Claire MillonigCase Study #1116 September 2014

Inflammatory Bowel Disease: Crohn’s Disease

I. Understanding the disease and pathophysiology

1. What is inflammatory bowel disease? What does current medical literature

indicate regarding its etiology?

Inflammatory bowel disease (IBD) is “an autoimmune, chronic inflammatory condition of the

gastrointestinal tract; IBD is actually the term designating a syndrome consisting of two

diagnoses: ulcerative colitis and Crohn’s disease” (Nelms G-13). These two have distinct

differences that identify them. The distinguishing factor is that Crohn’s disease is inflammation

found in any portion of the GI tract where as ulcerative colitis is inflammation only found in the

colon. Inflammatory bowel disease is a chronic condition that will stay with you life-long. There

is no known cure but treatments and medication to ease the symptoms. It has been found that

multiple factors contribute to these conditions, which include different environmental factors,

smoking, infections, intestinal flora, and changes in the small intestine which cause and

inflammatory response. There has also been found to be a genetic component to inflammatory

bowel disease, which is mostly observed within first-degree relatives. Inflammatory bowel

disease is most commonly found in well-developed countries within urban areas. This could be a

result to environmental factors like smoking, pollution and chemical exposure.

http://www.cdc.gov/ibd/

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?

Ulcerative colitis and Crohn’s disease have many similar symptoms and can sometimes be

mistaken for each other at first glance. They both are defined with “abnormal immune response

resulting in inflammatory damage of gastrointestinal mucosa” (Nelms 416). However when

looking at the pathology we are able to distinguish some differences. Ulcerative colitis is when

the GI tract cannot distinguish between foreign and self-antigens. In result inflammation occurs

in the colon, on the top layer only. Crohn’s disease consists of inflammation occurring anywhere

in the GI tract but most frequently found in the lower part of the small intestine moving into the

upper part of the large intestine. Unlike ulcerative colitis, Crohn’s affects all layers of the

intestine. However, ulcerative colitis and Crohn’s disease have similar, if not almost identical,

symptoms. These include fever, weight loss, abdominal and/or rectal pain, and chronic diarrhea

and blood and/or mucus present in the stool. It is a common problem with patients being told the

wrong diagnosis the first time. However, with further examination, specialists are able to

distinguish between the two and make the correct diagnosis.

http://www.cdc.gov/ibd/

3. A CT scan indicated bowel obstruction and the Crohn’s disease was classified as

severe-fulminant disease. CDAI score of 400. What does CDAI score of 400

indicate? What does a classification of severe-fulminant disease indicate?

CDAI stands for Crohn’s disease activity index. Scores above 150 indicate that the patient is

experiencing a flare up in their Crohn’s disease state and above 300 indicates they are

experiencing severe exacerbation of the disease. In a CDAI factors like diarrhea, abdominal pain,

abdominal mass and laboratory features are all taken into consideration when giving this number.

During severe exacerbation, low albumin levels and high white blood cell count are also

indicators of this state. There are four classifications, which indicate the stage of Crohn’s disease

the patient is currently. They are: mild-moderate disease, moderate-severe disease, severe-

fulminant disease and remission. The state that Mr. Sims was diagnosed with was severe-

fulminant. This means that he has “persisting symptoms in spite of introduction of steroids or

biologic agents as outpatients, or those presenting with high fever, persistent vomiting, evidence

of intestinal obstruction, rebound tenderness, cachexia, or evidence of an abscess” (Nelms 419).

Mr. Sims shows many of these indications, therefore was diagnosed in severe-fulminant disease

stage.

4. What did you find in Mr. Sims’ history and physical that is consistent with his

diagnosis of Crohn’s? Explain.

In Mr. Sims’ history and physical he states that he was diagnosed with inflammatory bowel

disease three years ago. At first they said it was ulcerative colitis but then six months later the

diagnosis changed to Crohn’s disease. He was hospitalized for over two weeks then was released

and was doing fine until this fall when school started. Mr. Sims is experiencing more diarrhea

and abdominal pain than before. He sought the help of his doctor in September and switched his

medications, which helped for a little while. Now his abdominal pain is unbearable and has

constant diarrhea and a fever. Diarrhea, abdominal pain and a fever are all indicators of Crohn’s

disease.

5. Crohn’s patients often have extraintestinal symptoms of the disease. What are

some examples of these symptoms? Is there evidence of these in his history and

physical?

Extraintestinal symptoms of Crohn’s disease can be identified as osteopenia, osteoporosis,

dermatitis, rheumatological conditions such as ankylosing spondylitis, ocular symptoms, and

hepatobiliary complications. Mr. Sims does not show any of these symptoms. It is possible

however that he has had these symptoms before and was just not able to recall them at the time

or did not link them to being caused by his Crohn’s disease.

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 are commonly used to inhibit the overall inflammatory response. This is most

likely to be used to treat patients with acute exacerbations, especially those in severe-fulminant

disease stage. However, results have shown patients becoming depended of the steroid, so

treatment is observed carefully. Mesalamine is used as an anti-inflammatory for the ileal and

colon area. Humira is a tumor necrosis factor (TNF) blocker. It decreases inflammation by

binding to TNF and blocking it from causing damage. Overall it helps reduce signs and

symptoms of Crohn’s disease.

http://www.medicinenet.com/mesalamine/article.htm

https://www.humira.com/crohns/how-humira-works-for-crohns

7. Which laboratory values are consistent with an exacerbation of his Crohn’s

disease? Identify and explain these values.

When diagnosing a person with exacerbation of their Crohn’s technicians typically look at

cytokines, anti-glycan antibodies (ASCA and ANCA), C-reactive protein, erythrocyte

sedimentation rate (EAR), calprotectin, lactoferrin, polymorphonuclear neutrophil elastate

(PMN-e), total blood counts and white blood cell counts. In Mr. Sims lab reports we see elevated

levels of C-reactive protein at a level of 2.8, when normal range is less than 1.0; we see a

positive result for ASCA antibodies; and we see a lower level of hemoglobin at 12.9, when

normal range is 12-15 in males. These all are indications that Mr. Sims is in fact experiencing

exacerbation of his Crohn’s disease.

8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why

he may be at risk for vitamin and mineral deficiencies.

Vitamin and mineral deficiencies in Crohn’s patients are very common. This is because of the

frequent diarrhea, medication, diet alterations, increased metabolic requirements and

inflammation of the intestines cause reduced absorption. A proper diet and supplement is very

important for Crohn’s patients. Now a day, food has less nutrient value anyway so making sure

that you are eating a healthy balanced diet is important. Taking a multivitamin and any other

supplements is normally necessary to make up for the excess excretion.

http://www.crohnsforum.com/wiki/Vitamin-and-Mineral-Deficiencies

9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel

syndrome, and provide a rationale for you answer.

Short bowel syndrome (SBS) “results from a large resection of the small intestine; or short bowel

syndrome intestinal failure results from surgical resection, congenital defect or disease-

associated loss of absorption and is characterized by the inability to maintain protein, energy,

fluid, electrolyte, or micronutrient balances when on a conventionally accepted, normal diet”

(Nelms 424). Under certain circumstances, each patient is diagnosed and assessed specifically to

their case. The long terms results are determined from how the specific patient’s body reacts to

the surgical resection. Mr. Sims would be a candidate for short bowel syndrome because of his

Crohn’s disease. This disease causes inflammation of the bowel in certain areas, which in severe

cases calls for resections of multiple areas. If these areas were removed and the digestive tract

was shortened, his symptoms may lessen.

10. What type of adaptation can the small intestine make after resection?

The extent of adaptation it must undergo is determined by the amount actually removed. Some

examples of new adaptations it must make are secretions, blood flow, mucosal cell growth and

the inner lumen increases in length and diameter to make up for the lost parts. Specifically, loss

of part or the whole ileum will result in decreased B12 and bile salts absorptions. This then leads

to malabsorption of fats and inability to absorb fats means that vitamin A, D, E and K cannot be

properly absorbed as well. Patients usually suffer from large amounts of diarrhea after this

procedure and experience other nutrient deficiencies. This re-adaptation may take anywhere from

one to two years after the surgery.

11. For what classic symptoms of short bowel syndrome should Mr. Sims’ heal care team

monitor?

Mr. Sims and his health care team should be especially aware of his vitamin and mineral levels.

In his history and physical he stated that he seems to have constant diarrhea. Keeping this in

mind, most of his nutrients are being excreted from the body before they are absorbed. Also, the

inflammation of his bowels decreases absorption of vitamins and minerals as well. After he

undergoes his surgery he will need to be extremely careful about this still along with monitoring

the absorption of macronutrients.

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?

The use of high-dose immunosuppression and autologous peripheral blood stem cell

transplantation is a new clinical trial for Crohn’s disease patients. Some have found it to be

extremely helpful and remain in remission to this day, but for some others they weren’t so

lucky. This transplant “may help by overcoming CD's genetic predisposition to circulate

leukocytes, while autologous transplants may clear the body of committed lymphocyte clones

and restore the lymphocytic imbalance in patients with CD” (Zhang). Use of the treatment for

Mr. Sims could be very beneficial. It would help reduce his symptoms from Crohn’s and let him

get back to living a normal life. Of course, he would still have to be cautious about coming out

of remission, as this is possible to happen.

http://www.hcplive.com/publications/surgical-rounds/2008/2008-03/2008-03_04

II. Understanding the Nutrition Therapy

13. What are the potential nutritional consequences of Crohn’s disease?

Crohn’s disease can affect patients in many different ways. They suffer from extreme diarrhea at

times, which leads to malnutrition. They experience abdominal pain and cramping along with

fever, blood and/or mucus in their stool. Many patients experience inflammation of their bowels,

which causes them to not be able to absorb any nutrient. This includes macronutrient as well as

vitamins and minerals. Most are advised to take a multivitamin and eat excess food when

experiencing diarrhea. But sometimes this can be difficult because their loss of appetite. Crohn’s

causes anorexia in a lot of cases and the patients typically experience weight loss. Especially in

younger children this needs to be monitored closely to avoid delayed growth.

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?

This resection of the jejunum and proximal ileum was performed in order to enhance nutrient

deliverance for Mr. Sims. A jejunostomy is defined as the placement of “a tube delivering

feedings through the abdominal wall to the jejunum” (Nelms 84). A jejunostomy was put in

place so that doctors can administer foods through the fistula in his stomach into the small

intestine. The food then continues through the digestive tract as normal so that the body can

absorb the nutrients. The preservation of the illiocecal valve and his colon remaining in tact will

create less problems using the jejunostomy to supply nutrients to the body. For the average male,

the small intestine is approximately 690 cm long. The resection of the jejunum and proximal

ileum by 200 cm leaves the small intestine to be about 490 cm long.

15. What nutrients are normally digested and absorbed in the portion of the small

intestine that has been resected?

The small intestine is where most of the absorption of nutrients takes place. When a patient

undergoes a resection surgery of the jejunum and proximal ileum, malabsorption can be a main

problem. Bile salts are normally absorbed in this area of the small intestine, but with insufficient

absorption, they are allowed to pass into the large intestine and stimulate fat and water

secretions, which leaves the patient with diarrhea. The malabsorption of fats is also a contributor

to diarrhea in the patient.

III. Nutrition Assessment

16. Evaluate Mr. Sims’ percent UBW and BMI.

Mr. Sims’ usual body weight is 140 pounds or 63.6 kg.

140/ 2.2 = 63.6 kg.

BMI = 63.6/1.8m2 = 19.6

Looking at his BMI, we can conclude that Mr. Sims is within the normal measurements however

he is on the lower end approaching underweight. It is important to take caution of this value

because as a Crohn’s patient, he is at risk to be underweight and unhealthy.

17. Calculate Mr. Sims’ energy requirements.

10 x 63.6 kg. + 6.25 x 175.26 – 5 x 35 + 5 = 1,561 kcals/day

1,561 x 1.6 = 2, 498 kcals/day

It is estimated that Mr. Sims needs approximately 2,498 kcals per day in order to maintain his

weight. However, with is diagnosis of Crohn’s disease, his caloric needs will be slightly higher

in order to compensate for lost nutrients.

18. What would you estimate Mr. Sims’ protein requirements to be?

2,498 x .35 = 874.3 kcals

874.3 kcals / 4 g. = 218 g of protein per day

For Crohn’s patients it is important to get the proper amount of nutrients because some may not

be able to be absorbed by the body. Therefore, we estimate that Mr. Sims would need about 35%

of his daily caloric intake to be from proteins. This comes out to be about 218 g of protein per

day. Most patients of Crohn’s experience weight loss because their body is excreting more

nutrients than is being taken in. To compensate for this their caloric and daily percent needs are

generally higher.

19. Identify any significant and/or abnormal laboratory measurements from both is

hematology and his chemistry labs.

In Mr. Sims lab reports we see a few different abnormal levels. We see that: his protein level is

5.5 when normal range is from 6-8; albumin (3.2) and prealbumin (11) levels are both below

normal limits; C-reactive protein level is 2.8, when it should be less than 1.0; ASCA came back

positive, which is an indicator of exacerbation of Crohn’s; hemoglobin level is 12.9, which is

low; transferrin is low at 180; ZPP is high at a level of 85; vitamin D is low at a value of 22.7;

free retinol (vitamin A) is low at a value of 17.2; and ascorbic acid is low at a value of less

than .1. All of these values indicate abnormalities and some are indicators that he is experiencing

exacerbation of Crohn’s. Also, we see that some of his vitamin levels are low, which indicates

that he is not properly absorbing these, they are being excreted or he is not taking in enough of

these vitamins.

IV. Nutrition Diagnosis

20. Select two nutrition problems and complete the PES statement for each.

Increased nutrient needs (NI-5.1; 10656) related to disease state of Crohn’s as evidence by BMI

of 19.6.

Unintended weight loss (NC-3.2; 10765) related to decrease in appetite as evidence by patients

statement of weight loss of approximately 25 or more pounds in the last 6 months.

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?

In order to choose the correct nutrition therapy for Mr. Sims, it is necessary to look at what

nutrients he is lacking, the method in which the food will enter into the body, and how severe his

case has become. Evaluating each of these factors allows a proper plan to be made. It is most

likely that Mr. Sims would receive enteral nutrition through the jejunostomy placed through his

abdomen. A nutrient rich formula would be inserted through this opening directly into his bowels

for absorption. Repair of the gut is very important after an exacerbation of Crohn’s episode and

the only way to ensure that you return to a healthy life style is to supply your body with the

proper nutrients. Protein is especially important for repair and regrowth of cells in your GI tract.

This will all be taken into consideration when a team evaluates the patient in order to give him

the best nutrition therapy.

http://www.ccfa.org/resources/diet-and-nutrition.html

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?

Low levels of serum phosphorus and serum magnesium are indicators of possible refeeding

syndrome. This syndrome is found in patients who are receiving parenteral or enteral feeding,

patients diagnosed with anorexia nervosa, alcoholism, cancer or anyone who has just had

surgery. Blood tests are done frequently to monitor these levels in patients who are risk for

refeeding syndrome.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC390152/

23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be

prevented?

Refeeding syndrome is defined as “metabolic alterations that may occur during nutritional

repletion of starved patients” (Nelms 92). When starvation lasts more than a few days, liver

gluconeogenesis slows and free fatty acids are used to produce energy as ketones. This causes

basal metabolic rates to decline. When carbohydrates are reintroduced to the system, it results in

a shift from ketones to glucose as the main energy source again. Our metabolism of glucose

requires large amounts of phosphorus, magnesium, potassium and thiamin. When serum levels of

these minerals drop the consequences can be severe. For example, hemolysis, impaired cardiac

function, impaired respiratory function and even possibly death. Mr. Sims at risk for this because

he currently has had minimal oral intake for the past few days due to decreased appetite. His

phosphorus, magnesium and potassium levels must be monitored closely and if necessary he

should be given a supplement to replenish these minerals. Supplementation should continue until

Mr. Sims is able to eat an adequate amount of calories containing the proper amount of nutrients.

To prevent refeeding syndrome, gradually introduce food orally and avoid overfeeding. As the

client slowly increases their caloric intake, risk of this syndrome will decrease.

24. Mr. Sims was placed on parenteral nutrition support immediately postoperatively, and

a nutrition support consult was ordered. Initially, he was prescribed to receive 200 g dextrose/L,

42.5 g amino acids/L, and 30 g lipid/L. His parenteral nutrition was initiated at 50 cc/hr with a

goal rate of 85 cc/hr. 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); and total kcal

from his PN.

(200 g dextrose/L) x (1L/1000ml) = 0.2 g dextrose/ml or 0.2 g dextrose/cc

(42.5 g AA/L) x (1L/1000ml) = 0.0425 g AA/ml or 0.0425 g amino acids/cc

(30 g lipid/L) x (1L/1000ml) = 0.03 g lipid/ml or 0.03 g lipid/cc

(0.2 g dextrose/cc) x (85 cc/hr) = 17 g/hr x 24 hr = (408 g dextrose per day) x (3.4 kcal/g) = 1632

kcal from CHO

(0.0425 g AA/cc) x (85 cc/hr) = 3.61 g/hr x 24 hr = (86.7 g amino acid per day) x (4 kcal/g) =

346.8 kcal from protein

(0.03 g lipid/cc) x (85 cc/hr) = 2.55 g/hr x 24 hr = (61.2 g lipid per day) x (10 kcal/g) = 550.8

kcal from lipid

Yes, I agree with the nutrition team’s decision to place him on parenteral nutrition. Mr. Sims

would not be able to handle an oral diet. With the administration levels they have prepared, he

will be receiving and accurate amount of calories to meet his daily needs. As he gains more

strength and is able to have more daily activities, his requirement will increase slightly.

http://www.dosagehelp.com/iv_rate_ml_adv.html

25. For each of the PES statements you have written, establish an ideal goal (based on the

signs and symptoms) and an appropriate intervention (based on the etiology).

Increased nutrient needs: Provide nutrition counseling with high calorie and nutrient dense meals

to compensate for excess excretion of nutrients.

Unintended weight loss: Increase caloric intake gradually by 200 kcals per day until daily

requirements are being met.

VI. Nutrition Monitoring and Evaluation

26. Indirect calorimetry revealed the following information:

Measure Mr. Sims’ Data

Oxygen consumption (mL/min) 295

CO2 production (mL/min) 261

RQ 0.88

RMR 2022

What does this information tell you about Mr. Sims?

The normal oxygen consumption is 250 mL/min and Mr. Sims is 295 mL/minute, which is

high. This is most likely because of the increased metabolic rate as a result of the Crohn’s

disease. The increased metabolic rate also causes the high CO2 production rate of 261

mL/minute. Mr. Sims respiration quotient (RQ) is within the normal range of .7-1.0.

However, his RMR value of 2022 is higher than what was estimated previously. This value

indicates he is using more energy at a resting state than normal.

27. Would you make any changes to his prescribed nutrition support? What should be

monitored to ensure adequacy of his nutrition support? Explain.

I believe that his prescribed nutrition support should suffice quite well but I would include a

vitamin and mineral supplement to be added to his nutrition support. His intake and output

levels must be closely monitored to make sure that his body is absorbing the nutrients that are

being administered. If his body is excreting rather than absorbing the nutrients, dosage would

need to be increased.

28. What should the nutrition support team monitor daily? What should be monitored

weekly? Explain your answers.

The nutrition support team should monitor his hematology and chemistry lab values daily. This

is necessary to make sure he is absorbing the correct amount of nutrients and improving from his

condition and not worsening. Also, his weekly goals should be to gain a certain amount of

weight each week. The nutrition support team should set weekly goals with Mr. Sims in order for

him to gain his strength and appetite back.

29. Mr. Sims’ serum glucose increased to 145 mg/dL. Why do you think this level is now

abnormal? What should be done about it?

This level is considered to be high for dextrose intake. Dextrose should be between 50% and

60% dextrose, but in this case they raised his level to 65% dextrose. This level should be

decreased into the normal range to obtain correct amounts of nutrients.

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.

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?

Mr. Sims should start off with strictly liquids and then progress to a low-residue diet, as

tolerated, four to six times per day. Some foods that should be avoided for the first 6 to 8 weeks

include tough meats, spinach, corn, peas, raisins, fruits with seeds and fruit skins and popcorn.

The nutrition support team needs to be sure to educate Mr. Sims to eat slowly, chew thoroughly

and drink proper amounts of fluid. If he still experiences excess or watery excretion, insoluble

fiber should be reduced and soluble fiber amounts should be increased. Some foods to decrease

the possibility of diarrhea include applesauce, bananas, tapioca, oatmeal, rice and pasta. If

positive results are observed after 8 weeks, the patient may begin trying more solid foods

(Nelms, 424).

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 measure for evaluation.

Mr. Sims will be directed to take a multivitamin as well as eat fruits and vegetables to obtain the

necessary amounts of vitamins and minerals for his body. At his next appointment, lab values

will obtained to make sure these levels are within normal limits and he is consuming the proper

amounts. Also, his caloric intake should be approximately 2, 500 calories per day in order for

him to regain the weight he has lost. This will be evaluated at his next appointment based on how

much weight he has gained back.

References

Crohn's & Colitis. (2014, February 6). Retrieved September 16, 2014, from

http://www.ccfa.org/resources/diet-and-nutrition.html

Hearing, S. (2004, April 17). Notes. Retrieved September 16, 2014, from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC390152/

Inflammatory Bowel Disease (IBD). (2014, January 14). Retrieved September 15, 2014, from

http://www.cdc.gov/ibd/

Learn how HUMIRA works for moderate to severe Crohn's disease. (n.d.). Retrieved September

16, 2014, from https://www.humira.com/crohns/how-humira-works-for-crohns

Mass/Time - IV mL Rate Questions. (n.d.). Retrieved September 16, 2014, from

http://www.dosagehelp.com/iv_rate_ml_adv.html

Mesalamine, Rowasa, Asacol: Drug Side Effects. (n.d.). Retrieved September 16, 2014, from

http://www.medicinenet.com/mesalamine/article.htm

Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont, CA: Wadsworth,

Cengage Learning.

Vitamin and Mineral Deficiencies. (n.d.). Retrieved September 16, 2014, from

http://www.crohnsforum.com/wiki/Vitamin-and-Mineral-Deficiencies

Zhang, L. (2008, April 7). Treating Crohn's disease with hematopoietic stem cell transplantation.

Retrieved September 16, 2014, from http://www.hcplive.com/publications/surgical-

rounds/2008/2008-03/2008-03_04