Complications of

Ulcerative Colitis

Leah WendlandSodexo Mid-Atlantic Intern

February 1st 2013

Objectives

Be able to identify intestinal complications of UC

Be able to identify an extraintestinal complication of UC

Identify a potential treatment of UC and potential side effects of this treatment

Ulcerative Colitis (UC)“Approximately 10% of ulcerative colitis (UC) patients

require a colectomy within 10years of diagnosis”

Ulcerative Colitis (UC)a type of inflammatory bowel disease (IBD) that affects the lining of the large intestine (colon) and rectum

Click icon to add picture

Intestinal Complications of UC

Malnutrition/Malabsorption Bleeding

anemia

Intestinal Infections Colorectal cancers Colectomy

Extraintestional Complications

Arthritis Diminished bone health Liver and Gall Bladder disorders

primary sclerosing cholangitis (PSC) cirrhosis

Thromboembolism Kidney stones

Treatments for UC

Diet/Nutrition Medication

Aminosalicylates Corticosteroids Immunosuppressants

Surgery

Long term effects of UC medication

Corticosteroids (prednisolone, methylprednisolone) Weight gain, excessive facial hair, HTN,

Hyperglycemia, osteoporosis/weakened bonesAnti-inflammatory

Aminosalicylates (mesalamine, balsalazide) nausea, vomiting, diarrhea, heartburn and headache

Anti-inflammatory

Immunosuppresents (Azasan, Imuran) Increased risk of infection/opportunistic infections

Anti-inflammatory

Nutrition Therapy for UC

Low- fiber diet during flare up High-fiber diet while in remission Possible lactose, gluten or wheat

intolerance Modify diet to fit needs of individual pt

No nuts, seeds, skins, popcorn etc.

AS 47 y/o F

Admitted 12/14 to post acute care/rehab floor

Patient admitted to this floor for PT 2° deconditioning

Antibiotic therapy

PMH

Ulcerative Colitis s/p colectomy 2°

severe colitis HTN GERD Recurrent renal stones Arthritis Appendectomy

Ulcerative Colitis Diagnosis 1996

16 years w/o major complications

Medical Diagnosis

S/P total colectomy with end ileostomy c/b rupture of Hartmann’s stump With perihepatic and intra-abdominal

abscesses Requiring antibiotic therapy

Deconditioning

Colectomy with End Ileostomy

Hartmann’s Stump

Location of Abscesses

Social History

Single Lives alone Has 2 grown children No reported drug or tobacco use

Nutrition AssessmentAnthropometric

Ht: 5’2” (156cm) Wt: 193# (87.6kg) Adj Wt: 130# (59kg) BMI: 34

Subjective/Objective

Pt consuming >75% meals

Stage 2 wound on buttock

Surgical wound on abdomen (healing)

Intra-abdominal abcesses

Nutrition Related Medication

Multivitamin Hydrochlorothiazide Folic Acid Ranitidine Zofran

Labs

Lab Value Range 12/15 12/19Sodium 136-145mEq/L 138 136Potassium 3.5-5.5mEq/L 3.6 3.6BUN 8-18mg/dL <5 L <5 LCreatinine .6-1.2 mg/dL .8 .8BG 70-110mg/dL 79 79Calcium 9-11mg/dL 7.8 L 7.8 LMagnesium 1.8-3mg/dL 2 2Phosphorous 2.3-4.7mg/dL 4.4 4.4WBC 4.8-11.8 11.7 12.5 H

Nutrition DxIncreased Nutrient Needs r/t wound healing a/e/b Stage 2 wound on buttock and surgical

abdominal wound

Unintentional Wt. Loss r/t medical course with low intake and increased needs a/e/b pt

reporting ~20# wt loss in <1month

Diet and Estimated Needs

Regular Diet >75% intake first visit

Ensure Complete TID

Caloric Needs: 30-35kcal/kg 30-35x adj BW59kg=

1770-2065kcal

Protein Needs: 1.3-1.5g/kg 1.3-1.5gx adj BW

59kg= 77-89g

Intervention and M/E

Nutrition Intervention: Rec Ensure Complete

TID Continue multivitamin,

folic acid

Monitoring and Evaluation PO/Supplement intake:

pt to meet ≥75% estimated needs

Weight: Pt to maintain weight +/- 3% in one month

Lab Values: monitor nutrition related lab values WNL

Follow Up

12/19: *my first contact Reported N/V Provided new diagnosis Altered GI function r/t colectomy and recent

hospital course a/e/b Pt reporting N/V, hx ileostomy and colectomy

Medications added Warfarin

Provided ileostomy nutrition education as well as Vit K/ warfarin education

Evaluation of Compliance

AS was actively engaged in education Asked questions Provided feedback on supplement and food Pt appeared to be motivated

Lab Values F/ULab Value Range 12/21 12/27 12/31 1/4 1/10Sodium 136-145mEq/L 139 140 141 140 140Potassium 3.5-5.5mEq/L 2.9 L 3.1 L 3.5 L 3.5

L4.4

BUN 8-18mg/dL <5 L <5 L <5 L <5 L

<5 L

Creatinine .6-1.2 mg/dL .7 .8 .7 .7 .7BG 70-110mg/dL 84 67 84 73 78Calcium 9-11mg/dL 7.3 L 7.6 L 7 L 7.4

L8.0 L

Magnesium 1.8-3mg/dL 1.9 1.6 L 1.7 L 1.8 1.9

Phosphorus 2.3-4.7mg/dL 3.0 3.0 n/a 3.0 n/a

WBC 4.8-11.8 9.5 9.2 9.2 10.9

11H

Date GI distress

PO New Medications

Change to care plan

Education Provided

12/21 No complaints

>50% KCL none Encouraged intake

12/27 N/V <50% none Consider appetite stimulant

Food preferences obtained

12/31 N/V <50% 2.5mg MarinolMagnesium

none Encouraged intake

Follow Up Chart

Follow Up Chart cont.Date

GI distress

PO New Medications

Change to care plan

Education Provided

1/4 Nausea <50%

none Discontinue ensureAdd resource breeze TID, arginaid BID, glutasolve 1x daily

Encouraged intake

1/9 N/V <50%

none MD to place NGT. Discontinue modulars

Encouraged intake, NGT for nocturnal feeds

1/10 N/V <50%

5mg Marinol BID

Attempt NGT again

Educated on importance of NGT

Hospital Course

Updates

References http://www.caet.ca/caet-english/education-ileostomy-guide.htm

http://www.askdrmakkar.com/ulcerativecolitis.htm

Forbes, A., Goldesgeyme, E., & Paulon, E. Nutrition in inflammatory bowel disease. Journal of Parenteral and Enteral Nutrition, 2011; 35(5), 571-580.

Peppercorn, M. Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults. UpToDate,2011

Ma, C., Crespin, M., Proulx, M., DeSilva, S., Hubbard, J., & Hubbard, J. Postoperative complications following colectomy for ulcerative colitis: a validation study. BMC Gastroenterology,2012;

Comorbidity in inflammatory bowel disease (San Roman,Munoz ,2011)

Ardizzone, S., Puttini, P. S., Cassinotti, A., & Porro, G. B. Extraintestinal manifestations of inflammatory bowel disease. Digestive and Liver Disease, 2008; S253-S259.

Herrera, J. Hepatobiliary complications of inflammatory bowel disease. Practical Gastroenterology,2006

Nguyen, G. C., & Sam, J. Rising prevalence of venous thromboembolism and its impact on mortality among hospitalized inflammatory bowel disease patients. American Journal of Gastroenterology, 2008; 2272-2280.

References cont. Warner, B. Short and long term complications of colectomy. Journal of

Pediatric Gastroenterology and Nutrition, 2009; 48(2), S72-S74. Loftus, E. V., Friedman, H. S., Delgado, D. J., & Sandborn, W. J. Colectomy

subtypes, follow-up surgical procedures, post surgical complications, and medical charges among ulcerative colitis patients with private health insurance in the united states. Inflammatory Bowel Disease, 2009; 15(4), 566-575.

Tappenden, K. Quest for excellence: inspiration from the illeum. Journal of Parenteral and Enteral Nutrition, 2010; 34(6), 716-722.

Camden, J., & Carucci, L. Internal illiac pseudoaneurysm rupture attributed to perforated hartmann's pouch diagnosed on ct. Open Journal of Radiology, 2012; 52-54.

Xue, H., Sufit, A., & Wischmeyer, P. E. Glutamine therapy improves outcome of in vitro and in vivo experimental colitis models. Journal of Parenteral and Enteral Nutrition,2011; 35(2), 188-197.

Questions?Thank you!!