Kaitlyn Click Professor Matuszak KNH 41116 September 2014

Lower GI Disorders Case Study #11

Case Questions:

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 diasnoses: ulcerative colitis and Crohn’s disease (Nelms, Sucher, Lacey & Roth, 2011, p. 377). Ulcerative colitis (UC) primarily affects the colon and rectum while Crohn’s mostly affects the ileum and colon. The diagnoses are very similar but have individual differences as well. IBD is mostly prevalent in the Northern Hemisphere, where it affects approximately 5 to 15 US citizens of 100,000 people. Both males and females are prone to the disease and it is highest in those of Caucasian and Ashkenazi ancestry. Complete etiology is currently unknown, however, the understanding is that many factors can cause IBD. These factors include several environmental factors such as smoking, infectious agents, intestinal flora, and physiological changes in the small intestine. Genetic factors and associations also play a strong role in susceptibility of IBD in both innate and acquired immune response cases. Approximately 5% to 15% of patients have positive family history. Also, identical twins have a much higher percentage than fraternal twins (Nelms, Sucher, Lacey & Roth, 2011, p. 415-417).

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?

Mr. Sims was initially diagnosed with ulcerative colitis and then with Crohn’s disease six months later when he was in the hospital for over two weeks. The initial diagnosis of UC could have been determined because of the peak onset age difference between the two diseases. Mr. Sims was 35 years old which suggests UC with a peak onset of 20 to 30 years of age, where as Crohn’s peak onset age is around the teens or twenties. Many signs and symptoms are also similar such as diarrhea, abdominal pain, fever, and weight loss. Lastly, many of the tests to determine the disease overlap such as fecal markers of inflammation: calprotectin (Cal), lactoferrin (Lf) lab results, imaging tests of wireless capsule endoscopy and colonoscopy, and other procedures such as mucosal biopsies. The chart below shows the differences between the two diagnoses and the italicized phrases indicate the similarities between the two (Nelms, Sucher, Lacey & Roth, 2011, p. 416-419).

Table 15.3

Ulcerative Colitis Crohn’s DiseaseEtiology Abnormal immune response

resulting in inflammatory damage of gastrointestinal mucosa; genetic susceptibility;

association with ex-smokers

Abnormal immune response resulting in inflammatory damage of gastrointestinal mucosa; genetic susceptibility;

association with cigarette smoking

Epidemiology Both sexes affected equally; higher prevalence in North America; highest incidence in Ashkenazi Jews;

approx. 10% of those with UC have a 1st degree relative with the disease; peak onset 20-30 years w/secondary peak in middle age

Both sexes affected equally; higher prevalence in North America; highest incidence in Ashkenazi Jews;

peak onset is teens to twenties

Pathology GI tract unable to distinguish foreign from self-antigens; characterized by chronic inflammation of colonic mucosa and submucosa, atrophy and possible dysplasia limited to colon; extent of disease varies and may only involve the rectum left side of colon to splenic flexure, or entire colon

Localized inflammation in bowel mucosa progressing through bowel wall; tends to be localized in terminal ileum and colon but can involve any portion of the GI tract

Signs and Symptoms Bloody diarrhea with mucusAbdominal and/or rectal painFeverWeight lossPossibly constipation and rectal spasmArthritisDermatological changesOcular manifestations

Chronic diarrheaAbdominal pain and crampingBlood and/or music in stoolAnorexiaWeight lossMalnutritionFeverDelayed growth in adolescents

Complications Severe bleedingToxic colitisToxic megacolonStricturesPerforationIntolerance to

MalabsorptionMalnutritionAbdominal fistulas and abscessesIntestinal obstructionBacterial overgrowth (blind

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immunosuppressionColonic stricturesDysplasiaCarcinoma

loop syndrome)GallstonesKidney stonesUrinary tract infectionsThromboembolic complicationsPerianal diseaseNeoplasia

Diagnosis Abdominal ultrasoundMRICTAntiglycan antibodies (ASCA/ANCA)Cal, Lf, PMN-e

Clinical presentation—CDAI scoreAbdominal ultrasoundMRICTAntiglycan anitbodies (ASCA/ANCA)Cal, Lf, PMN-e

Prognosis Chronic with repeated exacerbations and remissions; nearly 30% of those with extensive UC require surgery; patients with localized UC have prognosis, surgery rarely required, and life expectancy normal

Rarely cured, but characterized by intermittent exacerbations; approximately 70% require surgery

Treatment Reduce acute and chronic inflammation eventually resulting in remission; Drugs: immunosuppressants, adrenocorticosteroids, anti-inflammatory, biologic therapies, antidiarrheals, steroids; surgery: colectomy, subtotal colectomy, total proctolectomy with Brooke ileostomy, restorative proctocolectomy with ileal pouch-anal anastomosis

Based on severity of disease; drugs: immunosuppressants, antibiotics, steroids, methotrexate, biologic therapies; surgery: surgical removal of affected areas—may include ileocolic resections, segmental resections, total proctocolectomy and ileostomy

(Nelms, Sucher, Lacey & Roth, 2011, p. 416-417)

3. A CT scan indicated bowel obstruction and the Crohn’s disease was classified as severe-fulminant disease. CDAI score of 400. What does a CDAI score of 400 indicate? What does a classification of severe-fulminant disease indicate?

Crohn’s disease is described using the CDAI, which stands for Crohn’s Disease Activity Index. Many factors are evaluated using this index such as but not limited to abdominal pain, diarrhea, labs, and weight loss. Patients that have a score of over 150 are having a flare-up, where as those

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with a score over 300 are having severe exacerbation. Mr. Sims’ score of 400 indicates that he is at a moderate-severe stage of the disease. This means that he has failed to respond to treatment used for the mild-moderate stage or he has more major symptoms of fevers, significant weight loss, abdominal pain or tenderness, intermittent vomiting and nausea, or significant anemia. A severe-fulminant classification is the next stage with a CDAI greater than a score of 450. This stage of the disease indicates that individuals have persisting symptoms in spite of the introduction of steroids or biologic agents as outpatients, or patients with high fever, continuation of vomiting, intestinal obstruction, rebound tenderness, evidence of an abscess, or cachexia (Nelms, Sucher, Lacey & Roth, 2011, p. 418-419).

4. What did you find in Mr. Sims’ history and physical that is consistent with his diagnosis of Crohn’s? Explain.

Mr. Sims’ medical history indicates that his initial diagnostic workup showed acute disease within the least 5-7 cm of jejunum and first 5 cm of ileum. Crohn’s affects mainly the colon and ileum but can involve any portion of the GI tract (Nelms, Sucher, Lacey & Roth, 2011, p. 417). Also, he reports that once he went back to school, he was experiencing more diarrhea and abdominal pain, as well as a fever now. He has also lost a considerable amount of weight in the last six months, going from around 166-168 lbs to 140 lbs. Also, he has abdominal distension and extreme tenderness with rebound and guarding. These are all signs and symptoms associated with Crohn’s disease (Nelms, Sucher, Lacey & Roth, 2011, p. 416).

National Digestive Diseases Information Clearinghouse (NDDIC). (n.d.). Retrieved September

13, 2014, from http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/#5

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?

Examples of extraintestinal symptoms, or disease manifestations outside the GI tract, include osteopenia and osteoporosis, dermatitis, rheumatological conditions such as ankylosing spondylitis, ocular symptoms, and hepatobiliary complications (Nelms, Sucher, Lacey & Roth, 2011, p. 418). His history and physical did not show any signs of these symptoms.

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 anti-inflammatory drugs that are also immunosuppressive, meaning they reduce the activity of the immune system. They closely resemble the naturally occurring hormone, cortisol, which the body produces in the adrenal glands. Normal production is slowed down if corticosteroids are taken. These are usually prescribed to patients with moderate to severe symptoms.

Mesalamine, on the other hand, is a form of medication classified as aminosalicylates, which contain 5-aminosalicyclic acid, which helps to control inflammation. This medication is usually

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prescribed to patients with mild symptoms and with Crohn’s disease with ileal and colon involvement (Nelms, Sucher, Lacey & Roth, 2011, p. 419).

Humira is a prescription drug used to alleviate the signs and symptoms of Crohn’s disease. Crohn’s patients produce too much of a protein called TNF, also known as tumor necrosis factor. Too much of this protein can cause the inflammation that causes the pain, diarrhea, and symptoms associated with the disease. Humira works to target and block this protein and reduce the inflammation. This medication is also immunosuppressive and could make fighting potential infections more difficult.

Crohn's & Colitis. (n.d.). Retrieved September 13, 2014, from

http://www.ccfa.org/resources/corticosteroids.html

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

13, 2014, from https://www.humira.com/crohns/how-humira-works-for-crohns

National Digestive Diseases Information Clearinghouse (NDDIC). (n.d.). Retrieved September

13, 2014, from http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/#5

7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease? Identify and explain these values.

There are a couple of laboratory tests that can be indications that there was an exacerbation of Crohn’s disease. Assessing the RBC and WBC count can be an indicator. Usually, if the WBC count is on the high side, there was inflammation or infection present. A low RBC count can indicate possible anemia as well, which can be consistent with Crohn’s as well. An elevated C-reactive protein level can also indicate inflammation, as well as low albumin levels indicating severe or long-standing symptoms. Mr. Sims’ RBC count is in the normal range but on the lower end. Similarly, his WBC count is within the range but on the higher end. His C-reactive protein is consistent with the exacerbation because it is much higher than the reference range. His albumin level is lower then the range. Also, ASCA is a marker to distinguish between Crohn’s and UC, and Mr. Sims was positive. Lastly, his hemoglobin and hemocrit levels are low which can indicate anemia. These values show that he is experiencing severe symptoms, inflammation, and infection due to his diagnosis of Crohn’s disease and they are consistent with an exacerbation (Nelms, Sucher, Lacey & Roth, 2011, p. 418-419).

Reference Range 2/15RBC (x103/mm3) 4.2-5.4 F

4.5-6.2 M4.9

WBC (x103/mm3) 4.8-11.8 11.1C-reactive protein (mg/dL) <1.0 2.8Albumin (g/dL) 3.5-5 3.2ASCA Neg +

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Hemoglobin (Hgb, g/dL) 12-15 F14-17 M

12.9

Hemocrit (Hct, %) 37-47 F40-54 M

38

How do you diagnose Crohn's disease? | Beth Israel Deaconess Medical Center. (n.d.). Retrieved

September 14, 2014, from

http://www.bidmc.org/Centers-and-Departments/Departments/Digestive-Disease-Center/

Inflammatory-Bowel-Disease-Program/Crohns-Disease/How-do-you-diagnose-Crohns-

disease.aspx

8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why he may be at risk for vitamin and mineral deficiencies.

Mr. Sims is currently taking a multivitamin daily. Patients with Crohn’s disease, such as Mr. Sims, are at risk for a number of vitamin and mineral deficiencies. Some of these vitamins and minerals include vitamin B12, water-soluble vitamins, fat-soluble vitamins, folate, calcium and vitamin D, iron, magnesium, and zinc. First, since vitamin B12 is absorbed in the lower ileum, Mr. Sims is at risk of a B12 deficiency because of his surgical removal of 5-7 cm of jejunum and 5 cm of ileum previously. A diet low in fiber can result in a deficiency of vitamin C if not enough fruit is being eaten. Fat-soluble vitamins are a concern with steatorrhea. Calcium and vitamin D are a concern if there is long-term steroid use or decreased intake of dairy foods as a result of a lactose-restricted diet. Folate deficiency can be caused from medications used to treat IBD. Additionally, magnesium and zinc deficiency can occur when there is intestinal loss or high-volume diarrhea. And lastly, iron deficiency can occur from blood loss and malabsorption. Mr. Sims should continue to take his supplements because he already lacks fruits and vegetables in his diet. A nutrition consult to educate him on what fruits and vegetables would be appropriate for him could help with these deficiencies as well (Nelms, Sucher, Lacey & Roth, 2011, p. 420).

Crohn's & Colitis. (n.d.). Retrieved September 14, 2014, from

http://www.ccfa.org/resources/diet-and-nutrition-1.html

9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel syndrome, and provide a rationale for your answer.

Short bowel syndrome (SBS) is “decreased digestion and absorption that result from a large resection of the small intestine” (Nelms, Sucher, Lacey & Roth, 2011, p. 377). There are about four cases per 1 million considered to be SBS each year. Common causes for SBS include malignancy, harm from radiation therapy, multiple resections from Crohn’s disease, vascular accident, and trauma. Many factors are taken into consideration such as the remaining small intestine, colon and ileocecal valve presence, health of the remaining GI tract, and individual

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cases. Also, if there was more than 70% of the GI tract removed, there are severe nutritional and metabolic complications as a result. O’Keefe also defined SBS as “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, Sucher, Lacey & Roth, 2011, p. 424). Even though Mr. Sims is experiencing severe diarrhea and symptoms that would match up with SBS, I would not consider him a candidate yet because he has not had any surgeries or significant indicators. However, I do think that he is at a high risk of developing SBS if he continues to experience symptoms and inflammation without proper treatment and dietary consultation. His previous resection of his jejunum and ileum put him at a greater risk as well.

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

There are three phases of adaptation that the small intestine goes through after resection. The first phase is the first postoperative period that can last about 7 to 10 days. This phase is characterized by extensive fluid and electrolyte losses with large amounts of diarrhea. Patients are dependent on parenteral nutrition, which provides necessary nutrients and manages the fluid and electrolyte balance. The second phase can last several months. This phase is characterized by a reduction in diarrhea and initial stages of adaptation of the bowel. Enteral nutrition can be introduced in this phase and a slow transition to oral intake. Lastly, the third phase continues with adaptation. Increased blood flow, secretions, and cell growth characterize this phase. The inner lumen of the small intestine begins to increase in length, diameter, and villous height. This phase lasts 1 to 2 years. Enteral feeding is continued and supports the adaptation (Nelms, Sucher, Lacey & Roth, 2011, p. 425).

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

Since Mr. Sims is already experiencing, his health care team should continue to monitor his fluids and electrolytes, as well as the nutrients that he could be losing. This could lead to malabsorption and malnutrition that can be dangerous for Mr. Sims in his current state. His vitamin B12 and bile salts should be monitored because loss of ileum prevents absorption and reabsorption, respectively. This could also lead to fat malabsorption. Therefore, on top of monitoring his micronutrients, it is important that his health care team monitor his macronutrients as well. Nutritional and metabolic complications are possible if the ileocecal valve can no longer control intestinal motility and prevention of translocation of bacteria from the colon to the small intestine. The health care team should closely monitor vitamins A, D, E, K, and nutrients including sodium, magnesium, iron, zinc, selenium, and calcium if his diarrhea continues (Nelms, Sucher, Lacey & Roth, 2011, p. 425).

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 clinical trial using high-dose immunosuppression and autologous peripheral blood stem cell transplantation could help Mr. Sims by being an effective way to induce remission of his Crohn’s

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disease. There is still some controversy about the treatment, however, even in the incidences of relapse, the patients were able to control the disease activity with low doses of conventional therapy and corticosteroids. The treatment should be further analyzed but seems to currently do more good than harm.

Hasselblatt, P., Drognitz, K., Potthoff, K., Bertz, H., Kruis, W., Schmidt, C., ... Kreisel, W.

(2012, October). Remission of refractory Crohn's disease by high-dose

cyclophosphamide and autologous peripheral blood stem cell transplantation. Retrieved

September 14, 2014, from http://www.ncbi.nlm.nih.gov/pubmed/22937722

II. Understanding the Nutrition Therapy

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

There are many potential nutritional consequences of Crohn’s disease. Crohn’s is characterized by affecting the normal digestion and absorption of nutrients. It may also increase caloric, protein, and micronutrient needs, which can lead to malnutrition in may cases. Further consequences include inadequate energy intake, inadequate oral intake, impaired nutrient utilization, food-medication interaction, and altered nutrition-related lab results. Malnutrition can lead to anorexia, anemia, osteoporosis, a compromised immune system, and lack of wound healing. Due to the many problems that can arise from improper intake and absorption of nutrients, nutrition therapy is very important in management and treatment of Crohn’s disease. Furthermore, many deficiencies (discussed in the vitamin and mineral paragraph above) come from severe diarrhea, which accompanies Crohn’s and can contribute to the malabsorption and malnutrition issues. When there is inflammation, protein and energy needs are greater, sometimes by 150% and should be closely monitored (Nelms, Sucher, Lacey & Roth, 2011, p. 419-420).

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?

The small intestine is approximately 6 meters long (600 cm). This consists of the duodenum, the jejunum, and the ileum. Mr. Sims had 200 cm removed, which is about one-third of his small intestine. His resection was not too significant because the small intestine is capable of adapting and can adjust its function efficiently. Also, his ileocecal valve was preserved which protects the small intestine from bacteria translocation by staying closed except when digesting. Furthermore, over 50% has to be removed before there would be a significant reduction in the functional capabilities. For example, the duodenum can take over and perform the same functions as the jejunum. Therefore, in Mr. Sims’ case, his resection is not considered significant (Nelms, Sucher, Lacey & Roth, 2011, p. 377-378).

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Small/Large Intestine Length Ratio. (n.d.). Retrieved September 15, 2014, from

http://carta.anthropogeny.org/moca/topics/smalllarge-intestine-length-ratio

15. What nutrients are normally digested and absorbed in the portion of the small intestine that has been resected?

Mr. Sims had part of his jejunum and ileum resected. The jejunum is responsible for digesting and absorbing lipids, monosaccharaides, amino acids, small peptides, thiamin, riboflavin, niacin, pantothenate, biotin, folate, vitamin B6, vitamin C, vitamins A, D, E, and K, calcium, phosphorus, magnesium, iron, zinc, chromium, manganese, and molybdenum. The ileum is responsible for bile salts and acids, vitamin C, folate, vitamin B12, vitamin D, vitamin K, magnesium, and others (Nelms, Sucher, Lacey & Roth, 2011, p. 384).

III. Nutrition Assessment

16. Evaluate Mr. Sims’ % UBW and BMI.

Mr. Sims’ BMI classifies him as a normal weight. His %UBW indicates that he has moderate malnutrition. Additionally, he has unintentionally lost about 17% of his weight over the last six months.

BMI= kg/m2

Current weight: 140 lbs/2.2= 63.6 kgHeight: 69 in x 2.54 = 175.3 cm=1.753 m= 3.07 m2

BMI= 63.6 kg/3.07=20.7 kg/m2

%UBW = (100 x Actual Weight)/Usual body weight= (100 x 140)/168= 83.3%

% Involuntary wt loss = (UBW – actual body wt)/usual body wt x 100= (168 – 140)/(168) x 100= 16.7%

Nutrition assessment practice guideline. (n.d.). Retrieved September 16, 2014, from

http://www.mercycares.com/uploads/pdf/Adult nutrition assessment.pdf

17. Calculate Mr. Sims’ energy requirements.

Mr. Sims has lost almost 30 lbs in the last six months. To obtain his ideal body weight, the Hamwi Method was used. Mr. Sims is currenly about 20 lbs from his IBW. The Mifflin-St. Jeor equation was used and the activity factor for his actual energy needs. The activity factor of 1.4 was used for stress because he is a high school math teacher and responsible advisor of school

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clubs, assuming his physical activity only revolves around his involvement at the school. Using these equations, it was determined that he would need about 2300 kcal a day to maintain his ideal weight.

Hamwi Method to obtain Ideal Body Weight:

106 lbs + 6(9)= 160 lbs 160 lbs/2.2= 72.7 kg

IBW + 0.25 (usual- IBW)= 160 + 0.25 (168-160)= 162 lbs162 lbs/2.2= 73.6 kg

Mifflin-St.Jeor:

REE= 10 x wt(kg) + 6.25 x ht(cm) – 5 x age (yrs) + 5 = 10 x 73.6 kg + 6.25 x 175.3 cm – 5 x 35 + 5 = 736 + 1095.6 – 175 + 5 = 1661.6 kcal

Actual energy needs using the activity factor of 1.4:

TEE= REE x activity factor1661.6 x 1.4=2326.2 kcal~2300 kcal needed to maintain weight

(Baur, Liou & Sokolik, 2012, pg.118)(Mitchell, 2003, p. 398)

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

For Mr. Sims’ current weight, his protein requirements should be as high as 1.5 to 1.75 g protein/kg. This means that he should be getting between 95.4 grams and 111.3 grams of protein a day. His consumption should be this high because of his low albumin levels and significant loss of weight in the last six months (Nelms, Sucher, Lacey & Roth, 2011, p. 421).

Protein requirements:

1.5 g x 63.6 kg= 95.4 g protein/day 1.75 g x 63.6 kg= 111.3 g protein/day

19. Identify any significant and/or abnormal laboratory measurements from both his hematology and his chemistry labs.

The chart below indicates both the significant and abnormal lab results. Mr. Sims had low protein, albumin, and prealbumin levels, which indicates that there is malabsorption of protein due to his exacerbation of Crohn’s. Mr. Sims’ C-reactive protein was high which is also an

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indication that his Crohn’s has worsened. His HDL-C levels were also quite low which may be a result of malabsorption as well. His ASCA was positive, which is an indicator of Crohn’s instead of UC (Nelms, Sucher, Lacey & Roth, 2011, p. 417-419). In his hematology results, his WBC and RBC counts were in the normal range but just on the bubble of being too high and too low, respectively. His hemoglobin and hemocrit were low suggesting anemia. His transferrin and ferritin levels were low which indicates an iron deficiency. Also, high levels of ZPP (zinc protopophyrin) supports iron deficiency as well because when there is not enough iron for hemoglobin synthesis, zinc becomes substituted (Nelms, Sucher, Lacey & Roth, 2011, p. 57). Lastly, low levels of Vitamin D 25 hydroxy, free retinol, and ascorbic acid indicate deficiencies in vitamin D, vitamin A, and vitamin C due to symptoms of Crohn’s such as diarrhea, diet restrictions, and resection of the ileum (Nelms, Sucher, Lacey & Roth, 2011, p. 419-420).

Reference Range 2/15ChemistryProtein, total (g/dL) 6-8 5.5Albumin (g/dL) 3.5-5 3.2Prealbumin (mg/dL) 16-35 11C-reactive protein (mg/dL) <1.0 2.8HDL-C (mg/dL) >55 F, >45 M 38ASCA Neg +HematologyWBC (x103/mm3) 4.8-11.8 11.1RBC (x103/mm3) 4.2-5.4 F

4.5-6.2 M4.9

Hemoglobin (Hgb, g/dL) 12-15 F14-17 M

12.9

Hemocrit (Hct, %) 37-47 F40-54 M

38

Transferrin (mg/dL) 250-380 F215-365 M

180

Ferritin (mg/dL) 20-120 F20-300 M

16

ZPP (umol/mol) 30-80 85Vitamin D 25 hydroxy (ng/mL)

30-100 22.7

Free retinol (vitamin A; ug/dL)

20-80 17.2

Ascorbic acid (mg/dL) 0.2-2.0 <0.1

IV. Nutrition Diagnosis

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

PES #1: Malnutrition (NI-5.2) related to Crohn’s disease symptoms of diarrhea and malabsorption of nutrients as evidenced by abnormal laboratory values such as low vitamin D 25

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hydroxy, free retinol, and ascorbic acid and lack of nutrients present in the food specified in the patient’s self-repot of recent dietary intake.

PES #2: Inadequate protein intake (NI-5.7.1) related to need for greater amount of protein in diet from Crohn’s disease as evidenced by substantial weight loss in the last six months and low laboratory values of total protein, albumin, and prealbumin.

(Academy, 2014)

V. Nutrition Intervention

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 the first 7-10 day period, the nutrition support team will need to closely monitor Mr. Sims’ fluid and electrolyte levels. During this phase, he will experience a large volume of diarrhea, which will result in significant losses of fluids and electrolytes. They will also need to control his parenteral nutrition intake so that he can get the required nutrients as well as keep the fluid and electrolyte levels balanced. For several months following those 7 to 10 days, he will have fewer bouts of diarrhea and the support team should recognize a gradual adaptation of the remaining bowel starting. If so, they can route him to an enteral nutrition plan with a slow transition to an oral diet. Over the next couple years, there will be continues adaptation of the remaining bowel and the nutrition support team can evaluate how to proceed with enteral feeding and necessary nutrients in his diet to support successful adaptation (Nelms, Sucher, Lacey & Roth, 2011, p. 425).

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 serum magnesium is also known as hypomagnesaemia. This is a concern because this condition may result in tremor, muscle twitching, cardiac arrhythmias, and paralysis. On the other hand, an increase in the levels of magnesium, potassium, and thiamin due to anabolic needs may cause a drop in the serum phosphorus levels. If this is severe, it is a concern because it could result in hemolysis, impaired cardiac function, impaired respiratory function, or death (Nelms, Sucher, Lacey & Roth, 2011, p. 93). If magnesium levels are below 1.8 mg/dL, they are considered low. General symptoms may include but are not limited to personality changes, depression, nausea, anorexia, and vomiting. Also, magnesium is important for cellular energy metabolism. Similarly, phosphorus is important for the metabolism of substrates and is a component of ATP, DNA, and RNA. It also is a part of acid-base balance and a structural comenent in the body. Low serum level of phosphorus is also called hypophosphatemia (Nelms, Sucher, Lacey & Roth, 2011, p.132-133).

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

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Refeeding syndrome is a term describing “several common metabolic alterations that may occur during nutritional repletion of starved patients” (Nelms, Sucher, Lacey & Roth, 2011, p. 93). It is also defined as having possibly fatal shifts in fluid and electrolyte balances after receiving artificial feeding, either enteral or parenteral. The main feature is hypophosphatemia, however, other deficiencies can also occur including hypomagnesaemia. The starvation starts when the body switches to using fat and protein for energy instead of carbohydrate. This is usually aimed at preventing protein and muscle breakdown. In refeeding, the cells take up magnesium and phosphorus and when the cells undergo osmosis, this causes these mineral levels to deplete. This happens because of the surge of insulin and decrease secretion of glucagon. The insulin stimulated the fat, glycogen, and protein synthesis that caused the cells to take up the minerals. Refeeding syndrome can be prevented by first being able to identify if patients are at a high risk. Some indicators that a patient could be at a high risk include but are not limited to going five or more days with negligible food intake, reduced absorption of nutrients for example from IBD, increased metabolic needs, chronic malnutrition, uncontrolled diabetes, elderly, postoperative, anorexia, alcoholism, unintentional weight loss of >15%, low levels of potassium, phosphate, and magnesium before feeding, BMI < 16, little or no nutritional intake for >10 days, and oncology. According to these symptoms of high-risk patients, Mr. Sims is considered at risk for refeeding syndrome because he relates to several of the criteria, which is italicized.

Mehanna, H., Moledina, J., & Travis, J. (2008, June 28). What is refeeding syndrome? Retrieved

September 15, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/

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); lipid (g); and total kcal from his PN.

I agree with Mr. Sims’ team’s decision to initiate parenteral nutrition because he will need time to let his remaining bowel adapt (Nelms, Sucher, Lacey & Roth, 2011, p. 425). I originally estimated that he should get about 2300 kcal a day to maintain his ideal weight. With this plan, he will be getting right around that estimate with 2284 kcal/day. His protein requirement is slightly lower than in the PN plan at 86.7 g per day. I calculated that he should be getting between 95.4 g and 111.3 g per day.

1000cc= 1 L

50 cc/hour

Dextrose: 50cc/hr x 24 hr= 1200 cc/day= 1.2 L/day1.2 L x 200 g dextrose/L= 240 g dextrose/day240 g x 3.4 kcal/g=816 kcal dextrose/day

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Amino acids: 50cc/hr x 24 hr= 1200 cc/day= 1.2 L/day1.2 L x 42.5 g amino acids/L=51 g amino acid/day51 g x 4 kcal/g=204 kcal amino acids/day

Lipid: 50cc/hr x 24 hr= 1200 cc/day= 1.2 L/day1.2 L x 30 g lipid/L=36 g lipid/day36 g x 9 kcal/g=324 kcal lipid/day

Total kcal at initial rate of 50cc/hour: 1344 kcal/day

85cc/hour

Dextrose: 85cc/hr x 24 hr= 2040 cc/day= 2.04 L/day2.04 L x 200 g dextrose/L= 408 g dextrose/day408 g x 3.4 kcal/g=1387.2 kcal dextrose/day

Amino acids: 85cc/hr x 24 hr= 2040 cc/day= 2.04 L/day2.04 L x 42.5 g amino acids/L=86.7 g amino acid/day86.7 g x 4 kcal/g=346.8 kcal amino acids/day

Lipid: 85cc/hr x 24 hr= 2040 cc/day= 2.04 L/day2.04 L x 30 g lipid/L=61.2 g lipid/day61.2 g x 9 kcal/g=550 kcal lipid/day

Total kcal at rate of 85cc/hour: 2284 kcal/day

(Nelms, Sucher, Lacey & Roth, 2011, p. 95-97)

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).

PES #1 Goal: In order to prevent malnutrition, a goal would be to return Mr. Sims’ abnormal laboratory values to the reference range. This includes protein, hemoglobin and hemocrit to level out iron, transferrin and ferritin, free retinol for vitamin A, vitamin D 25 hydroxy for vitamin D, and ascorbic acid for vitamin C. Intervention: Once Mr. Sims returns to a normal eating pattern, he should gradually add more fruits and vegetables to his plate that are suitable with his diet restrictions. He should continue to consume a multivitamin. He should keep a food log and have regular check-ins with his nutrition support team. Lab results can be retaken to monitor the progress.

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PES #2 Goal: The goal to increase Mr. Sims’ protein intake is to return his low protein lab results back to normal through increasing his intake to the suggested 86.7 g/day through parenteral nutrition. Once he is able to eat a normal diet orally, it will be a goal to gradually increase his intake to his estimated needs of 95.4 g to 111.3 g per day. Intervention: The intervention would be to have his nutrition support team or dietitian help him to find ways to increase the protein in his diet. The dietitian can help him choose nutrient-dense and protein-dense foods that will help increase his protein as well as his weight, which has been greatly impacted from his low protein. Lab results can be retaken to monitor the progress.

VI. Nutrition Monitoring and Evaluation

26. Indirect calorimetry revealed the following information:

Measure Mr. Sims’ dataOxygen consumption (mL/min) 295CO2 production (mL/min) 261RQ 0.88RMR 2022

What does this information tell you about Mr. Sims?

RMR stands for “resting metabolic rate” and is also called REE or “resting energy expenditure”. This refers to measurement conditions when the patient is resting in a confortable position without other restrictions. This can be measured using the amount of oxygen and carbon dioxide inspired and expired. This value is obtained in the commonly referred to equation, the Mifflin-St. Joer Equation. This value tells the estimated caloric needs of Mr. Sims without an activity factor, therefore, at rest. According to the data, Mr. Sims needs 2022 kcal a day at rest to maintain his weight (Nelms, Sucher, Lacey & Roth, 2011, p. 59-60). RQ stands for “respiratory quotient” and it is obtained by dividing the volume of carbon dioxide released (261 mL/min) by the volume of oxygen consumed (295 mL/min). This equation can be used to find out what source of energy or fuel is being used. A RQ of 0.88 indicates that Mr. Sims is primarily using protein as a source of fuel.

Metabolism for energy and the respiratory quotient. (n.d.). Retrieved September 15, 2014, from

http://www.tiem.utk.edu/~gross/bioed/webmodules/respiratoryquotient.html

ABA:respiratory quotient - energy sources. (n.d.). Retrieved September 15, 2014, from

http://www.openanesthesia.org/ABA:Respiratory_quotient_-_Energy_sources

27. Would you make any changes to his prescribed nutrition support? What should be monitored to ensure adequacy of his nutrition support? Explain.

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I would make a few changes. First, I would redistribute the proportions of dextrose, amino acids, and lipids. I would increase the protein intake and decrease the dextrose intake. I would want the protein to be at least 95.4 grams per day, which is the lower spectrum of his estimated protein requirements. Additionally, several parameters should be monitored to ensure adequacy of his nutrition support. These parameters include sufficiency of nutrient intake (intake/output), electrolytes, creatinine, magnesium, phosphorus, calcium, liver function, triglycerides, weight (he should be gaining weight not losing anymore), fluids and hydration, vital signs, bowel function, blood glucose, and nitrogen balance (Nelms, Sucher, Lacey & Roth, 2011, p. 91).

28. What should the nutrition support team monitor daily? What should be monitored weekly? Explain your answers.

Parameters that the nutrition support team should monitor daily include nutrient intake/output sufficiency, electrolytes, BUN, creatinine, magnesium, phosphorus, calcium, weight, hydration and fluids, vital signs, bowel function, and blood glucose testing for hyperglycemia (3 times daily) (Nelms, Sucher, Lacey & Roth, 2011, p. 91, 101). Parameters that should be monitored weekly include liver function tests and triglyceride levels. Nitrogen balance should be tested when it is necessary. The patient should be monitored so closely to prevent any complications from occurring and harm from the parenteral nutrition plan. Once the patient is determined to be stable, the support team can adjust their frequency of monitoring the patient but it is always important to be as precise about monitoring as possible to ensure the health of the patient (Nelms, Sucher, Lacey & Roth, 2011, p. 91).

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?

Mr. Sims’ serum glucose is potentially elevated because of the amount of dextrose in the parenteral nutrition solution. An increase in serum glucose can be dangerous because it could lead to hyperglycemia/diabetes. Numerous complications are associated with diabetes such as inconsistent carbohydrate intake, altered GI function, altered nutrition-related lab values, food-medication reaction, and underweight, just to name a few. Again, I think the protein should be increased and the dextrose should be decreased until the serum glucose returns to normal (Nelms, Sucher, Lacey & Roth, 2011, p. 498).

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.

6.25 g protein = 1 g nitrogen

N2 balance= (dietary protein intake/6.25) – urine urea nitrogen – 4 = (86.7 g protein/6.25) – 18.4 – 4 = - 8.5 g

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Using the equation above for calculating the nitrogen balance on urinary nitrogen, Mr. Sims has a negative nitrogen balance of -8.5 grams. A negative nitrogen balance is interpreted, as the nitrogen excretion does not equal the nitrogen intake. In this case with a negative value, that means that nitrogen excretion is greater than the intake, signifying there is inadequate nitrogen intake or catabolism. By assessing the nitrogen balance, you can analyze the protein status as well. I am concerned with Mr. Sims’ negative nitrogen balance because that means that his protein is not in balance either. There are some problems with the accuracy of nitrogen balance studies including limitations such as error with the 24-hour urine collection, failing to account for renal damage, and the incompetence to measure nitrogen losses from some wounds, burns, diarrhea, and vomiting (Nelms, Sucher, Lacey & Roth, 2011, p. 53-54).

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?

On post-op day 10, Mr. Sims is showing signs of bowel sounds and is having bowel movements, his nutrition support team should start him on a low-residue, lactose-free diet. He should eat small, frequent meals throughout the day for the best tolerance. The fat should be reduced with added MCT or MCT-containing supplement if there is steatorrhea. Small amounts of fiber and then lactose can be gradually added to his diet as he tolerates them. Other foods may need to be restricted such as spicy foods, gas-producing foods, and caffeinated drinks. Mr. Sims’ diet advancement will be individualized to his needs (Nelms, Sucher, Lacey & Roth, 2011, p. 421).

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 measures for evaluation.

Some of the primary nutrition concerns as Mr. Sims prepared for rehabilitation after discharge are malnutrition and malabsorption of nutrients, maintenance of weight/gaining weight, adequate protein and energy consumption, maintaining a well-proportioned diet with the proper micronutrients and macronutrients, and mineral deficiencies. Many of these concerns can be taken care of through proper intake of vitamins and minerals. Mr. Sims should take a multivitamin as well as continue to learn what fruits and vegetables he can tolerate to get more nutrients into his system. He should also find new ways in which he can add more protein into his diet as well. A dietitian can help educate him on healthy ways he can do this. He should keep a couple logs to monitor his progress including: a dietary food log and a weight log to make sure he continues gain his weight back to his UBW. Consumption of foods with high amounts of antioxidants and omega-3 fatty acids have been known to protect against inflammation. In order to prevent another exacerbation of Crohn’s, a dietitian can educate Mr. Sims on which foods would be beneficial in this way. Some foods to watch out for that have been known to increase the risk for urolithiasis and kidney stones are high in oxalate. Some examples of these foods are cocoa, tea, wheat germ, strawberries, nuts, spinach, beets, baked beans, tofu, and peanut butter. Mr. Sims should also be encouraged to add probiotics into his diet to enhance the normal flora of the GI tract. This has been shown to decrease IBD symptoms and act as an anti-inflammatory agent. The nutritional outcomes that I would specify for Mr. Sims would be increasing his

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protein to the estimated range of 95.4-111.3 grams per day and returning his abnormal lab values to the reference range. In order to evaluate these, I would want to run his laboratory tests again and compare the data with his initial visit. He should keep in close communication with his nutrition support team and/or dietitian to assist him along the way and share his logs with for accountability (Nelms, Sucher, Lacey & Roth, 2011, p. 421-422).

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