Megan Blackburn

FSHN 450

Inflammatory Bowel Disease Case Study

CSU ID: 830130344I have not given or received any unauthorized assistance on this assignment:

___________________________________________________________

What in Mr. S’s history and physical findings are consistent with the diagnosis of Crohn’s?

Recent episodes of diarrhea accompanied by abdominal pain Acute severe RUQ, LUQ, RLQ, LLQ pain Weight Loss (~25 lbs) 101.5 Temperature (Fever) Loss of appetite Lactose Intolerance

Explain each laboratory finding (please use table format):

Lab Value Normal Range Patient Value Reason for DeviationAlbumin: 3.5-5.0 g/dl 3.2 g/dl Decrease due to

diarrhea.Prealbumin: 18-38 mg/dl 11.0 mg/dl Unintended wt.

loss/MalnutritionGlucose: 70-99 mg/dl 82 mg/dl N/ANa+: 136-144 mEg/L 136 mEg/L N/AK+: 3.5-5.0 3.7 mEg/L N/ACl-: 98-107 mEg/L 101 mEg/L N/ACreat: 0.4-1.2 mg/dl 1.8 mg/dl MalnuritionBUN: 8-23 mg/dl 11 mg/dl N/AAST: 10-37 U/L 35 U/L N/AALT: 4-40 U/L 22 U/L N/AAlk Phos: 40-120 E/L 120 U/L N/ACRP: <0/8 mg/dl 2.8 mg/dl High level of CRP

caused from Chron’s Disease

Cholesterol: 120-99 mg/dL 149 mg/dl N/ALDL-C: 100-130 mg/dL 101 mg/dl N/AHDL-c: <60 mg/dl 48 mg/dl N/AHgB: 14.6-17.5 g/dl 12.9 g/dl Deficiency of IronHct: 41-51% 38.9% Deficiency of IronMCV 78-93 87 fl N/AWBC: 3.2 x 103-10.6x103 11.1 x103/mm3 Infection/StressRBC: 4.7-6.1 x106/mm3 4.9 x106/mm3 N/AFerritin: 30-320 ng/ml 16 ng/ml Deficiency of IronPT: 12.0-15.5 sec 15 sec N/AVit D: >30 ng/ml 22.7 ng/ml Dietary Deficiency

What are the potential nutritional consequences of Crohn’s Disease? Malnutrition and weight loss due to decreased oral intake Protein losses from fistulae Loss of appetite (in fear of abdominal pain) Kidney Stones

Calcium Loss Imbalanced electrolytes Anemia

Why was Mr S previously prescribed a low fiber diet in the period following diagnosis? Since fiber is difficult for the body to digest, eating a low fiber diet may decrease

daily bowel movements and ease symptoms of Chron’s disease. After partial resection of bowel surgery/recovery he will have to continue a bland,

low-fiber diet.

Is Mr. S a candidate for short bowel syndrome syndrome (SBS)? Explain your rationale. Mr. S could be a candidate for SBS if he is getting surgical resection of 65-75%

of his small intestine. It is not stated how much resection of his small intestine is getting removed.

If patient develops SBS subsequent to surgery, what is the recommended MNT?(You do not need to recommend specific TPN) He will be NPO and on TPN for 7 – 10 days before transitioning to solid foods. Discuss MNT during the adaptation period and then after adaptation. During Adaption:

Stimulated by trophic hormones, nutrients, and drugs. Occurs via: structural changes in the SI, functional changes, and colon adaption

After Adaption: Restrict fluid with meals Lactose free Low fiber Energy: 35-40 Kcal/Kg Protein: 1.5 g pro/Kg Oral supplements Ca, Mg, Zn Consumption of complex carbohydrates Avoid simple sugars

Support your MNT recommendation with a recent journal reference. Include the full citation in acceptable reference format and a copy of the abstract from the article.

Abstract: Short bowel syndrome (SBS) is characterized by nutrient malabsorption and occurs following surgical resection, congenital defect, or disease of the bowel. The severity of SBS depends on the length and anatomy of the bowel resected and the health of the remaining tissue. During the 2 years following resection, the remnant bowel undergoes an adaptation process that increases its absorptive capacity. Oral diet and enteral nutrition (EN) enhance intestinal adaptation; although patients require parenteral nutrition (PN) and/or intravenous (IV) fluids in the immediate postresection period, diet and EN should be reintroduced as soon as possible. The SBS diet should include complex carbohydrates; simple sugars should be avoided. Optimal fat intake varies based on patient anatomy; patients

with end-jejunostomies can tolerate a higher proportion of calories from dietary fat than patients with a remnant colon. Patients with SBS are prone to deficiencies in vitamins, minerals, and essential fatty acids; serum levels should be periodically monitored and supplements provided as needed. Prebiotic or probiotic therapy may be beneficial for patients with SBS, although further research is needed to determine optimal protocols. Patients with SBS, particularly those without a colon, are at high risk of dehydration; oral rehydration solutions sipped throughout the day can help maintain hydration. One of the primary goals of SBS therapy is to reduce or eliminate dependence on PN/IV; optimization of EN and hydration substantially increases the probability of successful PN/IV weaning.

Citation: Matarese, Laura E. Nutrition and Fluid Optoimization for Patients With Short Bowel Syndrome. Journal of Parenteral & Enteral Nutrition. 2012; 37: 161-170.

Calculate Mr. S’s energy and protein requirement post-op (when he is on TPN): Energy Requirements: 25-30 Kcal/kg(63.6): 1590-1908 kcal/day Protein Requirements: 0.8-1 g/kg(63.6): 50.88-63.6 kcal/day

How will you adjust this requirement when he begins to eat solid food (assume SBS). What will you monitor to determine if this is correct?

I will measure his Albumin, Prealbumin, CRP, Hgb, Hct, and Vitamin D levels. I will also monitor his weight, and make sure he is gaining his weight back in a healthy manor. Also, it is important to monitor if his symptoms have dismissed, or if they are returning.

Energy: 35-40 kcal/kg(63.6)o 35 kcal * 63.6 = 2,226 kcal/dayo 40 kcal * 63.6 = 2,544 kcal/dayo 2,226-2,544 kcal/day

Protein: 1.5 g/kgo 1.5g * 63.6 kg = 95.4 g/kg

Select one nutrition problem and write two PES statements: one in the clinical domain and one in the behavioral domain. For each PES statement, establish a goal and appropriate intervention

PES: Inadequate oral intake R/T loss of appetite/fear of abdominal pain AEB unintended 25# wt. loss.Goal: Recommend that Mr. S find a diet that doesn’t make him have abdominal pain/Chron’s symptoms.Intervention: Complex Carbohydrates, Low fiber, Lactose free diet, Avoid simple sugars, restricted fluid with meals.(Next one on back)PES: Food and nutrition-related knowledge deficit R/T return of abdominal symptoms AEB diarrhea, malnutrition, and extreme weight loss.

Goal: Recommend that Mr. S changes his diet and practices it strictly. Recommend that Mr. S get the adequate knowledge about Chron’s disease and SBS.Intervention: Educate Mr. S about foods to avoid so symptoms do not return as heavily. Educate Mr. S about proper “treatment” for Chron’s disease and SBS.