CaseStudy12:InflammatoryBowelDiseaseCrohnsDisease

UnderstandingtheDiseaseandPathophysiology:
1. Inflammatoryboweldiseaseisanautoimmunediseasethatinvolvesinflammationofallorparts
ofthedigestivetract.IBSincludesconditionssuchasCrohnsdisease,ulcerativecolitisand
indeterminatecolitis.Althoughthesediseasesaresimilar,symptoms,gastrointestinal
involvement,biopsy,andantibodytestingdistinguishbetweenthethreetypesofIBS.Current
etiologyforIBScanbeexplainedbygenetics(chromosomes16,12,6,and14aremainlylinked
toIBS),environmentalfactors(antibiotics,NSAIDs,infectiousagents,stress,diet,smoking
doublestheriskofCrohns)andresearchersarefindingthatoralcontraceptiveuseandthe
individualsgastrointestinalmicrobiomecouldalsobepossibleetiologiesforIBS.
2. Unlikeulcerativecolitis,CrohnsdiseaseisntlimitedtotheGItract.Itcouldpotentiallyaffect
theeyes,joints,andliver.Ulcerativecolitisonlyaffectsthecolonwithsymptomsincluding
crampyabdominalpain,loosestools,bloodystools,urgentbowelmovements,fatigueandlossof
appetite.Crohnsdiseasesymptomsincludepersistentdiarrhea,crampyabdominalpain,fever,
occasionalrectalbleeding,andfatigue.Bothofthesediseasesaremarkedbyabnormalimmune
responseandcanresultinweightlossandlossofappetite.Althoughthereissomeoverlapping
symptoms,treatmentforthesetwoclassesofIBSwilldifferbasedoffthediagnosisandthe
individual.
3. Mr.PagehasverycommonsymptomsofCrohnsdiseasesuchaspersistentdiarrhea,severe
abdominalpain,fever,andacutediseasewithinthelast57cmofthejejunumandthefirst5cm
oftheileum.
4. Crohnspatientscanshowsymptomsrelatingtoarthritis,dermatological,hepatic,andeye
inflammation.Thecauseoftheseextraintestinalsymptomsarestillnotunderstoodfullybutare
likelyduetoaimmuneresponsecausingarthritisandissueswiththeskinandeyesaswellasthe
liver.
5. Corticosteroidsareantiinflammatoryandaimmunosuppressantthataremeanttosuppressthe
inflammatorygenesthatareactivatedduringaflareup.Thesetypesofdrugsinterferewiththe
inflammationprocessbybindingtoglucocorticoidreceptors,whichstimulatesanincreaserateof
antiinflammatoryproteinstobereleasedinthenucleusofcells.Mesalamineisalsoananti
inflammatorydrugthatworksbyhavinganeffectonthecolonicepithelialcellsandtherectal
mucosae.Theproposedmechanismisthatitreducestheproductionofprostaglandinsand
leuokotrienes(biologicallyactivemoleculesformedbyleukocytes).HumiraisaTNFblocker
(tumornecrosisfactor)usedforantiarthriticpurposes.PeoplewithCrohnstendtoproducetoo
muchTNFalphaandHumiraactsbybindingtotheexcessTNFtoreduceinflammationrelated
toarthritis.Therearenoknownfoodnutrientinteractionsforanyofthesedrugs.
6. LaboratoryvaluesconsistentwithanexacerbationofCrohnsdisease:
a. Hemoglobin(L)
Canindicateseverebloodlossfromstoolsduetobleedingineffectedareas
b. Hematocrit(L)
Couldindicateanemiafrombloodloss

c. Ferritin(L)
Impliesthatironlevelsarelow(oneofthebestwaystopredictirondeficiency
withIBSb/citinvolveslongtermironstores)
d. VitaminB12(WNL)
PeoplewithCrohnsusuallyhavelowB12sinceitisabsorbedintheterminal
ileum.Mr.PagesvalueisWNL.
e. Folate(WNL)
Somedrugssuchasmethotrexateandsulfasalazinecanlowerfolatelevels.
Shouldbemonitoredtoseeifsupplementationisneeded.
f. VitaminD(L)
UsuallylowinIBSpatientsbecauseitismoredifficulttogetfromfoodand
theyalreadyhaveamoredifficulttimeabsorbingnutrients
g. Creactiveprotein(H)
Highlevelsindicateinflammation
h. Albumin(L)
Indicationofchronicinflammation
i. Prealbumin(L)
Indicationofchronicinflammation
j. WBC(H)
Indicationthattheimmunesystemisnotbeingsuppressedandaresultof
inflammation
k. Osmolality(H)
CanbearesultfromdiarrheaandisusuallyhighinpatientswithIBS
7. Shortbowelsyndromeresultsinmalabsorptionduetolackoffunctionorlossof7075%ofthe
smallintestine.ThisiscommoninpeoplewhohaveCrohnsdiseasethathavehadabowel
resection.Mr.PagehasnothadabowelresectionbutdoeshaveCrohnsdiseasethathasaffect
thelast57cmofthejejunumandthefirst5cmoftheileum.Thesepartsthathavebeenaffected
havehadanimpactonabsorptionofmacroandmicronutrientsasevidencebysignificantweight
lossandlowlabvalues.Sincehisconditionhasgottenworsehewillundergoabowelresection
andisatriskforSBS.
8. Aftersurgicalresectionthesmallintestinecanmakecertainadaptationstoavoidmalnutrition.
Mostintestinaladaptationsoccurwithintheileum,whichcanpickuptheslackofthejejunumif
thatiswheretheresectionoccurred.Patientsthatundergoabowelresectionhavetoslowly
reintroducefoodandareusuallyputonparenteralnutritionandtransitionslowlyintoenteral
nutritionandthenintoanoraldiet.Duringtheadaptationprocess,severefluidandelectrolyte
losswillbeexperiencedduetodiarrheaandwillbegintoslowastheileumadapts.Thisprocess
cantakeupto12yearsbecausetheinnerlumenofthesmallintestineisincreasinginlengthand
diameterandtheintestinalvilliwithintheileumarelengtheningtoimproveabsorption.
UnderstandingtheNutritionTherapy:
9. Thesmallintestineisabout1516feetinlength(MNTPowerPoint)and1cmindiameter.The
smallintestineincludesthreesectionsknowastheduodenum,jejunum,andtheileum.Mr.Page
had200cmofhisjejunumandproximalileumremovedor6.5feetremovedfromhissmall
intestine.ThismeansthatMr.Pagehadabout40%ofhisbowelremoved.Thisresection
preservedthefirst100cmofhissmallintestine,whichiswheremostabsorptionoffoodand

nutrientstakeplace.Mostoftheresectiontookplacewithinthejejunum,whichmeansthatthe
ileumwillbeabletoadapttothechangesmade.Sincehisileocecalvalvewaspreservedhewill
stillbeabletoabsorbvitaminB12andbileacid.
10. Thejejunumandproximalileumareresponsibleforabsorbinglipids,monosaccharides,amino
acids,smallpeptides,thiamine,riboflavin,niacin,pantothenate,biotin,folate,vitaminB6,
vitaminC,VitaminA,D,E,andK,calcium,phosphorus,magnesium,iron,zinc,chromium,
manganese,andmolybdenum.Thesenutrientsarenotcompletelyabsorbedinthis200cmofthe
smallintestine.Mostcontinuetobeabsorbeduntiltheendofthesmallintestinewheretheyhave
enteredintotheenterocytesandcontinuetobeabsorbedintolymphaticorhepaticcirculation.
11. Thenutritionalrecommendationstoavoidinflammatoryflareupsareincreaseantioxidantintake,
possiblesupplementationofomega3fattyacidsandglutamine,consideringapro/prebiotic
mixture,andmaintainingalowfiberdiet.WithothersymptomsofCrohnsdiseasesuchas
diarrhea,gasandabdominalpain,Mr.Pageshouldavoidfoodsonthefoodstoavoidlistsuch
asyogurt,milk,beans,andsoda.Smallermealsmightalsobeadvisableinordertotakeinmore
caloriesoverthecourseofthedayinsteadof3largermeals.
NutritionAssessment:
12. Evaluationof%UBWandBMI
a. 140lbs./168lbs.=83.3%ofUBWor16.6%ofUBW(ModerateDeficit)
b. 20.7kg/m2(Normal)
13. EnergyandproteinrequirementsusingIBW:
a. Energy:
30kcal/kgx63.6kg=1900kcal
35kcal/kgx63.6kg=2220kcal
b. Protein:
1.5g/kgx63.6kg=95g
1.7g/kgx63.6=108g
14. Abnormallaboratoryvalues
a. Glucose(H)
PNmayhaveanexcessamountofdextroseinsolutioncausingglucoselevels
tospike
b. Osmolality(H)
Canbearesultofpostoperativesoluteimbalanceorthehighglucoselevelsin
theblood
c. Albumin(L)
Indicationofchronicinflammation
d. Prealbumin(L)
Indicationofinflammation
e. ALT(H)
f. AST(H)
Elevatedliverenzymesduetotaxationontheliverfromsurgeryandpost
operativerecovery
g. Creactiveprotein(H)

 Indicationofelevation
h. HDLC(L)
i.
j.
k.
l.

m.
n.
o.
p.
q.
r.

s.
t.

WBC(H)
Duetopostsurgeryrepairs,alsopreventinginfection
Hemoglobin(L)
Canindicateseverebloodlossfromstoolsduetobleedingineffectedareas
Hematocrit(L)
Couldindicateanemiafrombloodloss
MeanCellVolume(L)
CanindicatethatRBCsaremicrocytic(smallerthannormal)duetoiron
deficiency
MeancellHgb(L)
Indicationofanemia
MeancellHgbcontent(L)
Indicationofanemia
RBCdistribution(H)
Indicationofanemia
Ferritin(L)
Bestdeterminantoflongtermanemia
Iron(L)
Indicationofanemia
VitaminD(L)
Couldbeduetolowlevelsindietandstayinginsidetoomuch,alsohasbeen
linkedforareasonofdevelopingCrohnsbecauseofVitaminDhaslowering
inflammatorypropertiesbyblockingTNF.
Freeretinol(L)
CouldindicateaVitaminAdeficiency
Ascorbicacid(L)
CouldindicateaVitaminCdeficiency

NutritionDiagnosis:
15. PESstatements:
a. UnintendedweightlossR/TdecreasedabilitytoconsumesufficientenergyAEB:weight
lossof>16%withinthelast6monthsandpatientreportofanorexiaduetoabdominal
painanddiarrhea.
b. AlteredGIfunctionR/TdecreasedfunctionallengthofintestinaltractAEB:bowel
resectionof200cmofjejunumandproximalileum,40%ofsmallintestine.
16. Therecommendationwouldbeparenteralnutritionwithperipheralaccesseitherthroughthe
axillary,cephalic,brachial,orbasilicavein.
17. Lowserumphosphorusandserummagnesiumareindicationsofsevereundernutritionincluding
starvation;thiscouldbeduetomalabsoprtionfromsurgicalstressonhisbodyafterthebowel
resection.PatientsputonTPNneedtohavetheirelectrolytelevelsmonitoredincluding

phosphateandmagnesiumtoavoidrefeedingsyndrome.Mr.Pageisatriskforthiscondition
becausehewasputonPN.
18. Refeedingsyndromeresultsfromapatientbeingmalnourishedbeforeanaggressiveamountof
nutrientswasadministered.Thiscanhappenwhenpatients,likeMr.PageareprescribedPNand
aninfluxofnutrients;particularlycarbohydratesareintroducedtotheplasmaofanabolicpatients
(Krause,2012).Mr.PagewillbetransitioningfromPNtooralfeeding,whichiswhenheisat
riskforrefeedingsyndrome.RecommendationstoavoidrefeedingsyndromearetodecreasePN
tomaintainastablenutrientintake.InorderforapatienttobetakenoffPN,75%ofnutrientneed
shouldbemet.Patientsareusuallytransitionedfromaclearliquiddiettolowfiberandfatand
lactosefreediet.ThedietmustbeeasydigestibleinorderfortheGItracttoregainfunction.
19. IagreewiththedecisiontoinitiateparenteralnutritioninorderforMr.Pagesbodytoreadjustto
thesurgicaltraumathatheunderwent.Theinitialratewillbeunderhisestimatedkcalandprotein
needsinordertoavoidrefeedingsyndrome.Astheyincreasetherateto85cc/hrhewill
sufficientlymeethiskcalneedsbutwillbeunderinhisproteinaccordingtomy
recommendations.MysuggestionisthattheyincreasetheamountofaminoacidsinthePN
solutioninordertomeethisproteinrequirementsanddecreasehiscarbohydrateintake.Aswe
canseefromhislabvalues,hisglucoseisveryhighanditisdueto59%ofthePNsolution
containingkcalsfromdextrose.
a. 50cc/hr=1200mL/d(1.2L/d)
Dextrose:240g,816kcals
AA:51g,204kcal
IL:36g,360kcal
Totalkcal:1380kcal
b. 85cc/hr=2040mL/d(2.04L/d)
Dextrose:408g,1387.3kcal
AA:86.7g,346.8kcal
IL:61.2g,612kcal
Totalkcal:2346kcal
20. PESstatementgoalsandinterventions
a. UnintendedweightlossR/TdecreasedabilitytoconsumesufficientenergyAEB:weight
lossof>16%withinthelast6monthsandpatientreportofanorexiaduetoabdominal
painanddiarrhea.
Goal:Gaining1lbs./weekfromPNandoralfeedingregimen
Intervention:Mealandsnackeating5smallmeals/snackscomposedoffood
fromtherecommendedfoodlist
b. AlteredGIfunctionR/TdecreasedfunctionallengthofintestinaltractAEB:bowel
resectionof200cmofjejunumandproximalileum,40%ofsmallintestine.
Goal:Meeting>80%ofhisproteinneedspostoperatively
Intervention:Nutritioneducationpossiblesupplementationduetosignsof
malnutritionandtolerablefoodsforCrohnsandbowelresectionptsinorderto
meetneeds.
NutritionMonitoringandEvaluation:

21. AfterassessingMr.PageskcalandproteinneedsIwouldadjusttheamountofaminoacidinthe
PNsolution.Hisgoalrateof85cc/hrisunderhisproteinneedsby7.8%and59%ofhiskcalsare
comingfromcarbohydrates.HehaselevatedglucoselevelssoinordertomeethisenergyneedI
wouldlowerhiscarbohydrateintakebutincreasetheamountofkcalsfromprotein.Sincehis
serumphosphorusandmagnesiumwerelow,Iwouldrecommendmonitoringhiselectrolyte
levelsinordertoensureheisbeingproperlynourishedandhydratedfromPN.AsMr.Page
transitionsfromparenteralnutritiontoenteralfeeding,itisrecommendedthataverylowrateof
ENisadministeredatfirst(3040mL/hr)toensurethattheGItractwillbeabletotoleratethe
nutrients.AsthepatienttoleratestheEN,theratecanbeincreasedby2530mL/hrfor824
hours.OnceMr.Pageistolerating75%ofhisnutritionalneedsfromtheenteralnutrition,
parenteralnutritioncanbediscontinued.
22. Atthebeginningofthenutritionalsupport,weight,serumelectrolytes,serumglucose,clinical
status,cathetersite,temperature,andI&Oshouldbemonitoreddaily.Serumtriglycerides,
hemoglobin,hematocritandplateletcountshouldbemonitoredweekly.Otherthingsthatshould
bemonitoredbiweeklytoeverythreeweeksshouldbeBUN,serumtotalcalcium/ionizedCa,
inorganicphosphateandmagnesiumandliverfunctionenzymes.Monitoringthesenutrientsand
inpatienttreatmentsistoensurethatMr.Pageisbeingadequatelynourishedandisbeginningto
adapttothechangesinhisbody.Preventinginfectionisalsocrucialsincehisbodyisrecovering
fromamajorsurgicalprocedure.Asheprogressesinthehospitaltoanoutpatientsetting,mostof
thesethingswillbemonitoredweeklyorbiweekly.
23. Hyperglycemiaisoneofthemostcommonmetaboliccomplicationsfromparenteralnutrition.
Mr.Pageismostlikelyexperiencinghighbloodglucoselevelsfromexcesscarbadministration.
FromhisgoalPNgoalrateof85cc/hrthecarbohydratesmakeup59%ofthetotalkcalsfromthe
PNsolution.Althoughtherangeforcarbohydratesis5065%oftotalsolution;408gofcarbsin
the85cc/hrrateistoohighforMr.Pagesmetabolism.Irecommendloweringtheamountof
kcalsfromcarbohydratesandincreasingtheamountkcalsfromaminoacidsinorderforhimto
meethisproteinneedsandtocontinuetomeethistotalkcalneeds.
24. AsMr.Pagetransitionsintoaoraldietheshouldintroducefoodsthatarelowinfiber,fatand
lactosefree.Ifthedietitianrecommendsaoralsupplementbeverageitshouldcontainmore
complexcarbohydrates,whichavoidsimplecarbohydratessuchassweeteners.Heshouldtryan
easilydigestiblemealsuchsouporsomechoppedchickenwithgreenbeans.Introducingdifferent
typesoffoodslowlyandseeingwhatistolerated(doesnotcausen/v,doesnotresultindiarrhea)
willbecrucialtoavoidmalnutrition.Mr.PageshouldbeweanedfromPNwhen75%ofneeds
arebeingmetorally.
25. Themainnutritionalconcernwouldbeavoidingmalnutrition.Inordertopreventthis,protein,
iron,VitaminB12,electrolytebalance,andweightwouldneedtobecloselymonitored.Itwould
alsobeadvisabletorecommendaoralsupplementsuchasBoostandamultivitamintoensure
energyandmicronutrientneedsarebeingmet.Toensurethatheismeetinghisneedsmonitoring
hisweighttoseeifheisgainingweightwouldbeagoodindicationthatheissuccessfully
meetinghisenergyneedsandtoleratinghisoraldiet.Iwouldalsowanttocloselymonitorhis
serumproteinlevelsbytakinglabsinordertoseethathisdietisincludingenoughproteinto
continuetoaidhisrecovery.