Jenna Paterno
KNH 411
Professor Matuszak
9-17-13
Inflammatory Bowel Disease: Crohn’s Disease
1. What is inflammatory bowel disease? What does current medical literature
indicate regard it etiology?
Inflammatory bowel disease is an autoimmune disease that is a
chronic inflammatory condition of the gastrointestinal tract. IBD is a very
broad term that branches into two different diagnoses, ulcerative colitis and
Crohn’s disease. These two diseases have many similar characteristics but
also some very different ones that are easily to tell the two apart. As of right
now the etiology for inflammatory bowel disease is unknown. However,
there are some environmental factors that play a role in these conditions,
such as smoking, infectious agents, intestinal flora, and many more. An
important piece of information to know about IBD is that strongly passed
through genetics, meaning that if someone’s parent had IBD they have a
stronger chance of developing the disease compared to those who don’t have
a parent with IBD.
(Nelms pg. 415-416)
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 was initially diagnosed with ulcertative colitis because he
had symptoms that are similar for both diseases. He was experiencing
abdominal pain, weight loss, bloody diarrhea, and running a fever. These
symptoms are common between both, allowing a patient to be easily miss
diagnosed. However, a way to determine exactly what a patient has is by
narrowing their symptoms down and determining where the inflammation is
exactly in gastrointestinal tract. Mr. Sims was experiencing most of his
inflammation in the small intestine, which is more common in Crohn’s.
Crohn’s Disease
Similarities
Ulcerative Colitis
- Chronis diarrhea
- Abnormal immune
- Possible constipation and
- Abdominal cramping
response results in
rectal spasm
- Anorexia
inflammatory damages in
- Arthritis
- Malnutrition
the gastrointestinal mucosa. - Dermatological changes
- Malabsorption
- Fever
- Ocular manifestation
- Gallstones
-Weight loss
- Severe bleeding
- Kidney stones
- Abdominal pain
- Toxic colitis
- UTI
- Blood/mucus in diarrhea or - Toxic megacolon
- Perianal disease
stool
- Dysplasia
-Inflammation anywhere in
-Weakness
- Colonic Strictures
GI
-Only large intestine
(Nelms pg. 416)
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 indicated? What does a classification of severe-fulminant disease
indicate?
Since Crohn’s disease can have different types of symptoms,
depending on different cases there is the CDAI, Crohn’s Disease Activity
Index, to determine the severity of the disease. A score of over 150-220
patients are able to tolerate pain and not experience dehydration. A score of
220-440 means individuals are no longer responding to treatment and are
experiencing major symptoms of fevers, significant weight loss, abdominal
pain and many more. A score of 400 is considered a moderate-severe stage of
the disease. As mentioned before this indicates that the patient has failed to
respond to the medications or treatment for the disease. They are now
experiencing symptoms of a fever, weight loss, abdominal tenderness and
pain, nausea or vomiting, and significant anemia. A classification of severefulminant disease indicates a CDAI of greater than 450. This is followed by a
continuation of pain despite the introduction of steroids and biologic agents,
a high fever, vomiting, evidence of intestinal obstruction, tenderness,
cachexia, or an abscess.
(Nelms 419)
4. What did you find in Mr. Sim’s history and physical that is consistent with his
diagnosis of Crohn’s? Explain.
Some symptoms that Mr. Sims is experiencing are direct signs that he
is suffering from Crohn’s disease. He has been experiencing more diarrhea
and sever abdominal pain. When he was first diagnosed he lost about 25
pounds, but has regained it since he was able to control the disease with
medications. However, the abdominal pain is so sever that he said it makes it
hard for him to eat. Since he has been experiencing more pain he has re-lost
the weight, weighing in at 140 pounds. He is currently running a fever of
about 101.5 F. Abdominal pains and running a fever are an important key
factors for determining an inflammatory bowel disease. The inability to eat
food due to the severity of the pain in the abdomen could be a sign of
anorexia, which is key factor for narrowing it down to Crohn’s disease.
Chronic diarrhea is also important to help determine that Mr. Sim’s is
suffering from Crohn’s. Distention and extreme tenderness were two signs
and symptoms that were logged in Mr. Sims history that were consistent with
the diagnosis of Crohn’s
(Nelms 416)
5. Crohn’s patients often have extraintestinal symptoms of the disease. What
are some examples of these? Is there evidence of these in his history and
physical?
Extraintestinal symptoms of Crohn’s disease are symptoms that occur
outside of the GI tract. Some examples are osteopina, osteoporosis,
dermatitis, rheumatologic conditions such as: ankylosing spondylitis
(arthritis), ocular symptoms, and hepatobiliary complications. After looking
at Mr. Sims lab reports I did not come across any of these complications on
his history report or physical exam.
(Nelms 418)
6. Mr. Sims has been treated previously with corticosteroids and mesalamine.
His physician had planned to start Humira prior to this admission. Explain
the mechanism for each of these medications in the treatment of Crohn’s.
Corticosteroids: This is a medication that is a type of steroid. This steroid is
similar to the hormones that your adrenal gland produces to fight stress that
is associated with illness and injuries. This medication would be helpful for a
patient with Crohn’s because since they are sometimes in sever pain caused
by the abdomen, this steroid can add onto the hormone the adrenal gland
produces to fight the stress produced from the illness they suffering from.
("Medlineplus," 2010)
Mesalamine: Is an anti-inflammatory drug for the gastrointestinal tract, it is
in the class of medications called anti-inflammatory agent. It helps by
stopping the body from secreting a certain substance that causes pain and
inflammation. This would help a patient with Crohn’s because the medicine
can reduce the inflammation of the GI tract and reduce the amount of pain
they are having.
("Medlineplus," 2010)
Humira: This medication is used to reduce signs and symptoms and keep
and illness in remission in adults with Crohn’s disease. It works by binding
TNF (tumor necrosis factor) and helps prevent the inflammation of the
intestines. Someone with Crohn’s would use this medication to help prevent
the flair up of the disease and reduce the signs and symptoms that come
along with Crohn’s.
("Humira adalimumab ," )
7. Which laboratory values are consistent with an exacerbation of his Crohn’s
disease? Identify and explain these values.
When Crohn’s disease worsens there are certain lab values that can
help indicate how bad the disease may be. In patients who have sever cases
of this disease have low levels of protein and different vitamins due to the
lack of intake of food and the intensity of the food being washed out of the
system so quickly. On Mr. Sims labs it indicates his protein level, albumin
level, and prealbumin levels are low. His total protein level is 5.5 g/dL and
the normal range is 6-8 g/dL. His albumin level is 3.2 g/dL and the normal
range is 3.5-5 g/dL. Also his prealbumin is 11 g/dL and the normal range is
16-35 mg/dL. Some other protein levels that are off are his Transferrin and
ferritin. The normal range for transferring for a male is 215-365 mg/dL and
Mr. Sims is 180 mg/dL. The normal range fro ferritin is 20-300 mg/dL and
his is 16mg/dL. His vitamin D and A levels are both below the average range.
Mr. Sims vitamin D is 22.7 ng/mL and the average is 30-100ng/mL. His
vitamin a is 17.2ug/dL and the average range is 20-80ug/dL. These protein
and vitamin levels are important lab values to show that Mr. Sims is
experience a sever case of Crohn’s and it is affecting his absorption of
nutrients. His ERS value is his due to inflammation in the body. Alkaine levels
are high to show osteoporosis. HGL-low malnutrition.
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 should be on vitamin and mineral supplements because he is
at risk of deficiencies due to his disease (due to severe diarrhea and other
complications with the disease). Since he has been having chronic diarrhea
and sever abdominal pain, there are few ways the nutrients aren’t being
absorbed. If Mr. Sims consumed food it would go right threw him not giving
his food to absorb and correctly digest in the proper parts of the small
intestine. He has been having such sever abdominal pain that he doesn’t want
to eat any food. At this point Mr. Sims wouldn’t even have the chance to
consume the food with nutrients because he hasn’t been wanting to eat
anything.
(Nelms 420)
9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel
syndrome and provide a rationale for your answer.
Mr. Sims is a likely candidate for short bowel syndrome because of his
surgery of removing 200 cm of his jejunum. Removing any part of the small
intestines will cause a patient to be more likely of developing short bowel
syndrome. Each section of the small intestine absorbs and digests certain
nutrients. Removing certain sections causes a patient to lack the ability able
to absorb those nutrients. Short bowel syndrome is the decreased digestion
and absorption that results from a large resection (removal) of the small
intestine.
(Nelms 424)
("Short bowel syndrome ," )
10. What type of adaptation can the small intestine make after resection?
After the removal of a large section of the small intestine, the
remaining part has to adapt to the changes that were made. The inner lining
grows, increasing the surface area that absorbs nutrients. This adaptation
takes about two years to fully occur.
("Short bowel syndrome ," )
11. For what classic symptoms of short bowel syndrome should Mr. Sims health
care team monitor?
The main symptom for short bowel syndrome is diarrhea. This is
important to monitor because this could lead to other complications such as
dehydration, malnutrition, and weight loss. Some other symptoms are cramping,
bloating, heart burn, and fatigue. Depending on what section of the small
intestine was removed, there are certain nutrient deficiencies that Mr. Sims
health care team should monitor. If the duodenum is removed iron levels should
be looked at. If the jejunum is removed, which is the middle section,
carbohydrates, proteins, fat, and vitamins should be checked. If the last section
of the small intestines is removed, the ileum, bile acids and B12 should be
observed.
("Short bowel syndrome ," )
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?
Using high doses of immunosuppression are used in patients to
prevent the body from rejecting an organ transplant, treating graft-versushost disease in bone marrow transplant, treatment of an autoimmune
disease such as rheumatoid arthritis or Crohn’s disease. The
immunosuppressant suppresses the immune system so the body doesn’t
fight off the procedure that was done, in this case the removal of part of the
small intestine. AutoPBSCT is a procedure where stem cells are taken from a
patient before they under go an intensive surgery. Post surgery the patient
will receive the stem cells to help them recover successfully. This could help
Mr. Sims in recovering from his surgery of removing 200 cm of his small
intestine.
("American cancer society:," 2012)
II. Understanding the Nutrition Therapy
13. What are the potential nutritional consequences of Crohn’s disease?
Being diagnosed with Crohn’s disease you encounter a few nutritional
consequences that make it difficult to lead a healthy lifestyle. When you are
dealing with Crohn’s you are also dealing with malnutrition, inadequate
energy intake, inadequate food and beverage intake, inadequate vitamin and
mineral intake, and food medication interaction.
(Nelms 420)
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 average length of an adult small intestine is 400 cm. This
resection is very important because when any part of the small intestine is
removed it affects the digestion and absorption of certain nutrients
depending on which section is taken out. In this case part of the jejunum is
removed, which digests and absorbs carbohydrates, proteins, fats, and
vitamins. Part of the ileum was also removed so nutrients that are digested in
that section should be monitored.
("Short bowel syndrome ," )
15. What nutrients are normally digested and absorbed in the portion of the
small intestine that has been resected?
Since Mr. Sims only had 200 cm of his jejunum removed he wont be
able to absorb certain nutrients. Some nutrients that wont be digest and
absorbed are carbohydrates, proteins, fat, and vitamins. The ileum digest and
absorbs bile acids and B12.
("Short bowel syndrome ," )
III. Nutrition Assessment
16. Evaluate Mr. Sims % UBW and BMI.
UBW: 100Xactual body weight/ usual body weight
(140 lbs X .4536 kg)= 63.5 64 kg (165 lbs X .4536 kg)= 75 kg
(64 kg/75 kg) X 100= 85 %
This percentage shows that Mr. Sims is at moderate risk of malnutrition
BMI: wt. (kg)/ ht (meters2)
Weight: (140 lbs X .4536 kg)= 63.5 64 kg
Height: 5’9” 69”X 2.54 cm= 175 cm1.75 meters
64 kg/ (1.752)= 21 kg/m2 Normal BMI
To calculate Mr. Sims BMI I converted his weight in pounds to kg and
his height from feet to inches and converted that to centimeters. I then took
the weight in kg and divided it by meters2. The BMI came out to 21 kg/m2
which is a normal BMI. Mr. Sims has a normal/ healthy range BMI.
However, since he had a dramatic weight loss this could mean his weight
could keep decreasing falling into low BMI.
17. Calculate Mr. Sims energy requirements.
Mifflin-St. Jeor
10X wt(kg)+6.25 X ht (cm)- 5 X age (yrs) +5
10 X (64 kg)+ 6.25 X (175 cm)- 5 X(35)+ 5= 1554 kcals/day
1554kcals X 1.2= 1865 kcals/day
To determine Mr. Sims energy requirements I used the Mifflin-St. Jeor
method. I determined that his REE is 1554 kcals/day. However, I then
multiplied that number by 1.2 because his physical activity level is 1.2,
meaning he his bed bound. However, once he leaves the hospital his energy
needs may need to be adjusted depending on his physical activity level at
work and the amount of energy he needs to lead a healthy recovery.
18. What would you estimate Mr. Sims’ protein requirements to be?
.8-1.0g/kg post surgery per kilogram of body weight
64 kg X .8 g/kg= 51.2 g before surgery
64 kg X 1.0g/kg= 64 g post surgery
64 kg X 1.5 g/kg= 96g post
I would estimate Mr. Sims protein needs before surgery to be 51 grams/day.
Since Mr. Sims need extra amounts of protein after his surgery I multiplied his body
weight in kg by 1.0 g/kg and 1.5 g/kg coming to a range of 64g-96 grams.
19. Identify any significant and/or abnormal laboratory measurements from
both his hematology and his chemistry labs.
Mr. Sims hemoglobin and hematocrit levels are abnormal shown on
his hematology records. A normal range for hemoglobin are 14-17 g/dL and
Mr. Sims are 12.9. His hematrocrit levels are 38 % and a normal range is 4054 %. Some other important lab values that are significant are his protein
levels, albumin, prealbumin, transferrin, ferritin, and vitamin levels. His total
protein level is 5.5 g/dL and the normal range is 6-8 g/dL. His albumin level
is 3.2 g/dL and the normal range is 3.5-5 g/dL. Also his prealbumin is 11
g/dL and the normal range is 16-35 mg/dL. Some other protein levels that
are off are his Transferrin and ferritin. The normal range for transferring for
a male is 215-365 mg/dL and Mr. Sims is 180 mg/dL. The normal range fro
ferritin is 20-300 mg/dL and his is 16mg/dL. His vitamin D and A levels are
both below the average range. Mr. Sims vitamin D is 22.7 ng/mL and the
average is 30-100ng/mL. His vitamin a is 17.2ug/dL and the average range is
20-80ug/dL
IV. Nutrition Diagnosis
20. Select two nutrition problems and complete the PES statement for each.
1. Protein deficiency (NI-5.7.1) related to malabsorption of nutrients as
evidence by lab data.
2. Inadequate energy intake (NI-4.1) related to poor nutrition as evidence
by lab records/ unintentional weight loss and patients complaint about
not eating because he is in too much pain.
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 nutrition team should evaluate the levels of magnesium,
phosphorus, potassium and thiamin to determine what levels of PN are
needed and what nutrients he may need more of. The nutrition team should
also analyze Mr. Sims lab data to see what he is deficient in or may becoming
deficient in due to his disease.
(Nelms 92, 93)
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 important to monitor the levels of serum phosphorus and serum
magnesium because they are important factors in refeeding syndrome. A
severe drop in serum phosphorus levels can impair cardiac function and
respiratory function. The nutrition support team should monitor the serum
magnesium level and serum phosphorus levels and provide supplements
until the patient is receiving the proper feedings.
(Nelms 92,93)
23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can
it be prevented?
Refeeding syndrome is several common metabolic alterations that
may occur during nutritional repletion of starved patients. Mr. Sims could be
at risk for this syndrome because after his surgery it was noted by the
surgeon that he can consume food by mouth for at least 7-10 days. Once Mr.
Sims starts to consume food orally he could be at risk. A way to prevent
refeeding syndrome is to provide the patient with supplements of
phosphorus, magnesium, and potassium until the patient meets feeding
goals. Also starting parenteral feeding and after progression slowly adding
food back into the diet can help prevent refeeding syndrome.
(Nlems G-22,92-93)
24. 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.
Pro: 76.00 kg X 1.5 g= 114 grams of protein per day
(114 g/ 2022ml) X 100 = 5.2 %
CHO: (114 X 4kcal/g) + (55g X 11 kcals/g)= 1061kcals
2022kcals-1061 kcals= 955 kcals
955 kcals / 3.4 kcals/g= 281 g of dextrose
281/ 2022kcals= 1.4% CHO
Lipid: 76.00 kg X 1.2 g = 91.2 grams of lipids per day
1 mL/kcal= 2000  I used the 2022 kcal diet
2022 kcals X .3= 607 kcals / 11 kcals per gram= 55 g
55 g/2022 kcals= 2.72 % lipid or 27 g/L
Total kcal: 10 X (76.00kg)+ 6.25 X (175 cm)- 5 X(35)+ 5= 1684.75 kcals/day
1685kcals/day X 1.2 = 2022kcals/day
UBW (167 pounds or 75.9 kg) is used to estimate the kcal for the
patient. The usual body weight is used to determine the g of protein,
carbohydrate, and lipids.
I agree with the team’s decision to initiate parenteral nutrition
because it will help Mr. Sims increase his nutrient levels. He is not receiving
enough protein or carbohydrate to help his body recover through TPN.
Increasing the amount of protein (almost double the amount) and increasing
levels of carbohydrates will be an adequate amount to help Mr. Sims recover
and lead a healthy life.
Nelms (99-100)
25. For each PES statements you have written, establish an ideal goal (based on
the signs and symptoms) and an appropriate intervention (based on the
etiology).
1. Goal: Increase levels of protein to a healthy range.
Intervention: Increase consumption of protein during breakfast,
lunch, and dinner to at least 20 grams for each meal by consuming
foods higher in protein such as eggs, chicken or turkey, fish, beans,
and many more.
2. Goal: Increase energy intake to a healthy amount for his weight
and height.
Intervention: Increase consumption of foods that are easy for him
to digest and cause no to very minimal pain. Increase calories to
about 2,022 kcals/day in high levels of protein, carbohydrate, and
lipids to help gain back healthy weight.
VI. Nutrition Monitoring and Evaluation
26. Indirect calorimetry revealed the following information:
Measure
Mr. Sims’ Data
Normal
Oxygen Consumption (mL/min)
295
250
CO2 production (mL/min)
261
200
RQ
0.88
.7-1.0
RMR
2022
2022
What does this information tell you about Mr. Sims?
Mr. Sims oxygen consumption is higher then normal. This could be
caused by increased metabolic rate that could be caused from his Crohn’s
disease. His CO2 production is elevated, which also could result from Mr. Sims
disease. His RQ (respiratory quotient) is in between the normal ange of .71.0. Mr. Sims RMR, which is calories released per kg of body weight at rest) is
2022 calories. This matches the calculations used in question 24 to
determine his energy needs.
(McClave)
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 protein by about double the amount he is
currently receiving and increase his carbohydrate to an adequate amount to
allow his body to make a healthy recovery back. His daily levels of protein,
carbohydrates, lab values, new signs and symptoms (if any), weight change,
and levels of fluids should be monitored to receive adequate nutrition
support.
28. What should the nutrition support team monitor daily? What should be
monitored weekly? Explain your answer?
Mr. Sims vital signs, temperature, fluid levels (to prevent dehydration and
examine electrolytes), blood test to check levels of protein, and TPN should be
monitored daily to make sure that there are no sudden or different changes in
his day-to-day recovery. Magnesium levels, phosphate levels, full blood count
test. These should be taken to make sure that his Crohn’s disease is not
worsening and he is moving in the right direction after his surgery.
29. Mr. Sims’ serum glucose increased to 134 mg/dL. Why do you think this level
is now abnormal? What should be done about it?
Mr. Sims’ serum glucose level increased because before he had his
surgery he wasn’t consuming adequate amount of food for his body to absorb
and use for energy. Once his surgery was over he was put on PN his energy
started to come from the nutrients he was getting. His energy source then
changed from ketones to glucose, causing his levels to be elevated. Mr. Sims also
seems to be receiving large amounts of dextrose, which could also elevate his
levels of glucose. To lower the serum glucose the level of dextrose should be
lowered.
(Nelms 93)
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.
Nitrogen Balance: (dietary protein intake/ 6.25)- Urine urea nitrogen -4
(114/6.25)- 18.4 -4= -4.16 g
The nitrogen balance of -4.16 g indicates that there is a great nitrogen
excretion then nitrogen intake. Increasing his protein levels will help
increase his nitrogen levels causing the nitrogen balance closer to zero or
even positive. This would be good to see in Mr. Sims case because this would
show he would be getting adequate amounts of protein for his needs.
There are problems with accuracy of nitrogen balance studies because
the levels of nitrogen that are collected could be lost in some other aspects
other then urine. Other ways nitrogen can be lost are threw wounds, burns,
diarrhea, and vomiting. When measuring nitrogen balance it is hard to
determine the nitrogen loss from those other factors. This causes a natural
error in the studies for nitrogen balance.
(Nelms 54)
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?
If the nutrition support team feels that Mr. Sims is ready to try foods
they should start him off with a clear liquid diet. He would be given foods
such as broths, jell-o’s, and juices. The should slowly introduce these into his
diet. Once they see positive results after introducing clear liquids, the
nutrition support team should start to introduce foods that are soft and easy
to chew and digest. Avoid lactose products and spicy foods would be
important during this next step to avoid indigestion, bloating, and cramping.
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.
The primary nutrition concerns the nutrition team would have as Mr.
Sims prepares for rehabilitation after his discharge would be the nutrients
and vitamins that are absorbed by the jejunum, the section that was removed
in the small intestine. Since the jejunum digest and absorbs carbohydrates,
proteins, fat, and vitamins the nutrition team should be primarily concerned
about these areas. He should be taking supplements for the vitamins that his
records show he is low in and some sort of protein supplement to increase
his protein levels. Fat and carbohydrate?
American cancer society: Stem cell transplant . (2012, Oct 24). Retrieved from
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