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Case Study
Medical/Surgical
Andrea Taufer
Crohn’s disease is an inflammatory bowel disease (IBD) that causes inflammation of the
lining of the digestive system. More than half a million Americans have been diagnosed with
Crohns. The exact cause is unknown, but researchers believe that it could be a combination of
genetics, environmental factors, and an abnormal immune response that may result in the
inflammation of the digestive tract (1).
One hypothesis for the cause of Crohns is that a virus or bacterium may trigger the
disease. When the immune system tries to fight off this microorganism an abnormal immune
response causes the immune system to attack the cells in the digestive tract, as well as the virus
or bacterium. Crohns may also be hereditary, this disease is more common in people who have
family members with Crohns. Experts suspect that one or more genes may make people more
susceptible. Chromosomes 16, 12, 6, and 14 are the main areas of linkage being studied, which
are often seen in the Jewish population. Recently 21 new genes for Crohns have been identified,
several related to the promotion of inflammation (2).
Some risk factors for Crohns include: being of Eastern European (Ashkenazi) Jewish
descent, having a close relative with the disease (1 in 5 people with Crohn's disease has a family
member with the disease), cigarette smoking, and living in an urban area or in an industrialized
country. This disease can occur at any age, but most people are diagnosed before they're 30 years
old(2).
Inflammation of Crohn's disease can affect different areas in different people. The most
common areas affected are the last part of the small intestine and the colon. Some common signs
and symptoms may include diarrhea, abdominal pain and cramping, blood in stool, ulcers,
reduced appetite and weight loss(3). Tests for the diagnosis of Crohns include colonoscopy,
lower gastrointestinal series with barium enema, endoscopy, and biopsy (2).
The main treatment for Crohns is medication. The focus of the medications is to stop
inflammation in the intestine, prevent flare-ups, and keep the patient in remission. Some
common medications used to treat Crohns include immunosuppressive, antibiotics, steroids, and
anti-tumor necrosis factor medications. Surgery may be needed if medicine is ineffective, if
patients are experiencing serious side effects, if symptoms can only be controlled with long-term
use of corticosteroids, or if the patient develops complications such as fistulas, abscesses, or
bowel obstructions. Surgical intervention is required in more than 60% of patients. Surgery
involves removing the affected portion of the intestines to preserve as much of the intestines as
possible so that normal function can be maintained. Crohn's disease tends to return to other areas
of the intestines after surgery(4).
DB is a 80 year old white female with a past medical history of Crohn’s disease, a
colectomy and ileostomy in 2008 for megacolon that was just almost gangrenous, acute renal
failure (stage 4), osteoporosis, osteoarthritis, lumbar spine and hip fracture, and GERD. DB
previously smoked a pack a day for 50+ years and usually has an ounce of bourbon a night which
she has been doing for the past 3-1/2 years.
DB is 149 cm, 41 kg, with a BMI of 18.47, IBW of 43.18, and % IBW 94.95. She is a
widowed retired secretary, and lives at home. BD’s has a daughter and care taker who helps her
with chores, grocery shopping, and cooking. DB was admitted to the hospital by her daughter.
They were going to the IV center for an infusion of fluid, however DB was so weak she could
not get up so EMS was called. DB diagnostic impression was dehydration and hyponatremia.
I chose DB as a case study due to her past medical history of Crohns and the
complications she has had due to it, including a colectomy and an ileostomy. Many patients with
Crohns require surgery due to severely damaged portions of the digestive tract, which need to be
removed. In DB’s case she had a colectomy and ileostomy where all or part of the colon was
removed, the small intestine was then attached to the abdominal wall in order to bypass the large
intestine and digestive waste then exits the body through this artificial opening. The benefits of
surgery are usually temporary, the disease often recurs, frequently near the reconnected tissue or
elsewhere in the digestive tract. It’s estimated that 3 of 4 people with Crohn’s disease eventually
need some type of surgery. Many will also need a second procedure or more. The best approach
for Crohns patients is to follow surgery with medication to minimize the risk of recurrence.
Due to DM’s past history of smoking there was at higher risk of developing Crohn's
disease compared to non-smokers. Crohn's disease patients that smoke have an increased number
of relapses, repeat surgeries, and may require aggressive immunosuppressive treatment. People
with Crohn's disease are strongly encouraged by their physicians to stop smoking in order to
prevent flare-ups of the disease. Tobacco is the best established environmental factor affecting
the susceptibility to develop Crohns. Patients who stop smoking for at least 6 months are at a
lower risk of relapse in the following 12-18 months, as compared to non-quitters. The effect of
smoking has been reported to be more marked in women(5).
Laboratory findings
Laboratory findings
Lab
Normal range
Sodium
136-145
Potassium
3.2-5.1
Chloride
101-111
CO2
22-30
BUN
6-20
Creatinine
.4-1.4
Value
138
3.2
L88
H42
H59
H2.1
Lab
Hemoglobin
Hematocrit
Magnesium
Glucose
Ca
GFR
Albumin
Normal range
13.2-17.8
40-50
1.7-2.6
74-100
8-10.2
Low >=60
3.5-5.2
Value
L8.9
L27.2
2.5
84
8.5
L22.7
3.7
Abnormal values are highlighted in red.
Chloride can be low with any disorder that causes low blood sodium. CO2 can be increased
due to DB’s acute renal failure. Her increased BUN and creatinine and low GFR are due to acute
renal failure. Low hemoglobin and hematocrit may be due to anemia(6).
The following is a list of drugs that BD was on during her hospital stay:
Albuterol- Bronchodilator that relaxes muscles in the airway and increases air flow to the lungs.
Side effects include: hypokalemia, hyperglycemia and lactic acidosis. Diabetic ketoacidosis has
been reported due to overdose of albuterol.
Budesonide- Steroid that prevents the release of substances in the body that cause inflammation.
Budesonide is used to treat mild to moderate Crohn's disease. Side effects include: hypokalemia,
weight increase, oropharyngeal candidiasis, dry mouth, taste perversion, nausea, dyspepsia, and
abdominal pain.
clopidogrel - Keeps the platelets in blood from coagulating to prevent unwanted blood clots that
can occur with certain heart or blood vessel conditions. Side effects: bloody or tarry stools, blood
in your urine.
fentaNYL - Narcotic pain medicine. Side effects: dry mouth, nausea, vomiting, constipation,
white patches or sores inside your mouth or on your lips.
Heparin- Treats and prevent blood clots in the veins, arteries, or lung. Side effects: hyperkalemia,
hyponatremia, and hypertriglyceridemia.
Iron polysaccharide - Dietary supplement that prevents and treats iron deficiencies and iron
deficiency anemia. Side effects: stomach upset, nausea or vomiting, constipation, diarrhea, and
black or darker stools.
Magnesium oxide - Supplement to maintain adequate magnesium in the body. Side effects:
hypocalcemia.
Mesalamine - Affects a substance in the body that causes inflammation, tissue damage, and
diarrhea, used to treat ulcerative colitis, proctitis, and proctosigmoiditis. Side effects: severe
stomach pain, cramping, fever, headache, bloody diarrhea, mild nausea, vomiting, stomach
cramps, diarrhea, gas, and constipation.
Sodium bicarbonate- Relieves heartburn and indigestion. Sodium bicarbonate is also used to
make the blood and urine less acidic in certain conditions. Side effects: nausea or vomiting,
swelling of feet, ankles or legs, decreased appetite, constipation; dry mouth or increased thirst; or
increased urination.
Sodium Chloride 0.9% 1,000 mL - Treats or prevents sodium loss caused by dehydration,
excessive sweating, or other causes. Side effects: nausea and vomiting, stomach pain, swelling in
hands, ankles, or feet(7).
Medical Nutrition Therapy
The role of dietary habits on the development of Crohns is far from being well
established. Food intolerances are very frequent, but usually inconsistent among patients,
therefore no general dietary recommendations can be made in these patients. Overall patients
should eat a diet as varied as possible.
Previously physicians based dietary counseling for IBD patients on restrictive criteria.
This was because bowel rest was thought to induce remission. Controlled trials have showed that
drug-induced remission was not influenced by the type of nutritional support such as enteral,
parentral, or oral intake. Currently the recommendation of “bowel rest” has been abandoned,
and IBD patients are now advised to eat a diet as unrestricted as possible.
Crohns patients are now advised to avoid only those food items which repeatedly and
systematically worsen their symptoms. The two most common food groups the raise concern are
dairy foods and dietary fiber.
Many patients report milk intolerance and fear that milk will cause a flare up, but none of
the components of milk have been proven to play a role in promoting bowel inflammation,
causing the disease or triggering a flare. Therefore, inflammatory bowel disease patients should
not limit their milk intake during flares unless it clearly worsens symptoms. Even in these cases,
dairy foods with lower lactose contents such as yogurt and cheese may be well tolerated.
Fiber restriction may be necessary during and immediately after a flare-up. Some
common foods that should be avoided are beans, legumes, whole grains, popcorn, nuts, seeds,
and raw vegetables and fruit. Normally people should consume between 20 and 25 g of total
fiber each day, but for those on a low-residue fiber diet, the amount should be 10 to 15 g or less.
During remission tolerance of fiber varies among individuals. If the small intestine is
narrowed in places, it may be necessary to eat a low-fiber diet to avoid blockages; otherwise,
fruits, vegetables and whole grains can generally be tolerated. Cooking fruits and vegetables may
help if raw foods cause problems. Dietary fiber is important for health in general, so the goal is
to find what can be tolerated and in what amounts
Patients with inflammatory bowel disease (IBD) are considered to be at significant
nutritional risk, it is estimated that 60% to 75% of patients with Crohn’s disease experience
malnutrition. Potential nutrient deficiencies include energy, protein, fluid electrolytes, iron,
magnesium, zinc, calcium, vitamin D, vitamin B-12,and folate. Nutrient deficiencies often
manifest themselves as osteopenia, osteoporosis, and osteomalacia(8).
Some factors that might alter nutrition status include decreased nutrient intake, fear of
eating, anorexia, nausea, vomiting, diarrhea, abdominal pain, restrictive diets, medication side
effects, oral aphthous ulcerations, taste changes, bacterial overgrowth, vitamin and mineral
needs, surgical resection, inflamed/ulcerated mucosa, blood loss, increased needs for healing,
malabsorption/maldigestion, and drug-nutrient interactions. Nutrition therapy is used to correct
deficiencies, reduce inflammation, and maintain nutritional status (9).
Nutrition History:
DB states she has a hard time keeping up her weight due to her bowls moving so much
and also struggles with electrolyte balance. DB has previously followed a renal diet restricting
phosphorous and potassium. Due to DB’s loss of fluid and sodium from her ileostomy she does
not restrict her sodium intake unlike most patients following a renal diet. DB also consumes
artificial sweetened products instead of the regular version because she is trying to prevent
diabetes. DB also consumes boost, a nutritional supplement at home, twice a day. DB has a
daughter and care taker, they do her grocery shopping, and prepare her meals.
During her stay at the hospital DB was on a regular diet and received glucerna three times
a day per DB’s request. The glucerna alone provided 855kcals and 42.6g protein. The rationale
behind DB’s diet order is to make sure DB is getting adequate nutrition and does not lose any
additional weight. Calorie and protein needs were assessed using her current body weight.
Calories were calculated at 30-35 kcals/kg equaling 1230-1435kcals, and protein at .6-.75g
protein/kg due to her stage 4 renal failure equaling 24.6-30.75g. Fluid was per MD due to her
dehydration and hyponatremia.
Below is a typical day’s intake, this does not include the boost she consumes at home.
Breakfast:
Lunch:
Dinner:
½ c Oatmeal
¼ c Blueberries
1c Skim Milk
½ cup mixed vegetable
½ cup white rice
1 medium fillet
¼ c grits
1/12 slice angel food cake
24-hour recall nutrient analysis is as follows (10):
Nutrients
Total Calories
Protein (g)***
Protein (%
Calories)***
Carbohydrate
(g)***
Carbohydrate (%
Calories)
Dietary Fiber
Total Fat
Saturated Fat
Monounsaturated
Fat
Polyunsaturated
Fat
Cholesterol
Calcium
Average Eaten
1172 Calories
91 g
31% Calories
Nutrients
Potassium
Sodium**
Copper
Average Eaten
1996 mg
2022 mg
667 µg
140 g
Iron
20 mg
48% Calories
Magnesium
218 mg
11 g
22% Calories
5% Calories
7% Calories
Phosphorus
Selenium
Zinc
Vitamin A
1447 mg
184 µg
5 mg
876 µg RAE
7% Calories
Vitamin B6
0.9 mg
180 mg
635 mg
Vitamin B12
Vitamin C
8.8 µg
27 mg
No education was needed to be given to the patient. DB speaks English, and there did not
seem to be any barriers to learning. DB was knowledgeable about her condition but has a hard
time keeping up with her electrolytes and making sure she is adequately hydrated. These are the
main areas of concern after discharge.
This case study has taught me a lot about Crohns disease. It has shown me how prevalent
this disease is and how there is still so much research that needs to be done on the causes and
treatment of Crohns. Nutritionally Crohns patients can be difficult because there is no one diet
that can treat the patient. Each patient must be assessed for their individual food
tolerances/intolerances and then we have to find ways to make sure the patient is getting
adequate nutrition with a variety of food groups.
Bibliography
1. Crohns Online. What is Crohns Disease. Available at:
http://www.crohnsonline.com/what-is-crohns-disease/default.aspx. Accessed February
20, 2013.
2. Nutrition Care Manual. Crohns Disease. Available at:
http://nutritioncaremanual.org/content.cfm?ncm_content_id=91937. Accessed February 25,
2013.
3. Mayo Clinic. Symptomns. Available at: http://www.mayoclinic.com/health/crohnsdisease/DS00104/DSECTION=symptoms. Accessed February 19, 2013.
4. US Department of Health and Human Services. Crohns. Available at:
http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/. Accessed February 20, 2013
5. Cabré E Domènech E. Impact of environmental and dietary factors on the course of
inflammatory bowel disease. World J Gastroenterol. August 7, 2012.
6. Frances Fischback, Marshall B. Dunning II. A Manual of Laboratory and Diagnostic
th
Tests. 8 ed. 2009.
7. Drug Information Online. Drug Index A-Z. Available at: http://www.drugs.com.
Accessed February 29, 2013.
8. US Department of Health and Human Services. Crohns. Available at:
http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/. Accessed February 20, 2013
9. L. Kathleen Mahan, Sylvia Escott-Stump. Krause’s Food, Nutrition, & Diet Therapy.
th
11 ed. 2004.
10. United States Department of Agriculture. Food Tracker. Available at:
https://www.supertracker.usda.gov/foodtracker.aspx. Accessed February 12, 2013