Crohn’s Disease

By Kristin Weil and Jade Miles

What is Crohn’s Disease?

A type of inflammatory bowel disease (IBD) Inflammation of the digestive tract Affects all layers of the mucosa Can affect anywhere from the mouth to the anus

Most common area is the combination of the ileum and the colon Diseased area not always continuous

Crohn’s Disease

Cause: unknown Auto-immune

Who does it affect? Affects men and women equally African-Americans have decreased risk Symptoms occur between ages 15 to 30

Signs and Symptoms Severe abdominal pain Diarrhea Rectal bleeding Weight loss Fever

Research Article: MNT

Controlled trial comparing two types of enteral nutrition in treatment of active Crohn’s disease: elemental v polymeric diet

Objective: To compare how efficient both an elemental enteral diet (EED) and polymeric defined formula diet (PFD) are on disease activity and nutritional status of a patient with Crohn’s disease.

Design: Prospective randomized clinical trial

MNT Research Article Continued

Participants: 30 patients from two hospitals met the criteria: Active Crohn’s disease (CDAI > 150) Malnutrition and/or non-responsive to steroids Didn’t fall into any exclusion criteria categories No significant differences in age, sex, duration or activity of

disease, or previous complications or surgery

Independent Variables: EED (Vivonex HN) or PFD (Realmentyl or Nutrison)

Dependent Variables: Nutrition status and disease activity

MNT Research Article Continued

Methods: Patients randomly placed into EED or PFD group Nasogastric TF; no other food or caloric drinks allowed.

Medications d/c during study Therapeutic period lasted from 4-6 wks with the median

being 30 days Used CDAI to assess activity of Crohn’s disease once/wk Fecal output measured for 3 continuous days 3 times Colonoscopy before nutrition support initiated and after

therapeutic period Measurements to assess inflammation HGB, alb, and transferrin levels and anthropometric data

gathered on days 0, 14, 21, and 28

MNT Research Article Continued

Results: Remission of Crohn’s disease (CDAI < 150) in 21 of 30 patients

by week four - 10 from EED vs. 11 from PFD Significant decrease in fecal output was similar in both groups Colonoscopic lesions ameliorated with no significant difference

between the groups All patients had dramatic increase in inflammation Body wt, triceps skinfold, creatinine index, and albumin levels

improved in both groups Conclusion:

No significant difference between a polymeric or elemental enteral formula.

Enteral nutrition support may help achieve clinical remission of active Crohn’s disease

Research Article: CAM

Title: The Relation between Antioxidant Status and Alterations in Fatty Acid Profile in Patients with Crohn Disease and Controls

Objective To investigate if there is a correlation between serum antioxidant levels and fatty

acid profile in patients with active CD or inactive CD and in controls Design

Observational Study Design Variables

Independent: Active or Inactive CD Dependent: Association of the serum antioxidant levels and the fatty acid profile

CAM Research Article Continued

Methods 3 groups in study

Active CD (12) Inactive CD (50) Control (70)

Antioxidant status (taken from blood sample after overnight fast) Beta-carotene Copper Vitamin A Vitamin E Selenium Zinc

Fatty Acid Profile (Ethylenediaminetetaacetic acid (EDTA) blood sample after overnight fast)

Saturated fatty acids Polyunsaturated fatty acids Monosaturated fatty acids

Dietary Intake Food Frequency Questionnaire (FFQ)

CAM Research Article continued

Results

Conclusion There is a correlation between serum antioxidant status and fatty acid

profile Results may play role in pathophysiology or treatment of CD Further research needs to be conducted

Antioxidant Status Fatty Acid profile

Active CD

Lower B-carotene Higher copper than

Inactive CD

Higher SAFA, lower linoleic acid, and lower PUFA than inactive CD

Inactive CD

Lower B-carotene, vit. E, vit. C, zinc, and

selenium than control

Higher SAFA, lower arachidonic acid and

linolenic acid than control

Matthew Sims: Assessment

Anthropometrics Age: 35 Sex: Male Height: 5’9” (175 cm) Weight: 140 lbs (64 kg) BMI: 20.7 IBW: 160 lbs %IBW: 88% %UBW: 83% (loss over 6 mos)

Matthew Sims: Assessment

Medical History Complaint: Exacerbation of abdominal pain and

diarrhea Diagnosed with Crohn’s Disease 2 ½ years ago Previously hospitalized for 2 wks Allergies: possibly milk Underwent resection of 200 cm of jejunum and proximal

ileum with placement of jejunostomy Placed on parenteral nutrition

Matthew Sims: Assessment

Medication History Previously took corticosteroids 6-mercaptopurine

Immunosuppressive drug Usually treats leukemia Side effects: headache, weakness or achiness, darkening of skin,

loss of appetite or weight Multivitamin

Matthew Sims: Assessment

Social History Both Matthew and his wife purchase and prepare the food

Nutrition History Since being diagnosed with CD went on low fiber diet, and

drank Boost between meals to increase his calorie intake Had difficulty eating due to his abdominal pain and diarrhea Previously saw a dietitian to

Decrease diarrhea Create ways to keep him from being dehydrated Gain weight

Matthew Sims: Assessment

Recent dietary Intake: AM: Cereal, small amount of skim milk, toast or bagel, juice AM snack: Cola, sometimes crackers or pastry Lunch: Sandwich (ham or turkey) from home, fruit, chips, cola Dinner: Meat, pasta or rice, some type of bread, rarely eats

vegetables Bedtime snack: Cheese & crackers, cookies, cola

24 hr recall Clear liquids

Matthew Sims: Assessment

Biochemical Analysis Mild depletion of protein levels High c-reactive protein Low HGB, HCT and Ferritin

Anemic

Matthew Sims: Assessment

Parental Nutrition Initiated at 50 ml/hr with a goal rate of 85 ml/hr Composition

200 g/L dextrose = 1,387 kcal/day 42.5 g/L protein = 347 kcal/day 2,285 kcal/day 30 g/L lipid = 551 kcal/day

Needs Energy needs: 2,628 kcal/day Protein needs: 77 grams/day

Diagnosis

Clinical [NC-3.2]:

“Involuntary weight loss related to abdominal pain and diarrhea as evidenced by severe weight loss of 28 pounds in past 6 months.”

Intervention

Normalize alb, TTHY, transferrin, HGB, HCT, and ferritin levels

Current parenteral formula is not meeting patient’s kcal needs.- Recommend different formula providing 2,650 kcals instead of 2,285 kcals

Prevent any further weight loss & improve weight status

Monitor/Evaluate

Monitor albumin, prealbumin, transferrin, HGB, HCT, ferritin, and c-reactive protein levels

ADAT from clear liquids to regular diet. Wean patient from parenteral nutrition - discontinue once he is meeting 75% of kcal needs from oral diet-Consider TF if not meeting all of his needs orally within 3 days, or TPN if not tolerating

Follow-up with outpatient RD in 1 week and monitor weight status

References

“Crohn’s Disease.” National Digestive Diseases Information Clearinghouse (NDDIC). Retrieved November 17, 2008. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/index.htm

Geerling, B., Houwelingen, A., Badart-Smook, A. Stockbrugger, R., Brummer, R. “The relation between anitoxidant status and alterations in fatty acid profile in patients with Crohn disease and controls.” Scandinavian J Gastroenterol 1999:34: 1108- 1116.

Mahan, L., & Escott-Stump, S. (2004). Krause's Food, Nutrition, & Diet Therapy. Philadelphia: Saunders.

Pagana, K., & Pagana, T. (2007). Mosby's Diagnostic and Laboratory Test Reference (8th Ed.). St. Louis: Elsevier.

Rigaud, D., et al. “Controlled trial comparing two types of enteral nutrition in treatment of active Crohn’s disease: elemental versus polymeric diet.” Gut 1991:32: 1492-1497.