to his lack of protein supply, I would increase protein intake through ingestion
of amino acids.
To ensure adequacy of his parenteral nutrition, the patient should frequently
be weighed, visually assessed, and subject to laboratory tests that can monitor his
fluid and electrolyte levels. This needs to be under severe scrutiny as to prevent
dehydration, malnutrition, and proper rehabilitation from surgical procedures
(Nelms, 100).
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[28] What should the nutrition support team monitor daily? What should be
monitored weekly? Explain your answers.
There are several guidelines available to monitor parenteral nutrition care
daily as well as weekly to ensure proper rehabilitation. Some quantities to assess
daily would be intake and output levels, electrolytes, as well as nutrient levels
including magnesium, phosphate, and calcium. Deficiencies in these electrolyte
levels could create onset complications in surgical healing. Primarily,
hyperglycemia measurements should be conducted 3-4 times per day. Input and
outtake levels give insight to proper absorption and fecal losses. Any severe
changes in these levels could implement more extreme treatment plans. Weight,
fluid status, physical examinations, vital signs, bowel function, and blood glucose
levels can all aid the support team in evaluating the efficiency of the parenteral
nutrition plan (Nelms, 91).
Weekly monitoring would involve liver function tests and triglyceride levels.
Daily monitoring of the above quantities can be altered to weekly once the patient
exhibits nutritionally stable output and absorption. Cooperation to the parenteral
nutrition plan will allow for less close monitoring, but only once the gastrointestinal
tract seems to efficiently support the nutrition and stability of the intestine. Some
complications that can arise from inadequate parenteral nutrition include serious
infections that are caused by increased absorption of bacteria and potentially due to
improper allocation of parenteral solutions. Cholestasis can cause bile accumulation
in the gallbladder (Nelms, 101).
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[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?
Elevated levels of glucose in the blood can be observed after parenteral
nutrition is enacted. Abnormally high levels can also indicate that the patient is
being overfed after periodic malnutrition, because the ketone bodies previously
used for energy acquisition are now substituted for glucose metabolism as a
primary source of energy. In order to sustain these glucose levels at a more normal
amount, dextrose could be reduced to bring his blood sugar levels back to
equilibrium while still maintaining proper energy intake. Hyperglycemia can arise if
the blood glucose levels remain inflated.
[30] Evaluating 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.
Nitrogen Balance = dietary protein intake/6.25 – urine urea nitrogen - 4
(86.7 g/6.25) – 18.4 – 4 = -8.5 g
The goal of nitrogen balance is for the amount of nitrogen excreted to equal
the amount ingested. Mr. Sim’s had a negative nitrogen balance of 8.5 grams,
indicating more of his nitrogen is excreted than he is able to take in. This
measurement of nitrogen balance also correlates the protein levels within the body.
This is of concern because one of the main goals for Mr. Sim’s is to replenish the
protein and albumin that had been lost through his persistent diarrhea. Additional
protein supplementation through amino acids and protein rich, digestible foods
should be enacted in order to improve the nitrogen balance.
The accuracy of nitrogen balance is certainly up for debate because 24-hour
urine collection undeniably contains error. Some sources of nitrogen loss that aren’t
accounted for within this equation include renal impairment, wounds, burns,
diarrhea, and vomiting (Nelms, 54).
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[31] On post-op day 10, Mr. Sims’ team notes he has had bowel sounds for the previous
48 hours and had his 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?
Once bowel movements are possible and the volume of diarrhea decreases,
the patient has entered the second phase of post-operative treatment. Enteral
nutrition is initiated and the potential for an oral diet becomes attainable. Small and
frequent meals reduce the digestive complications that can result from overfeeding
to quickly. It is necessary for his primary diet after surgery to consist of lactose free
food products as well as low residue meals. Energy requirements can still be met so
long as supplementation from MCT can compensate for the reduction in fatty foods.
High fat in the feces may indicate that a substitution for high fat foods is of necessity.
Foods powerful in flavor such as spicy, overly sweetened, and fried foods should be
restricted in the first phases of the oral diet as well as foods that would produce
excessive flatulence (Nelms, 421). Once the nutrition team can confirm that Mr.
Sim’s is tolerating the initial oral diet, lactose and fibrous foods can be reintroduced
in order to return to normal nutrient supplementation.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
[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.
The main goals of Mr. Sim’s rehabilitation after discharge would be to return
to his usual body weight by supplying his nutrition plan with the protein and
electrolyte supplements that were lost through his diarrhea output. By maximizing
protein and energy intake, Mr. Sim’s can strengthen his gastrointestinal tract and
retain the desire to consume foods. It is important for the patient to consume fruits,
vegetables, and extra supplementation to replenish the magnesium, phosphate and
calcium that were depleted in his post-surgical recovery. To prevent future
inflammation, foods high in antioxidants and fatty acids are beneficial. A great
source for omega-3 fatty acids include seafood such as salmon and trout. The
aftermath of inflammatory bowel disease can include kidney stones and urolithiasis.
To prevent these disorders from developing, the patient can supplement the body
with foods high in oxalate. Some examples include strawberries, nuts, spinach,
peanut butter, tofu, and vitamin C supplements. It would be beneficial for Mr. Sim’s
to actively record his fecal patterns, weight fluctuation, and food journals in order to
conclude how effective his dietary intake is improving his inflammatory bowel
disease. The nutritional support team could observe his progress and advise him on
dietary arrangements that would reintroduce normality into his daily routine.
Source: Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
References
Crohn’s Disease Medication Options. Crohn’s & Colitis Foundation of America: What
are Crohn’s and Colitis. Retrieved on 14 Sept 2014 from
http://www.ccfa.org/what-are-crohns-and-colitis/what-is-crohnsdisease/crohns-medication.html.
Crohn’s Disease Treatment. Humira. Retrieved on 14 Sept 2014 from
https://www.humira.com/crohns/treatment
Hasselblatt, P., Drognitz, K., Potthoff, K., Bertz, H., Kruis, W., Schmidt, C., & ... Kreisel,
W. (2012). Remission of refractory Crohn's disease by high-dose
cyclophosphamide and autologous peripheral blood stem cell transplantation.
Alimentary Pharmacology & Therapeutics, 36(8), 725-735. doi:
10.1111/apt.12032
Hearing, S.D. Refeeding Syndrome. (2004). British Medical Journal 328(7445), 908909. Retrieved on 14 Sept 2014 from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC390152
Hendrickson, B.A., Gokhale, R., Cho, J.H. (2002). Clinical Aspects and
Pathophysiology of Inflammatory Bowel Disease. American Society for
Microbiology: Clinical Microbiology Reviews, 15(1), 79-94. doi:
10.1128/CMR.15.1.79-94.2002.
Klapproth, J.M., Yang, V.W. (5 Jan 2012). Malabsorption. Medscape: Drugs and
Diseases. Retrieved on 13 Sept 2014 from http://emedicine.medscape.com/articl
e/180785-overview
Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy and
Pathophysiology (2nd ed.). Belmont, CA: Brooks/Cole Cengage Learning.
Parrish, C.R. Low Serum Phosphorus Got You Down? (2013). Nutrition Issues in
Gastroenterology 120, 26-36. Retrieved on 14 Sept 2014 from
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/diges
tive-health/nutrition-support-team/nutrition-articles/Parrish_Glassman_August_13
Sieroslawska, A. The Small Intestine. KenHub. Retrieved on 14 Sept 2014 from
https://www.kenhub.com/en/library/anatomy/the-small-intestine
Siobal, M.S., Baltz, J.E. A Guide to the Nutritional Assessment and Treatment of the
Critically Ill Patient. (2013). American Association for Respiratory Care, 27-37.
Retrieved on 14 Sept 2014 from
https://www.aarc.org/education/nutrition_guide/
Smith, A., Morimoto, M., Chmielinska, J.J. Intestinal Inflammation Caused By
Magnesium Deficiency Alters Basal and Oxidative Stress-induced Intestinal
Function. (2008). Molecular and Cellular Biochemistry 306(1-2), 56-69.
DOI: 10.1007/s11010-007-9554-y.