Maria Chavez
Case Number 11-Inflammatory Bowel Disease: Crohn’s
Please answer the following questions from your lab text on Mr. Sims:
1. What is inflammation bowel disease? What does current medical literature indicate
regarding its etiology? Inflammatory bowel disease (IBD) involves chronic inflammation
of all or part of the digestive tract. IBD primarily includes ulcerative colitis and Crohn's
disease. Both usually involve severe diarrhea, pain, fatigue, and weight loss.
The etiology/causes of IBD are unknown. One possible cause is an immune system
malfunction
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 ulceration colitis?
The only way to be diagnosed with ulcerative colitis and then diagnosed with Crohn’s is by
being misdiagnose in the first place.
Ulcerative colitis is an inflammatory bowel disease that causes long-lasting inflammation and
ulcers in the innermost lining of your large intestine and rectum. The ulcerative colitis
inflammation is continuous compared to Crohn’s that may have segments of healthy and
inflamed portions.
Crohn's disease, inflammation often spreads deep into affected tissues. The inflammation can
involve different areas of the digestive tract (the large intestine, small intestine or both.) Also all
the layers of the mucosa are affected.
Both ulcerative colitis and Crohn’s have the same symptoms; diarrhea, pain, fatigue, and weight
lost.
9. is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel syndrome,
and provide a rationale for your answer.
Since the patient has gone a bowel resection, the main cause of short bowel syndrome is bowel
resection. Therefore, the patient could be a candidate for short bowel syndrome. however, the
amount of bowel removed does not qualify him to have short bowel syndrome.
Short bowel syndrome is a condition in which nutrients are not properly absorbed
(malabsorption) because a large part of the small intestine is missing or has been surgically
removed.
When medications are no longer effective at controlling the inflammation and managing the
symptoms of Crohn’s disease, or when complications develop, treatment sometimes includes the
removal of affected sections in which nutrients could be not properly absorbed. Therefore the
patient could be a candidate for short bowel syndrome.
10. What type of adaptation can the small intestine make after resection?
For some people, short bowel syndrome is a temporary problem. Even after extensive surgery,
the remaining small intestine is sometimes able to adjust to the short bowel length by working
harder than before. Although intestinal adaptation may begin soon after the onset of short bowel
syndrome, it may take as long as two years before the small intestine has fully adjusted. True
intestinal adaptation is achieved when a person can successfully digest and absorb all necessary
nutrients through the GI tract.
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?
Since the small intestine is about 6 meters (600cm), the patient now has about 400cm left.
Overall, the patient lost about 1/3 of this small intestine. This resection is significant, but it
doesn’t qualify him to have short bowel syndrome since an individual needs to lose about ½ of
the bowel to be qualified.
19. Identify any significant and/or abnormal laboratory measurements from both his
hematology and his chemical labs.
For hematology:
Hemoglobin (12.9 g/dL) and Hematocrit (38%) are low compared to normal values respectively
(14-17g/dL and 40-54%). This is due since the patient has an ulceration which he is losing blood.
For chemistry
Protein is lab values (5.5 g/dL) are lower than normal values (6-8g/dL). Protein is low in this
patient due to malnutrition and inflammation.
Albumin (3.2 g/dL) and prealbumin (11mg/dL) are also lower than the normal levels (3.5-5g/dL
and 16-35mg/dL). These values are low due to the inflammation that the patient is currently at
C-reactive protein is another inflammation marker. C-reactive protein value (2.8mg/dL) is higher
than normal value (<1.0 mg/dL)
HDL the patient levels of HDL (38mg/dL) could be lower than normal (120-199mg/dL) since the
patient has lost significant amount of weight and has affected the fat storage include his
cholesterol.
What are Mr. Sims Estimated needs for energy, protein and fluid?
Energy= used Harris Benedict formula with activity factor of 1.2 and injury factor of 1.3;
1,568.82 kcals/day
Protein=1.2-1.5 grams of PRO/kg; 76.32-95.4
Fluid= 35ml/kg/day; 2,226ml/day
23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be
prevented?
%Usual wt =Current weight/usuall weight X100= 83.33%.
Based on his usual weight percentage, the patient is in mild degree of malnutrition. Although, the
degree of malnutrition is not severe, the patient can still be at risk for refeeding syndrome. The
patient is at risk since the patient hasn’t being able to eat in a while, is in tube feeding and his
laboratory results indicate malnutrition and vitamin deficiencies. In addition, the patient needs to
have a special diet due to his recent surgery stating with clear liquids and progressed into small
frequent meals if adequate. To prevent this syndrome, the individual needs to start with small
frequent meals and small amounts of food and drink.
24. I agree with the team’s decision to initiate parenteral nutrition since it is unknown how long
will the patient will need PN.
The PN will meet his estimated needs and more. Compared the estimated needs versus the PN,
the patient is receiving more kcals and more fluid. Also, the patient is meeting the estimated
amount of protein through the parenteral nutrition.
For treatment: 85ml/hr X24 hrs=2040ml total
Protein: 2040ml /X=1000,ml/42.5 grams 86.7 grams of protein for the day
CHO: 2040/X=1000ml/200grams 408 grams of CHO (dextrose) for the day
Fat: 2040ml/X=1000ml/30g 61.2 grams of fat for the day
Total Kcals: 2,343.6 kcals are provided by the PN
86.7 that by 4 to protein344.4 kcals
408 that by 3.4 for CHO1,387.2 kcals
61.2 that by 10grams612 kcals
26. Please see article on Blackboard in course documents.
What does this information tell you about Mr. Sims? There is a table on pg 124
The oxygen consumption and the CO2 production tells me the patient’s energy expenditure by
measuring O2 and CO2. Based upon the information provided by the table and the equation on
the article, the patient estimated needs are 2,091.3 Kcals/day.
The RQ (respiratory quotient) tells me the ratio between C02 and O2. The RQ can help
determine the net substrate utilization and can also serve as a quality control indicator. Also the
RQ value can suggest the presence of technical errors in measurement. However, the patient’s
value is within good values (0.67-1.2).
RMR (resting metabolic rate) tells me how many calories the patient is burning without doing
anything but rest.
30. Evaluate the following 24 hour urine data: 24 hr 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.
86.7 grams protein divided by 6.25 grams N2=13.8 grams N2
13.8grams-18.4 grams+3.4 grams N2 insensibl losses= - 7.36 grams so, negative nitrogen
balance
This means that the intake of nitrogen into the body is greater than the loss of nitrogen from the
body, so there is an increase in the total body pool of protein. A negative value can be associated
with several causes including serious injuries and during periods of fasting/starvation.
Excess nitrogen can be toxic to the body, however, I don’t think we should be concern with that
since the goal is to improve the patient’s health by improving his diet and having extra nitrogen
won’t hurt him. Since the patient is malnourish, the patient will utilize protein more efficiently
than those who are normally replete and hence give an overestimate of normal nitrogen
retention/balance.
There are many problems with the accuracy of nitrogen balance since every detail needs to be
precise in order to have accuracy including recording protein intake appropriately and measure
urination just to name a few.
31. Client Education Material on Blackboard in course documents.
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?
The patient will be allowed to try first clear foods such apple juice, Gatorade, and gelatin since they will
get absorbed in the stomach but will make the small intestine start working.
I will monitor for physical signs such as the patient not having discomfort such as diarrhea, vomiting,
bloating and cramping. Also I will continue monitoring bowel movement and glucose. In addition,
monitor weight to determine if patient still losing weight or gaining weight.
32. What would be the primary concerns as MR. Sims prepared 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.
First nutritional outcome and concern is to progress to full texture food and eat the amount of
kcals needed to have an adequate nutrition (approximately 2091.3 kcals based upon IC)
Second nutritional outcome is to normalize lab values such as hemoglobin and hematocrit,
In addition, the patient will need to take a multivitamin, iron, and folate supplementation.