Emily Hawley
KNH 411
Case Study #11: Crohn’s Disease
1. What is inflammatory bowel disease? What does current medical
literature indicate regarding its etiology?
a. Inflammatory bowels disease is an autoimmune, chronic inflammatory
condition of the gastrointestinal tract: IBD is actually the term designating a
syndrome consisting of two diagnoses: ulcerative colitis and Crohn’s disease.
(Nelms 377) The complete etiology of both ulcerative colitis and Crohn’s disease
is unknown at the present time, however it is understood that several factors
play a role in the conditions. These include environmental considerations such as
diet, smoking, infectious agents, physiological changes in the small intestine
from which an abnormal inflammatory response is triggered, and intestinal flora.
There is a very strong association between genetics and IBS. There is evidence
shows that with a positive family history, 5-15% of patients will have IBS.
Identical twins there is a 44% chance and fraternal a 3.8% chance (415). Several
tests can be done in order to diagnose inflammatory bowel disease. These
include abdominal ultrasound, MRI, CT scan, and antiglycan antibodies. The most
prevalent way to diagnose and describe Crohn’s disease is using the CDAI. A
score of over 150 indicates a flare-up of the disease, and a score over 300 means
the patient is experiencing a severe exacerbation of the disease. Calprotectin,
lactoferrin, and polymorphonucler nuetrophil electase levels in the stool have
been found to be indicative of exacerbations of Crohn’s disease as well. Low
albumin levels and elevated WBC are also common. In the case of ulcerative
colitis, more than 5 daily bowel movements, large amounts of hematochezia,
temperature above 37.5°C, pulse above or equal to 90/min, and hemoglobin less
than 10 g/dL are all indicative of severe activity of ulcerative colitis (416).
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?
Mr. Sims ulcerative colitis could have gotten worse and been considered
Crohn’s because of the further infected GI mucosa. UC and Crohn’s are both
characterized by exacerbations of the disease process interspersed with
period of remission. 50% of patients with UC have the disease only involving
the rectum. Damage to the intestinal mucosa only involves the first two
layers of tissues in the colon and rectum. Crohn’s disease can affect any
portion of the GI tract from the mouth to the anus, but mostly affects the
ileum and colon. Crohn’s disease can damage all layers of the GI mucosa
(417).
3. A CT scan indicated bowel obstruction and the Crohn’s Disease was
classified as severe-fulminant disease. CDAI score of 400. What does a
CDAI score of 400 indicate? What does a classification of severefulminant disease indicate?
CDAI score of 400 falls into the Moderate-Severe Disease being between 220
and 450. This means that the individuals who have failed to respond to
treatment for the stage below or patients with more major symptoms
including fevers, significant weight loss, abdominal pain or tenderness,
intermittent nausea or vomiting, or significant anemia. Severe-fulminant
disease indicates that individuals have persisting symptoms even with
introduction to steroids or biologic agents as outpatients, or they have high
fevers, persistent vomiting, evidence of intestinal obstruction, rebound
tenderness, cachexia, or evidence of abscess (419).
4. What did you find in Mr. Sims’ history and physical that is consistant
with his diagnosis of Crohn’s? Explain.
Mr. Sims is running a fever of 101.5. His abdomen is distended and there is
extreme tenderness which is causing him extreme abdominal pain and
cramping. There is minimal bowel sounds. He is experiencing more chronic
diarrhea as he stated he is experiencing it more often. Patient is constantly
losing weight. He was first diagnosed with ulcerative colitis which later
turned into Crohn’s after it become more severe.
5. Crohn’s patients often have extraintestinal symptoms of the disease.
What are some examples of these symptoms? Is there evidence of these
in his history and physical?
Extraintestinal symptoms of Crohn’s disease are symptoms that happen
outside of the GI tract. These symptoms include osteopenia and osteoporosis,
dermatitis, rheumatological conditions such as ankylosing spondylitis, ocular
symptoms, and hepatobiliary complications (418). Mr. Sims is not
experiencing any of these symptoms in his history or physical.
6. Mr. Sims has been treated previously with corticosteroids and
mesalamine. His physician had planned to start Humira prior to his
admission. Explain the mechanism for each of these medications in the
treatment of Crohn’s.
Treatments for inflammatory bowel syndrome include antibiotics,
immunosuppressive medications, immunomodulators, and biologic therapies as
well as surgical intervention. Corticosteroids like presnisone or budenoside are
often used to treat acute exacerbations, especially in severe-fulminant disease,
but patients are at risk for becoming steroid dependant. Aminoalicylate
medications like mesalamine and sulfasalazine are used in Crohn’s disease when
the ileal and colon are involved. Antibiotics and biological therapies such as antiadhesion molecules and anti-interleukin antibodies are also used. Humira is a
biologic therapy for Crohn’s disease, which works to interrupt tumor necrosis
factor alpha and thus the cytokinedirected inflammatory activity (419).
7. Which laboratory values are consistent with an exacerbation of his
Crohn’s disease? Identify and explain these values.
Mr. Sims has decreased protein, Albumin, and Prealbumin levels. Protein
values need to be increased because a lot of it is lost due to the inflammation
of the GI tract. ASCA, which is the presence of antibodies, is high which is
specific to Crohn’s. Hematocrit is low, Hemoglobin is low, transferrin is low,
ferritin Is low due to blood loss and malabsorption. Vitamin D and free
retinol(Vitamin A) is lost through steatorrhea (420).
8. Mr. Sims is currently on several vitamin and mineral supplements.
Explain why he may be at risk for vitamin and mineral deficiencies.
Mr. Sims is at risk for vitamin and mineral deficiencies because t is common
to have nutrient deficiencies with Crohn’s disease. Protein-calorie
malnutrition as well as other nutrient deficiencies can be caused by
decreased nutrient intake, malabsorption, drug-nutrient interactions,
anorexia, and protein losing enteropathy. Without taking supplements it can
lead to osteoporosis, anemia, poor wound healing, and a compromised
immune system. Increased motility decreases the success of digestion and
absorption, severe diarrhea can result in malabsorption of all nutrients. A lot
of the time patients reduce intake to decrease their symptoms which further
decreases dietary intake (420).
9. Is Mr. Sims likely a candidate for short bowel syndrome? Define short
bowel syndrome, and provide a rationale for your answer.
Short bowel syndrome results from a large resection of the small intestine.
Since Mr. Sims is a candidate for short bowel syndrome because he has a
disease associated with loss of absorption and is characterized by the
inability to maintain protein, energy, fluid, electrolyte, and micronutrient
balance when on a conventionally accepted, normal diet (424).
10. What type of adaption can the small intestine make after resection?
There are three phases for SBS post operation. The first stage involves
extensive fluid and electrolyte loss with large volumes of diarrhea. The
second phase involves the reduction of diarrhea volumes for several months.
During the third phase, there is continued adaptation of the remaining bowel.
That includes increased blood flow, secretions, and mucosal cell growth. The
inner lumen of the small intestine increases both in length and diameter with
additional increase in villous height. This phase lasts for 1 or 2 years (425).
11. For what classic symptoms of short bowel syndrome should Mr. Sims’
health care team monitor?
Short bowel syndrome is characterized by inability to maintain protein,
energy, fluid, electrolytes, or micronutrient balances on a normal diet (424).
12. Mr. Sims is being evaluated for participation in a clinical trial using
high-dose immunosuppression and autologous peripheral blood stem
cell transplantation. How might this treatment help Mr. Sims?
Most transplants are done by peripheral blood tem cell transplantations. This
will help Mr. Sims because it is a different route to go for treatment since he
does keep getting worse every time he goes into the hospital. Delayed gastric
emptying may persist for months following the transplant, which would help
Mr. Sims, gain weight (717).
13. What are the potential nutritional consequences of Crohn’s Disease?
Potential nutritional consequences of Crohn’s Disease includes: cachexia,
which is body emaciation by the fat and muscles catabolizing to fuel the
inflammatory response; Vitamin deficiency due to the malabsorption of
essential nutrients; Parenteral Nutrition due to the incapability of absorbing
essential nutrients; and malabsorption of fat due to the rapid passing
through diarrhea (crohn).
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 is about 6 meters, or 20 feet long. 200 cm is equal to 2
meters in length so the resection removed about 1/3 of the small intestine,
which would make the resection very significant.
15. What nutrients are normally digested and absorbed in the portion of
the small intestine that has been resected?
Jejunum is responsible for absorption of lipophilic nutrients (proteins, fats,
cholesterol and the fat-soluble vitamins A, D, E and K) and absorption of
water. The ileum is the primary site of reabsorption of bile acids, B12, and
anything the jejunum didn’t absorb.
16. Evaluate Mr. Sims’ % UBW and BMI.
%UBW= (100 x Actual Weight)/Usual body weight
=(100 x 140)/167
=83.8%
BMI= 63.5 kg/ 1.752
=20.8
17. Calculate Mr. Sims’ energy requirements.
Harris Benedict= 66.5+(13.75 x 63.5)+(5 x 175)-(6.78 x 35)
=1,577.3
EER= 1,577.3 x 1.6
= 2,523.7
*Increase energy requirements for healing process to 2,800
18. What would you estimate Mr. Sims’ protein requirements to be?
Protein requirements= weight in kg x 1.5 g/kg
63.5 kg x 1.5g/kg= 95.3 g/day PRO
Protein requirement increased to 1.5g/kg for adults with GI inflammation
19. Identify any significant and/or abnormal laboratory measurements
from both his hematology and his chemistry labs.
Chemistry
Protein
Deficient by 0.5 g/dL
Albumin
Deficient by 0.3 g/dL
Prealbumin
Deficient by 5.0 mg/dL
HDL
Low by 7 mg/dL
Hematology
Hemoglobin
Low 1.1 g/dL
Hematocrit
Deficient by 2%
Transferrin
Low by 35 mg/dL
Ferritin
Low by 4 mg/mL
Vitamin D
Deficient by 7.3 ng/mL
Vitamin A
Deficient by 2.8 ug/dL
20. Select two nutrition problems and complete the PES statement for each.
(NC-3.2) Involuntary weight loss related to abdominal pain and admission to
hospital for Crohn’s flare as evidenced by significant weight loss.
(NC-1.4) Altered GI function related to abdominal pain, tenderness, and
diarrhea as evidenced by history of Crohn’s disease.
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?
Seven things in developing the PN prescription is:
A. Establish dosing weight and energy requirements
B. Calculate a protein goal
C. Distribute remaining kcal between carbohydrate and lipid
D. Consider the electrolyte needs for this patient
E. Consider vitamin and mineral requirements
F. Establish fluid requirements
G. Calculate the final parenteral prescription (97).
22. The members of the nutrition support team note his serum phosphorus
and serum magnesium are at the low end of the normal range. Why
might that be of concern?
It is critical to monitor serum levels of phosphorus, magnesium, and
potassium, and to provide supplementation as needed until the patient is
receiving goal feedings. It needs to be monitored to avoid overfeeding and
avoid refeeding syndrome. Low levels may result in hemolysis, impaired
cardiac function, impaired respiratory function, and even death (93).
23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How
can it be prevented?
Refeeding syndrome is a term used to describe several common metabolic
alterations that may occur during nutritional repletion of starved patients. It
is a risk for patients who present with malnutrition, those who have a history
of long term inadequate oral intake, and those who have had minimal intake
for several days as a result of NPO status or poor appetite (92).
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 50cc/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.
PN is a good decision because he is unable to meet his nutritional needs
either by an oral diet or through use of enteral nutrition. He will better
absorb nutrients after his bowel resection (93).
PRO (g): 2,523.7/4= 630.9(30%)= 189 g
CHO (g): 2,523.7/4= 630.9(50%)=315.5 g
Lipid (g): 2,523.7/9=280.4(20%)= 56.1
Total kcal: 2,523.7 kcal
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).
A few goals based off of the PES statements are to increase his weight,
increase physical activity and normalize his GI function. After Mr. Sims is
discharged from the hospital a nutrition consult will be done to discuss ways
to increase his weight and send him home with a few menu ideas. The
dietitian will discuss the importance of a higher protein diet (150% above
normal protein requirements) and the importance of fat content as well.
Another goal is to normalize his GI tract and decrease his diarrhea Dietary
fiber intake may improve symptoms of patients with inflammatory bowel
disease.
26. Indirect calorimetry revealed the following information:
Measure
Mr. Sims’ Data
Oxygen Consumption (mL/min)
295
CO2 production (mL/min)
261
RQ
0.88
RMR
2022
What does this information tell you about Mr. Sims’?
Indirect calorimetry is used to determine the energy requirements of
critically ill or mechanically ventilated patients, and to monitor the adequacy
and appropriateness of nutritional support. Mr. Sims is burning a lot of his
calories while at rest.
27. Would you make any changes to his prescribed nutrition support? What
should be monitored to ensure adequacy of his nutrition support?
Explain.
I would increase his energy needs due to the fact that at his resting metabolic
rate he is burning a high amount of energy.
28. What should the nutrition support team monitor daily? What should be
monitored weekly? Explain your answers.
The patient can also receive many infections while on the PN. An infection
can be introduced into the bloodstream as well as the GI tract because it is
non-functioning. The risk for infection should be monitored daily (101). The
patients weight should be monitored weekly because there will be
involuntary weight loss during the tube feeding. Oral diet is the best way to
achieve nutrition goals and without it the patient can lose weight (102).
29. Mr. Sims’ serum glucose increased to 145 mg/dL. Why do you think this
level is now abnormal? What should be done about it?
This means that his blood glucose levels are high. This level is now abnormal
because the PN has too high of a carbohydrate content. The dextrose levels in
the PN order should be decreased to lower hi serum glucose to a normal
range below 125 mg/dL.
30. Evaluate the following 24 hour urine data: 24 hour urinary nitrogen for
12/20:18.4 grams. By using the daily input/output record for 12/20
that records the amount of PN received, calculate Mr. Sims’ nitrogen
balance on postoperative day 4. How would you interpret this
information? Should you be concerned? Are there problems with the
accuracy of nitrogen balance studies? Explain.
Urinary nitrogen test is used primarily as a biomarker of the validity of
dietary assessments; 24-hour urine nitrogen is the most well known
biological marker. The apparent accuracy of 24-hour urine nitrogen as a
biological marker led to the suggestion that it be used to validate estimates of
protein intake from various dietary survey methods. The use of 24-hour
urine nitrogen depends on the assumption that subjects are in nitrogen
balance and there is no accumulation due to growth or repair of lost muscle
tissue or loss due to starvation, dieting or injury. (Bingham)
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?
A liquid diet ensures that the area around the removed parts of the GI tract
begin to heal properly without disruption possible irritating food particles.
Within a few days a soft diet will begin. If the soft diet seems to work then he
can slowly start to come back to a normal diet again with the restrictions of
the diet he was already on to prevent another surgery.
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.
His primary nutrition concerns as he prepares for discharge is to be sure to
obtain enough energy and protein needs. He should eat smaller meals more
often and be sure that he chews his food well. Separate solids and liquids
during the meal as much as possible because too much liquid can cause a
column effect. Avoid stimulants like alcohol and caffeine as much as possible.
Vitamins and minerals are very important due to the fact there will be less
absorption in the GI tract so supplementation will be needed. Foods high in
these have been associated with protection against inflammation. Two
outcomes will be weight gain to his usual body weight of 166-168 lbs. as well
as reduce his inflammation down by taking supplements with probiotics and
prebiotics to be able to eat a normal diet (422.)
References
Bingham, S. (2003) Urine Nitrogen as a Biomarker for the Validation of Dietary
Protein Intake. Journal of Nutrition.