Download Inflammatory Bowel Disease - KNH 411 Medical Nutrition Therapy

Inflammatory Bowel Disease
1) Description of patient and diagnosis
Matthew Sims is a 35-year-old Caucasian high school math teacher. He was
diagnosed with inflammatory bowel disease, specifically Crohn’s disease, 2 ½ years ago,
when he lost 25 pounds. Initial diagnostic workup indicated acute disease within the last
5-7 cm of the jejunum and first 5 cm of the ileum. After hospitalization, he was able to
regain the weight back to his usual body weight, which is 166-168 pounds. Mr. Sims has
recently had recurring symptoms, which include unbearable abdominal pain, diarrhea,
and fever. He has also lost all of the weight that he was able to regain, now being back
at 140 pounds.
A CT scan indicated a bowel obstruction, and Crohn’s disease was diagnosed as
severe-fulminant disease. Mr. Sims underwent a resection of 200 cm of the jejunum and
proximal ileum with placement of a jejunostomy. Mr. Sims was put on PN immediately
post-operatively, and a nutrition support consult was ordered.
(Medical Nutrition Therapy Case Study 14)
2) Discussion of the disease: Inflammatory Bowel Disease
a. Etiology Inflammatory bowel disease (IBD) is characterized as an autoimmune,
chronic inflammatory condition of the gastrointestinal tract. IBD is the general
term for either of two diagnoses: ulcerative colitis and Crohn’s disease. The
complete etiology of both ulcerative colitis and Crohn’s disease is unknown at
the present time, however it is understood that many factors play a role in the
conditions. These include diet, smoking, infectious agents, physiological changes
in the small intestine from which an abnormal inflammatory response is
triggered, and genetics.
(Pathophysiology of Inflammatory Bowel Disease: An Overview)
b. Diagnostic Measures There are several tests that can be done in order to
diagnose inflammatory bowel disease. These include abdominal ultrasound, MRI,
CT scan, and antiglycan antibodies (ASCA/ANCA). 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 90/min, and
hemoglobin less than 10 g/dL are all indicative of severe activity of ulcerative
colitis.
(Nutrition Therapy and Pathophysiology Ch. 15)
c. Treatment
i.
Medical, surgical and/or psychological treatment Treatments for
inflammatory bowel syndrome include antibiotics, immunosuppressive
medications, immunomodulators, and biologic therapies as well as
surgical intervention. Medical treatment for UC has used combinations of
both antibacterial coverage and anti-inflammatory therapy.
Immunomodulators work to inhibit inflammatory cell proliferation by
interrupting cellular RNA and by inhibiting overall immune response.
Antibiotics are used in UC only when there is an acute infection.
Treatment for Crohn’s disease can utilize all of these same medical
treatments. Corticosteroids are often used to treat acute exacerbations,
especially in severe-fulminant disease, but patients are at risk for
becoming steroid dependant. Antibiotics and biological therapies such as
anti-adhesion molecules and anti-interleukin antibodies are also used.
Treatment by surgery is required for over 60% of patients with
inflammatory bowel disease. The most common procedure in ulcerative
colitis patients is a total colectomy, and in Crohn’s disease patients, an
ileostomy. Sugery is typically performed when a patient is unresponsive
to medications or disease-related complications begin to occur.
(Nutrition Therapy and Pathophysiology Ch. 15)
ii. Medical Nutrition Therapy Most individuals with Inflammatory Bowel
Disease experience weight loss and nutritional deficits. Nutritional
therapy is often required during times of exacerbation or recovery from
surgery, in the form of enteral or parenteral nutrition. IBD can affect
normal digestion and absorption, increase caloric and protein needs, or
result in protein-energy malnutrition. When inflammation is present in
the patient, they could need up to 150% of their normal protein
requirements.
During times of exacerbation of the disease, Enteral Nutrition is usually
necessary to help maintain or improve the patient’s nutritional status and
weight. Most researchers say that Parenteral Nutrition is not necessary
and does not provide benefits, however PN may be required postoperatively or until there is adequate intestinal adaptation. Protein
requirements may be as high as 1.5-1.75 g/kg for adults. If oral intake is
initiated, it should be made up of low-residue, lactose-free items. Fiber
and lactose should be introduced gradually as the patient’s GI function
begins adapting. All patients should receive a multivitamin that meets
100% of the RDA for all nutrients.
During times of remission, maximizing energy and protein intake should
be the primary goal. This is needed to restore function and facilitate
rehabilitation.
In the case of Mr. Sims, he has been prescribed to parenteral nutrition
post-operatively. His parenteral nutrition prescription is as follows:
◦1,500-1,600 kcals
–(20 kcals*76.6kg) (Refeeding must start with fewer kcals/kg)
◦115 grams protein (460 kcals)
–(1.5 g/kg)
◦ 33 grams fat (297 kcals)
–(100 cc’s 30% intralipid; 3kcals per cc)
◦210 grams CHO (843 kcal)
–Remaining calories
◦150 milliequivalents of sodium and potassium EACH
–(2 mEq/kg)
◦16 mEq magnesium
–(8-24 mEq daily)
◦1,600 cc’s fluid
◦1 Multivitamin vile and 1 trace element vile
The reduction of diarrhea volumes predicts the beginning of adaptation
of the remaining bowel. At this point, I would begin enteral nutrition with
Mr. Sims, and gradually transition into an oral diet. At this point, Mr. Sims
should also be taking a multivitamin daily that fulfills all of his RDA needs
for all nutrients.
During his remission, Mr. Sims should maximize energy and protein
intake to facilitate rehabilitation. Physical activity will also help to rebuild
muscle mass and protein stores. Mr. Sims should consume foods high in
antioxidants and omega-3 fatty acids, as these have been shown to
reduce inflammation.
(Sample Adult PN Order Form, Figure 7.9 & Nutrition Therapy and
Pathophysiology)
(http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000200.
htm)
iii. Prognosis Typically, IBD is characterized by a sequence of remissions
and exacerbations, with acute attacks lasting weeks to months. The
mortality rate for inflammatory bowel disease ranges from approximately
1.4 times the general population (Sweden) to 5 times the general
population (Spain). Most of this increase appears to be in the Crohn’s
disease population, while the ulcerative colitis population appears to
have the same mortality rate as the general population.
An average patient with ulcerative colitis has a 50% probability of having
another episode during the next 2 years. However, patients may have
only one flare over 25 years and some may never have another flare
again. Ulcerative colitis is considered to be cured once a colectomy takes
place.
The course of Crohn’s disease is much more viable than that of ulcerative
colitis. Remission and exacerbations are sure to occur in Crohn’s patients,
with the relapse rate over 10 years being 90%. Surgical intervention is a
treatment option for Crohn’s disease, it is not curative and the disease
recurrence rate after surgery is high.
(http://emedicine.medscape.com/article/179037overview#aw2aab6b2b5)
(http://www.ncbi.nlm.nih.gov/pubmed/17206705)
References:
Nelms, Sucher, Lacey, Roth. 2011. Published by Wadsworth, Cengage Learning.
Baltimore, CA. Nutrition Therapy & Pathophysiology
Nelms, Long, Lacey. 2009. Published by Wadsworth, Cengage Learning. Baltimore, CA.
Medical Nutrition Therapy: A Case Study Approach.
Pathophysiology of Inflammatory Bowel Disease: An Overview by Rebecca Thoreson and
Joseph Cullen.
Inflammatory Bowel Disease. (2012). E-Medicine Health. Retrieved from
http://www.emedicinehealth.com/inflammatory_bowel_disease/page12_em.ht
m
Diagnosing and Managing IBD. (April 30, 2011). Crohn’s and Colitis Foundation of
America. Retrieved from http://www.ccfa.org/resources/diagnosing-andmanaging-ibd.html
Chen-Maynard, PhD. (n.d.) Calculating Parenteral Nutrition. Retrieved from
http://health.csusb.edu/dchen/368%20stuff/TPN%20calculation.htm
Walker, Joe. Low Residue Diet. Retrieved from http://diverticudiet.com/nutrition-fordiverticulitis/low-residue-diet/
Diet Plan. Low Residue Diet. Retrieved from
http://wholesomedietplan.com/article/Low_Residue_Diet.html
Tine, Jess. 2007. Changes in clinical characteristics, course, and prognosis of
inflammatory bowel disease during the last 5 decades. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/17206705.
MedLine Plus. 2013. Low-residue Fiber Diet. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000200.htm