Ischemic colitisIschemic colitis

Stephanie Klein

Sodexo Mid-Atlantic Dietetic Intern

February 4, 2013

Major Case Study Presentation

ObjectivesObjectivesAudience will be able to name three

risk factors associated with ischemic colitis (IC)

Audience will be able to name the “gold standard” for diagnosing IC

Audience will be able to identify one difference between IC and IBD

Audience will be able to describe appropriate treatment options for IC

General Information: NTGeneral Information: NT48 year old femaleAdmitted on 12/11/12 for chronic

diarrhea, wt loss, metabolic acidosisChief complaint: weakness, anorexia

4-5 months, diarrhea (2-3 episodes/day)

Consult from MD for wt loss/diarrheaPt seen: 12/13, 12/14, 12/18, 12/20,

12/21

Diet PrescriptionDiet PrescriptionNPO upon admission (12/11-12/12)Advanced to clear liquids during first

assessment (12/13)

Past Medical HistoryPast Medical History Cholescytectomy

Childhood post-

Streptococcal

Glomerulonephritis s/p

three kidney transplants

Hemodialysis (with 2nd

kidney transplant)

Chronic

immunosuppressant

medication

Hepatitis C

Breast augmentation

Abdominoplasty

Bilateral thigh lift

Liposuction of knee

Fat injected into buttock

Chronic diarrhea/abdominal

cramping 5-6 years

36 pound wt loss

intentionally

Additional 20 pounds-

unintentionally

Negative for celiac disease

◦ Gastroenterologist

Social HistorySocial HistorySingle, Iranian womanDenies alcohol/drug useLives with fatherOnly childLived in Iran from age 5-18Mother recently passed away of small

bowel lymphoma r/t Crohn’s disease (10/12)

Current MedicationsCurrent MedicationsCellcept*PrografCentrum Silver IronPotassium ChlorideMagnesium OxideSodium BicarbonateVitamin B12Phytonadine (Vitamin K)ZantacZofran NS @ 150 ml/hr

AnthropometricsAnthropometricsWeight: 45.5 kg (100 lbs)

Height: 64 in (5’4)

BMI: 17 (underweight)

UBW: 54.5 kg (120 lbs)

% change: 16.5 % over 8 months

Initial Nutrition Assessment-Initial Nutrition Assessment-12/1312/13

Performed by RD at Suburban Hospital High calorie/protein diet- reviewed with Dietitian

PTAAvoids greasy/high fiber foodsLoves cottage cheese and fruitDrinks Boost 1x daily- willing to try other

supplementsCachectic, thin arms, temporal/clavicular wastingSkin appeared gray/paleEst. Energy needs: 1590-2045 (35-45

kcals/kg)Est. PRO needs: 55-65 g (1.2-1.4 g/kg)Documented Malnutrition

Recommendations-12/13Recommendations-12/13PES: Malnutrition r/t chronic diarrhea AEB BMI

17, wasting apparent, 16.5% wt loss in 8 months

Recommendations: Advance diet past CL to low fiber, Ensure TID, Magic Cup TID, appetite stimulant

Imodium given PTA- no improvement Goals: Diet advancement, tolerance of diet

w/out diarrhea, wt gain, maintain skin integrity

Monitor: nutrition orders, new wt, skinRisk: High (3-5 days)Awaiting EGD/colonoscopy planned for 12/14

Labs 12/13Labs 12/13Refer to handoutIndicative of metabolic acidosis:

◦ ↓ bicarbonate◦ ↓ pH◦ ↓ pCO2

◦ ↑ chloride◦ ↑ pO2

↓ K & ↓ Mg- diarrheaMg- repleted so was actually highPt diagnosed with non-anion gap

acidosis

Metabolic AcidosisMetabolic AcidosisCharacterized by a reduction in serum HCO3

◦ Secondary decrease in pCO2 & blood pH

NT:

◦ Low serum bicarbonate (HCO3)

◦ Decrease in pCO2 (rapid breathing- response

to low pH)

◦ Reduction in blood pHComplications

◦ Systemic vasodilation◦ Hypotension

Treatment: Sodium Bicarbonate

Follow-up: 12/14Follow-up: 12/14Colonoscopy:

◦ Patchy colitis throughout colon

◦ Not typical of Crohn’s disease

◦ Normal ileum◦ Hemorrhoids◦ Some shallow

ulcers◦ Biopsy results

pending

EGD:◦ Normal

esophagus/duodenum

◦ Gastritis◦ Possible small

bowel diseaseViral vs. Crohn’s

◦ Biopsies

Nutrition Assessment Nutrition Assessment 12/1412/14

Follow-up visit #1:◦Reports feeling better◦Appetite remains low◦Few bites of ice cream◦<25% meals consumed- inadequate◦No wt changes (100#)◦Reports wanting to gain wt-

motivated◦Diarrhea x 2◦Dislikes Ensure/Magic Cup

LabsLabs

12/14 Pt’s value Normal range

Indication

Potassium 3.4 mEq/L ↓ 3.5-5.5 mEq/L Diarrhea

Chloride 119 mEq/L ↑ 100-111 mEq/L Metabolic acidosis

CO2 19.9 mMol/L ↓ 22-32 mMol/L Metabolic acidosis

Education 12/14Education 12/14Low fiber foodsSmall frequent meals- assist po

intake/wt gain

Taste testing: ◦Vital po supplement◦Elemental- absorbed more efficiently ◦Greek yogurt (AM)- vanilla vs.

strawberry◦Peanut butter crackers (PM)

Recommendations 12/14Recommendations 12/14PES: No new diagnosisRecommendations: Continue regular diet, Vital

po TID, Greek yogurt AM, PB crackers PMCalories/protein kept the same- promote wt gain

Goals: intake at least 50% meals, wt gain1lb/week, soft formed stool

Pt wants to gain 25#- realistic goal of 1 lb/weekMonitor: adequacy of meal/supplement intake,

wt, labs/lytes, GI function, biopsy resultsRisk- High (3-5 days)

Follow-up 12/18Follow-up 12/18Biopsies still pendingDifferentiate IBD vs. GVHDStool samples pending

◦ Parasites, CMV-opportunistic infection MD thinking about lowering dose of

Cellcept◦ Possible cause of diarrhea

Nutritional Assessment Nutritional Assessment 12/1812/18

Follow-up visit #2:◦Appetite returned- consumes 75% of all

meals◦Drinks one Boost per day◦Prefers Boost over Vital po but willing to

mix for better tolerance◦Received Ensure- mix up with diet office◦2 pound wt loss (44.5 kg)◦Most likely d/t fluid◦Better appetite & appeared better◦No diarrhea today- believes resolving

LabsLabs12/18 Pt’s value Normal range Indication

Potassium 3.4 mEq/L ↓Trending WNL

3.5-5.5 mEq/L Diarrhea *Additional K+ ordered by MD- on K+ protocol

Chloride 112 mEq/L ↑Trending WNL

100-111 mEq/L Metabolic acidosis

CO2 20 mMol/L ↓Trending WNL

22-32 mMol/L Metabolic acidosis

Magnesium 1.5 mEq/L ↓ 1.6-2.6 mEq/L Diarrhea*on mg protocol

Education 12/18Education 12/18Discussed importance of po intakeContinued to encourage small

frequent meals (6-8)Encouraged mixing Vital po + Boost

for better tolerance & additional kcals/PRO

Recommendations 12/18Recommendations 12/18PES: No new diagnosisRecommendations: Continue regular diet,

Vital po TID- clarified to diet office, continue snacks (Greek yogurt & PB crackers)

Goals: sameMonitor: sameNote: closely monitoring biopsy results & wtRisk- High (3-5 days)

Follow-up: 12/20Follow-up: 12/20Follow-up visit # 3:

◦ MD ordered consult- “increase Na intake” (hypotension)

◦ Biopsy results- ischemic colitis◦ Plans for CT of abdomen

◦ Unable to educate or weigh: patient in pain

◦ Asked to come back 12/21

◦ Father reports pt consumes 75% of all meals & Boost/Vital po daily (mixed)

◦ d/c’d snacks (yogurt/PB crackers)

◦ Reports pain d/t consuming fried chicken- one episode of diarrhea

Labs/Plan 12/20Labs/Plan 12/20Unremarkable

◦ All values WNL◦ Clinically improved◦ Pt appears better, despite pain

No education performed◦ Left handout on high calorie/protein foods

New diagnosis: Altered GI function r/t chronic diarrhea AEB colonoscopy results revealing IC.

Recommendations: d/c snacks, Vital po TIDGoals: sameMonitor: same (no longer monitoring biopsy

results)Risk- high (3-5 days)- plans to educate 12/21

Ischemic colitis (IC)Ischemic colitis (IC)Lack of perfusion to colonMost common type ischemic injury1 in every 2000 hospitalizationsTypical in splenic flexure or “watershed”

areasLow blood flow areas- veins small/narrowOcclusive or nonocclusiveRight side (cecum/ascending)- typically

acuteMost cases mild/transientRare- gangrenous/severe

Picture of ICPicture of IC

Risk factorsRisk factors> 60 years of ageFemaleIBSCOPDCardiac/vascular diseaseHypercoagulable conditionsSepsisCocaine abuseLong distance running

Risk Factors-cont.Risk Factors-cont.InfectionsParasitesViruses (CMV-cytomegalovirus)Decline in intestinal blood pressureLupusHypovolemiaImmunosuppressive agentsLaxativesRenal failure requiring HDArterial hypertension, dyslipidemia, and

diabetes

Clinical manifestationClinical manifestationAbdominal painDiarrheaGastrointestinal bleeding (acute)Occasionally nausea

DiagnosisDiagnosisSuspicionBarium EnemaCT scanAbdominal radiographyColonoscopy- gold standardEGDStool samples- parasites, viruses Laboratory values- WBC, CRP

IC vs. IBDIC vs. IBD IC often misdiagnosed for IBD IBD (Crohn’s & Ulcerative colitis)Crohn’s- inflammation throughout entire GI tractUlcerative colitis- inflammation of colon/rectum IC- lack of perfusion to the colon causing

inflammation IBD may be hereditary or autoimmune reaction IBD before 30 years old IC >60 years old Industrialized country= higher risk for IBD Immunosuppressant meds= higher risk for IC

ComplicationsComplicationsBowel perforationPeritonitisPersistent bleedingProtein-losing enteropathyIntestinal stricturesResection

◦High risk for mortality◦Poor long term prognosis◦If done early- minimizes adverse

outcomes

Treatment- ICTreatment- ICConservative treatment

◦IV fluids◦Bowel rest◦Antibiotics◦Clear liquids

Parenteral NutritionResection

◦Poor prognosis◦High risk for mortality

NT’s TreatmentNT’s TreatmentIV fluids (NS @ 150 ml/hr)Sodium bicarbonatePotassium protocol (KCl)Magnesium protocol (Magnesium

oxide)Bowel rest (2 days NPO)Clear liquids (1 day)No TPN or resection indicated at this

timeSymptoms resolved; stable upon d/c

Final Assessment 12/21Final Assessment 12/21Not a full assessment- just educationCT scan- colonic wall thickening↑ CRP (5 mg/L) - all other labs WNLLast education:

◦ High calorie/high protein foods◦ Promote wt gain

PES: No new diagnosisRecommendations, goals, and

monitoring= sameRisk: Medium (pt eating well, >75% meals,

labs WNL, stool samples pending)= 5-7 daysD/C’d 12/24/12- plans to f/u w/MD as

outpatient

Final thoughtsFinal thoughtsCause still unknown- stool samples

pending upon d/cSuspect CMV/immunosuppressant

medicationsPt would benefit from consistent

outpatient f/up with MD & RD

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Questions??Questions??