Medical Nutrition

Therapy in
Patients with
Crohns disease

Major Case
Study

Ashley Spence
Dietetic Intern
University of
Maryland
College Park

April 7th, 2015

TABLE OF CONTENTS
I.

Executive Summary.........................2

II.

Case Report....................................3

III.

Hospital Course of Patient...............6

IV.

Case Discussion............................10

V.

Appendices...................................13

VI.

Glossary.......................................15

VII.

References....................................16

EXECUTIVE SUMMARY
Crohns Disease (CD) is one of two diseases that make up Irritable Bowel
Disease (IBD). Crohns Disease may be described by other medical terms
including colitis, regional enteritis, ileitis, or terminal ileitis. CD is a chronic
inflammatory disease of the intestines, primarily causing ulcerations of the
small and large intestines, but can affect the entire digestive system from
the mouth to the anus. CD is the result of an autoimmune response caused
by chronic inflammation from T-cell activation leading to tissue injury due to
defective regulation and the release of inflammatory substances which
result in direct injury to the intestine. Transmural- inflammation effects all
tissue layers. Crohns causes several complications including inflamed
intestinal tissue; thickened intestinal wall which leads to narrowing and
blockages; ulcerations which may lead to tunneling and fistulas; and
nutritional deficiencies. Patients will often experience abdominal pain,
diarrhea, decreased appetite and intake, weight loss, and rectal bleeding.
Patients diagnosed with CD experience cycles of active Crohns and relapse.
Remission periods can last for months or years depending on the individual.
Symptoms can range from mild to severe dictating the course of treatment.
Malnutrition and inadequate dietary intake are of concern for patients with
Crohns Disease.
Early research on CD dates back to the 1950s. Research regarding the
nutritional management of Crohns Disease is available beginning in the
1960s and is in line with current research available at present. Medical
nutrition therapy for mild to moderate cases of Crohns includes a low fiber,
low residue diet with oral supplementation when needed. In severe cases of
CD, medical nutrition therapy can include enteral feeds and TPN. Much of
what a patient with Crohns disease consumes may not get absorbed during
the digestive process depending on the severity of the case, putting the
patient at nutritional risk.
Complementary and Alternative Medicines (CAM) are used to address the
management of Crohns Disease. Various vitamins, minerals, herbs,
homeopathy and/or acupuncture have been used by some patients. Vitamin
and mineral supplements include Zinc (26mg), folic acid (800mcg), Vitamin
D (1,000 IU), Calcium (1,000-1200mg), omega-3 fatty acids (2.7g/d),
probiotics, n-acetyl glucosamine, and glutamine. Herbals include Slippery
elm, Marshmallow, Curcumin/Tumeric, Cats Claw, and Boswellia.
Homeopathy therapies include Mercurius, Podophyllum and Veratrum
album.

CASE REPORT
GENERAL INFORMATION

X.X. is a 66 year old Caucasian American female admitted to University of

Maryland Baltimore Washington Medical Center in Glen Burnie, Maryland
in December 2014. The patient reported to the emergency room after being
advised by her home nurse her blood work results indicated anemia. The
patient also reported dizziness, left sided abdominal pain, weakness, and
diarrhea. Patient noted having no appetite for several days prior to
admission. The patient received treatment for active Crohns and was
discharged after seven days.
SOCIAL HISTORY

Patient is married and lives at home with her husband. Patient has family
history of cancer on both maternal and paternal sides. Patient mother is
living; father is deceased. Patient has a history of smoking one pack of
cigarettes per day for forty-five years. Patient quit on November 19th, 2013.
Patient reported monthly alcohol use. Patient denied drug use.
MEDICAL/SURGICAL DATA

Past Medical History

Past medical history includes Crohns Disease, myocardial infarction (2000),
bilateral carotid stenosis, bowel obstruction, acute renal failure (2010),
transient ischemic attack (2000), Peripheral Vascular Disease, esophageal
reflux, and stage 3 Chronic Kidney Disease.
Past Surgical History
Past surgical history includes stented coronary artery (2000), carotid
endarterectomy (2010), laparoscopic ileostomy/colostomy (2010, 2014),
cholecystectomy, sigmoidoscopy (2013), laparoscopy diagnostic lysis of
adhesions (2014), esophagogastroduodenoscopy (2014), colon surgery,
debridement of abdominal wall (2014), and I&D abdominal wound abscess
(2014). During this hospital stay patient underwent guided aspiration for
percutaneously drained intra-abdominal abscess at the site of a previous
fistula. Patient also received three units of blood during a transfusion.
Patient reported having a lactose intolerance.
Admitting Physical Examination

At time of admission, patients blood pressure was low (102/52) and

temperature was slightly elevated (99.9).
Laboratory Results
Refer to Appendix A for laboratory results during this hospitalization.
Medications
Refer to Appendix B for complete lists of home and in-patient medications.
Diagnostic Tests with Results
Date

Diagnostic
Test

Results

Dec X

Chest CT

No active disease process is identified.

EGD Biopsy

EGD and enteroscopy to proximal jejunum. HH

with non-stenotic Schatzki ring. No bleeding
areas in stomach. No Crohns up to proximal
jejunum.

Dec X

Abnormal matted small bowel loops in the left mid

abdomen adjacent and continuous to the left
MR
Enterograph anterior abdominal wall, with proximal and distal
loops demonstrating bowel dilatation, wall
y (MRE)
thickening, with extensive trans-mural hyperenhancement of all these loops consistent with
active Crohns Disease. There is a rim enhancing
fluid collection anterior to these loops best seen
on axial 32 consistent with an extraluminal
abscess measuring 6x2.6x6.4 cm in the region of
previous extravasation of oral contrast on the CT
scan consistent with a fistula and extraluminal
abscess. No definite enterocutaneous fistula seen.
Mild edema in the adjacent left abdominal wall.
Remainder of the small bowel loops particularly in
the right lower quadrant involving extensive
portions of the ileum also demonstrating focal
areas of bowel wall thickening, mild small bowel
distention extending to neoterminal ileum with
trans-mural enhancement consistent with active
Crohns Disease. Apparent hydronephrosis of the
left kidney without change since the previous CT
scan without a definite cause of obstruction?
Passive distention versus inflammatory stricture.
Delayed coronal MR imaging could be obtained
for an MR IVP.

Dec X

Dec X

C. Diff

Negative

Dec X

CT

Guided Aspiration

NUTRITIONAL HISTORY FROM INITIAL ENCOUNTER

Diet History
Patient reported having no appetite prior to admission for several days.
Patient utilized cyclic TPN every 12 hours at home plus a liquid diet by
mouth. Multivitamins were added to TPN three times per week. Patient
reported liquid diet included whey protein shakes and jello. Supplements
such as Ensure caused diarrhea and were avoided. No food allergies were
noted at time of initial consult. No problems with chewing were noted. No
problems with swallowing were noted since 10/28/2014 at time of
esophagogastroduodenoscopy with salivary dilatation.
Weight History
Using the Hamwi equation to calculate ideal body weight (IBW) for women,
X.X.s ideal body weight is 135 pounds. Per patient, X.X. X.X.s usual body
weight (UBW) is 152 pounds. According to patient report, significant weight
loss occurred in approximately ten months beginning March of 2014. The
patient has experienced significant weight loss since March 2014 of 43
pounds (28%) of UBW. Earliest documented weight available recorded in
July 2014.
Date

Weight (in
pounds)

Source of
Weight

% UBW

% IBW

March
2014

152

Reported

100

112.5

July 15

126

Measured

82.8

93.3

Oct 24

117

Measured

77.5

86.6

Nov 28

111

Measured

73.0

82.2

Nov 30

110

Measured

72.3

81.4

Dec 9

113

Measured

74.3

83.7

Dec 10

109

Measured

71.7

80.7

Physical Activity Level

Patient was not ambulatory during the current hospitalization. Information
regarding the patients physical activity level prior to admission was not
documented.
5

Estimated Nutrient Needs

Source

Kcal
Requirements

Protein
Requirements

Fluid
Requirements

Facility Standards

30-35 kcal/kg
1488-1736 kcal

1.4-1.8 g/kg
64-82 g

25-30 ml/kg
1240-1488 ml

Evidence Analysis
Library (EAL)

n/a

n/a

n/a

Online Nutrition
Care Manual
(NCM)

n/a

n/a

n/a

Use of Vitamins/Minerals, Oral Liquid Supplements, and/or Alternative

Supplements
Patient reported adding vitamins and minerals to TPN three days per week.
Patient also reported taking juniper tar and sugar for colds in addition to a
tincture of opium (paregoric) for diarrhea. She did not report taking any
other complementary or alternative medicine supplements.
Cultural Attitudes That Influence Dietary Intake
Patient did not report any cultural or religious preferences or attitudes that
may impact food preferences or impose restrictions during hospitalization.
Past Nutritional Therapy
N/A. Previous hospital admission was for urinary infection. Nutrition was
not consulted.

HOSPITAL COURSE OF PATIENT

MEDICAL TREATMENT

Day 1- Patient complained of dizziness, weakness, left sided pain, and

diarrhea upon arrival at emergency room. Patient was advised to go to
the ER by home health nurse due to blood work results indicating anemia.
At admission her hemoglobin and hematocrit were noted as 5.3 and 15.6.
Patient blood pressure was low (102/52) and temperature was slightly
elevated (99.9). Chest X-Ray noted patient central line was in good
position. No active disease process was identified. No obvious bleeding
was noted. GI consulted by ER because of history of GI bleed with
Crohns. Ordered for blood transfusion of three units of packed red blood
cells (PRBC). Diet: Low residue, 4g Na restriction then changed to Clear
Liquid.

 Day 2 -Nutrition consult ordered secondary to new TPN order/request. At

time of nutrition consult, patient had complaints of diarrhea. Diet history
provided by patient disclosed decreased appetite and po intake of liquid
diet only. Nutrition recommendation given for TPN in addition to low fiber
diet and oral supplements when medically able. Gastroenterology consult
noted. MRE revealed [abnormal matted small bowel loops in the left mid
abdomen with proximal and distal loops demonstrating bowel dilatation,
wall thickening consistent with active Crohns Disease. MRE also
indicated fluid collection consistent with abscess consistent with a fistula.
Mild edema was also noted in left abdominal wall. Remainder of the small
bowel loops in the right lower quadrant involving extensive portions of
the ileum also demonstrating focal areas of bowel wall thickening and
mild small bowel distention consistent with active Crohns Disease].
Patient labs indicated elevated blood sugar, likely to steroids; TPN
decreased. Patient received three units of PRBC.
Diet: NPO at time of consult. TPN 618 kcal. Evening of 12/10: Low
residue, Ensure Clear BID. Intake 25-50% of meals; Supplement 50%.
Day 3- Patient reported complaints of malaise, weakness, and diarrhea.
Anemia improving, intra-abdominal abscess noted at site of previous
fistula even though no active fistula seen, and etiology of GI bleed
unclear. MD noted patient was septic and started patient on an antibiotics
(vancomycin and zosyn). Patient continued enticort and pentasa for
Crohns Disease. Diet: Full liquid. TPN 317 kcal. Intake 50-75% of meals.
Day 4 As per patient chart, patient continued to report diarrhea; other
symptoms improved. During nutrition follow-up patient reported eating
well and drinking supplements until NPO status was applied. Patient
continued with diarrhea but noted tincture of opium helped symptoms
when at home. Patient also noted lactose allergy not mentioned
previously. Patient reported dormant Crohns for several years until
recent ileostomy (2014); noted symptoms last for six to seven months with
diarrhea. Diet: NPO for procedure (guided aspiration). TPN 317 kcal.
Day 5 and 6 - Patient continued with diarrhea. Other symptoms and
activity level improving. Discharge pending. No urgent patient updates
noted in chart. Diet: Low residue, 4g Na restriction, TPN. Intake not
documented in chart.
Day 6 - Patient discharged. Patient discharged with central line for TPN
at home. Discharge diet- low residue, low fat, low salt, and low
cholesterol.
NUTRITIONAL TREATMENT

Nutrition Assessment
Age: 66 years old
7

Labs (12-9-2014):

Gender: Female
Weight:
Admission weight: 109#
UBW: 152# (reported)
Last documented weight:
126#
Weight loss from UBW: 43#,
28%
Weight loss from last
documented weight: 17#,
13%
Height: 57 or 170.2cm
BMI: 17.2 (underweight)
PMH: Crohns Disease, myocardial
infarction (2000), bilateral carotid
stenosis, bowel obstruction, acute
renal failure (2010), transient
ischemic attack (2000), Peripheral
Vascular Disease, esophageal reflux,
and stage 3 Chronic Kidney Disease
Symptoms: dizziness, weakness,
left side pain, diarrhea
Diet History: Poor/no appetite for
several days PTA. Liquid diet
consisting of whey protein shakes
and jello. Intake is questionable.
Cyclic TPN (every 12 hours).

Na: 134 (H)

K: 4.3
Cl: 100
Cr: 1.11 (H)
Glucose: 105
BUN: 27 (H)
Ca: 7.9 (H)
WBC: 22.5 (H)
Hct: 15.6 (L)
Hgb: 5.3 (L)
MCV: 86
MCH: 29.4
Medications prior to admission:
Mycostatin (antifungal)
Oxycodone (narcotic/pain/ )
Entocort (steroid/anti-inflammatory/
treats Crohns symptoms/can cause
hyperglycemia)
Tylenol (fever reducer/ minor
aches/pains)
Norvasc (treats high BP/ chest pain)
Pentasa (treats/prevents flare-ups of
Crohns)
Protonix (reflux)
Carafate (treats ulcers)
Xanax (anti-anxiety)
Colestid (reduces cholesterol)
Zofran (anti-nausea/vomiting)
Atenolol (beta blocker)
Current Diet: NPO/ TPN

Nutrition Diagnosis
Inadequate oral intake (NI-2.1) related to Crohns Disease exacerbations
and Chronic GI bleed discomfort as evidenced by prolonged poor po
intake PTA and 13% weight change in 5 month period.
Malnutrition (NI-5.2) related to Altered GI function, active Crohns
complications and matted bowel loops as evidenced by prolonged poor
po intake, muscle loss (temples, clavicles, shoulders, arms) and
8

documented severe 13% weight change in 5 month period.

Underweight (NC3.1) related to Crohns Disease flare, prolonged poor
appetite, and minimal intake of liquid diet as evidenced by severe,
unintentional 28% weight change/43 pound weight loss from UBW of 152
pounds.
Increased nutrient needs (NI-5.1) related to altered GI function
secondary to Crohns Disease as evidenced by unintentional weight loss,
malnutrition, and need for TPN therapy.
Nutrition Intervention
Nutrition Prescription
1. 1488-1736 kcal/day diet
2. PRO- 50-55 g/day (1-1.1 g/kg)
3. Fluid- 1240 mL (25 mL/kg)
4. TPN to provide 1488 kcal, 50g
PRO, 265g dextrose
5. Low residue/Cardiac diet (when
medically able pending diet
advancement)
6. Oral supplements- Ensure Clear
(when medically able pending diet
advancement)

Intervention with goals

Initiate parenteral nutrition (ND2.2) Patient receives TPN within 24
hours. Goal: Nutrition support
meets >75% of estimated needs.
Meals and Snacks (ND-1.2.6)
Initiate low residue/cardiac
combination diet per diet
advancement when medically able.
Goal: Patient consumes >25% of
meals.
Commercial beverage (ND-3.1.4):
Initiate nutrition supplements BID
per diet advancement when
medically able GOAL: Oral
supplements to provide 400kcal,
14g PRO to meet increased energy
needs.
Vitamin and Mineral Supplements
(ND- 3.2) Continue MVI.
Coordination of Nutrition Care (RC1) Collaboration with other
providers (RC-1.4): Weigh and
document po intake daily.

Nutrition Monitoring and Evaluation

Indicators
1. Parenteral Nutrition Intake
(1.3.2)
2. Total energy intake (FH9

Criteria
1. Patient will tolerate TPN.
2. Patient consumes >25% of
meals.

1.1.1.1)
3. Liquid meal replacement or
supplement (FH-1.2.1.3)
4. Weight (AD-1.1.2)

3. Patient consumes >75% of

nutrition supplements.
4. Patient will not lose any
additional weight during this
admission.

PRESENT NUTRITIONAL THERAPY

Date

Diet

Modifications

Average
Intake

Nutrition
Supplement(s)

Avera
ge
Intak
e

Day 1

Low
Residue
, 4g Na

n/a

0%

None

Day 1

Clear
Liquid

n/a

0%

None

Day 2

NPO
for
testing

n/a

None

Day 3

Low
Residue

n/a

50-75%

Ordered for Ensure

Clear BID

50%

Day 4

Full
Liquid

n/a

50-75%

Canceled by
nursing

Day 5

NPO for
procedu
re

n/a

None

Day 6

Low
Residue
, 4g Na

n/a

Not
documen
ted

None

None

Day 7

Low
Residue
, 4g Na
10

n/a

Not
documen
ted

*Patient received TPN throughout hospital stay. Pt received approximately

417 kcal per day (3 day average) between time of consult and follow-up.
Patient was discharged on the seventh day.

11

CASE DISCUSSION
MEDICAL CONSIDERATIONS

X.X. arrived to the emergency room with complaints of dizziness and

weakness; she later reported diarrhea and left sided pain. Upon admission
she presented to the medical team with normochromic-normocytic anemia
and an acute Crohns Disease (CD) flare. Crohns Disease is one of two
major types of Irritable Bowel Diseases (IBD) affecting 130 individuals out
of every 100,000 (5). Crohns Disease is more prevalent in Caucasian and
Ashkenazic Jewish ethnic groups although other minority groups are also
affected (1). Crohns Disease is an auto immune disorder characterized by
chronic inflammation of the intestines, but can affect the entire digestive
system, typically the distal ileum and the colon (6). In Crohn's disease,
healthy bowel may be present in between inflamed portions. Nutritional
status is negatively impacted by Crohns Disease, which is characteristic of
disordered eating as well as other levels of clinical practice where nutrition
is relevant including malaise and anorexia, malabsorption, gut losses of
nutrients, and the psychology of food habits associated with CD (4). IBD
disorders such as Crohns Disease have been linked with significant
morbidity and mortality causing a significant impact on quality of life (8).
Persons with Crohns Disease are a higher risk for developing Colon Cancer,
Osteoporosis (may be related to steroid use), gallbladder and liver disease
(7).
The etiology of Crohns Disease has yet to be determined; however research
indicates both genetic susceptibility and environmental and dietary factors
play a role (8). Individuals diagnosed with CD present with several signs
such as abdominal pain in the right lower quadrant; diarrhea; fever;
decreased appetite or intake; weight loss; rectal bleeding; arthritis; skin
problems; and fever. When individuals are in the midst of an active flare,
symptoms can last from days to months. Symptoms present because of
several complications of CD such as inflamed intestinal tissue; thickened
intestinal wall leading to narrowing and blockages; ulcerations leading to
tunneling and fistulas; nutritional deficiencies; inadequate dietary intake;
and, malabsorption. The complications distinctive of Crohns are the
primary cause for altered gastrointestinal function resulting in impaired
absorption and utilization of nutrients.
Smoking increases the risk of developing Crohns Disease and may also
worsen disease progression. Individuals diagnosed with CD and are also
smokers are at higher risk to have relapses, need medications to control
symptoms and inflammation, and have repeat surgeries (7). Eliminating
smoking can reduce the risk of developing CD.
12

There are no medications or surgical procedures that can cure Crohns

Disease; treatment is focused on symptom resolution, limiting further
inflammation, and fostering remission. Research suggests multiple ways to
manage Crohns Disease symptoms both medically and nutritionally
depending on the severity of the disease. Medical management may include
the use of antibiotics for mild cases, corticosteroids for moderate cases, and
surgery for severe cases. A combination of antibiotics, steroids, and surgery
is also utilized in patient care. Nutritional management of Crohns Disease
is also dependent on the gravity of the disease. In less severe cases, where
energy needs can be met orally, a low fiber-low residue diet is
recommended while symptoms are present (?). Fiber is slowly added back
to the diet as tolerated. For moderate to severe cases where nutritional
needs cannot be met orally or malnutrition is suspected, oral
supplementation or the use of nutrition support is recommended (2). For
malnourished patients or those at risk of malnutrition, oral nutrition
supplements are well tolerated and beneficial; up to 600 kcal/day is
recommended (2). Research has also shown the use of enteral nutrition
support is effective in inducing and lengthening remission periods (10).
Controlled trial studies have shown patients treated with elemental diets
improved as much or more than those undergoing steroid treatment alone
(7). Parenteral nutrition support is reserved for individuals that are unable
to meet needs orally or through enteral support alone due to intestinal
failure, short bowel syndrome, or bowel resection (2).
The psychology of food and nutrition also plays a vital role in the nutritional
management of Crohns Disease. Due to the progression and cyclic nature
of the disease, patients often become frustrated and depressed. Beliefs and
attitudes regarding foods are affected. Challenging aspects of the
psychology of food and nutrition in CD include poor food choice; avoiding
meals and specific foods or food groups; food grazing; or self-experimenting
with diet (4). Individuals may also turn to complimentary or alternative
medicines to help cope with symptoms, such as tincture of opium for
diarrhea relief.
NUTRITIONAL THERAPY

X.X. was admitted with poor to no appetite and GI symptoms including

diarrhea, GI bleeding, and abdominal pain. Patient reported severe 43
pound weight loss prior to admission due to Crohns exacerbations and poor
oral intake. Patient reported cyclic TPN use at home combined with a liquid
diet consisting of whey protein shakes. The patient reported her usual
weight as 152 pounds (69kg); however, upon admission the patient only
weighed 113 pounds (51kg). At the time of the initial nutrition consult, her
weight had been adjusted to 109 pounds (49kg). Based on facility
standards, her calorie needs were 1488-1736 kilocalories (30-35 kcal/kg)
13

and fluid needs were 1240-1488 ml (25-30 ml/kg). Per facility standards for
patients with stage 3 Chronic Kidney Disease, her protein requirements
were 1.0-1.1 gm/kg protein for a total of 49.6-54.5 gm of protein per day.
In the absence of Chronic Kidney Disease, higher amounts of protein would
have been indicated to prevent further muscle wasting. Fluctuations in
intake throughout the course of the hospital stay are a result of unstable
diet status. X.X. teetered between food by mouth and NPO for seven days.
X.X. reported the return of her appetite upon admission and described it as
starving. X.X. was willing to eat in spite of persistent diarrhea. As a
precaution, X.X. was checked for C.diff on Day 3 of hospital admission but
results were negative. Diarrhea is a common complaint and symptom of
Crohns.
After arrival to the hospital, X.X. was immediately placed on a low fibercardiac combination diet before the nutrition consult for TPN
recommendations were ordered. The cardiac combination was added due to
the patients history of myocardial infarction and stented coronary artery.
During the evening of X.X.s first day of admission the diet orders were
changed to clear liquid, then changed again to NPO for a procedure the
following day. She revealed during the initial consult that she was unable to
eat from either tray before they were taken from her room. During days
when X.X. was allowed to eat by mouth, she ate well. In consideration of
suspected malnourishment, nutrition recommendations included an oral
supplement, Ensure Clear, when medically able. The patient reported
drinking all supplements and was tolerating well. The nutrition supplement
was discontinued by nursing because of misinterpreted admission report of
Ensure causing diarrhea and reporting Ensure allergy.
Overall, on days when X.X. was cleared to eat by mouth, she ate well with
no complications other than persistent diarrhea. The patient was discharged
at the end of the weekend without further report. Upon discharge the
patient was ordered to continue cyclic TPN at home and a low residue
cardiac combination diet by mouth.

IMPLICATIONS OF FINDINGS TO THE PRACTICE OF DIETETICS

Nutrition is the primary therapy in individuals with CD. EliminationReintroduction diets, supplements and enteral and parenteral feeds are
beneficial in reducing remission, symptoms, and inflammation (2).
Elimination reintroduction diets are used in patients who can still meet
needs orally. Elimination induces remission by elemental feeds.
Reintroduction slowly transitions patients to Low Fiber/Low residue diets.
Low fiber/Low residue diets reduce inflammation and symptom
exacerbations caused by increased amounts of fiber. Research shows
14

elimination-reintroduction diets have 2 year remission rate of 59% (2). Oral

nutritional supplements up to 600 kcal/day are beneficial in meeting needs
orally.
For individuals that cannot meet needs orally, enteral nutrition can induce
and maintain remission and is used as a first line defense. Enteral feeds are
associated with growth, weight gain, and minimal side effects as compared
to steroids or other medication management (2). Enteral feeds are also
associated with mucosal healing and reduced inflammation and are
therefore preferred (2). Enteral feeds have anti-inflammatory effects on the
intestine due to fat content; new research suggests lower fat feeds are more
effective. Nocturnal tube feeding can also promote weight gain and growth.
Research shows nocturnal feeds of 1-1.5 L of non-elemental feeds can
improve weight and growth (2).
PN can be used to improve nutritional status before bowel surgery. TPN
however is only indicated with the presence of intestinal failure, multiple
bowel resections, or high output fistulas (2). In general, oral intake should
be continued if the patient is on EN or TPN when possible to maintain gut
integrity (2).
The registered dietitian plays a vital role in the nutritional management of
Crohns Disease. Patients with CD have nutritional needs greater than
other individuals. Dietitians help manage care and prevent or reduce
deficiencies, weight loss, and malnutrition associated with CD. As the
nutrition expert, they can offer advice for all stages of Crohns Disease to
ensure needs are met with individualized care.
WEBSITES AVAILABLE TO SUPPORT PATIENTS INCLUDE:

Crohns and Colitis Foundation of America - http://www.ccfa.org/whatare-crohns-and-colitis/what-is-crohns-disease/

Crohns and Colitis Foundation of America , Crohns and Colitis
Community- http://www.ccfacommunity.org/
National Organization for Rare Diseases (NORD)https://rarediseases.org/rare-diseases/crohns-disease/#standardtherapies

15

APPENDICES
APPENDIX A: LABORATORY RESULTS
Lab

Reference Range

Na

135-146 mmol/L

12/9

12/10

12/11

12/12

12/13

12/1
4

12/15

134

134

137

137

137

3.5-5.3 mmol/L

4.3

4.1

7.6

4.0

4.2

Cl

98-107 mmol/L

100

102

100

103

100

CO2

22-32 mmol/L

27

26

22

26

28

Creatin
ine

0.6-1.1 mg/dl

1.11

1.19

1.40

0.96

0.97

Glucose

<140 mg/dl

105

79

169

189

137

259

205

BUN

7-20 mg/dl

27

20

24

26

30

Bili
Total

0.1-1.3 mg/dl

0.3

0.7

0.8

0.7

0.7

Ca

8.1-10.7 mg/dl

7.9

8.1

7.7

8.2

8.3

Phos

2.4-4.7 mg/dl

4.4

6.2

3.5

Mg

1.7-2.2 mg/dl

1.9

3.0

2.2

AST

15-41 IU/L

20

18

20

ALT

17-63 IU/L

43

35

38

WBC

4.8-10.8 k/uL

22.5

28.5

13.2

14.5

10.6

Hct

34.9- 44.5

15.6

28.1

26.5

29.6

30.3

Hgb

12.0-15.5

5.3

9.4

8.5

9.8

9.8

MCH

27-33 pg/cell

29.4

28.7

31.5

28.1

28.0

MCV

80-96 fL/cell

86

86

87

85

86

APPENDIX B: MEDICATIONS

Home Medications
Medication

Mycostati
n

Dosa
ge

Freque
ncy

Function

Nutritional
Implications

antifungal

Nausea, vomiting,
diarrhea
(less common)

Oxycodon
e
16

narcotic/pain

Can cause
constipation

Entocort

Tylenol

steroid/antiinflammatory/ treats
Crohns symptoms

Can cause
hyperglycemia,

fever reducer/ minor

aches/pains

Loss of appetite,
nausea, vomiting

steroids increase bone

loss-increase calcium
and vitamin D intake.

(less common)

Norvasc

treats high BP/ chest

pain

Pentasa

treats/prevents flareups of Crohns

/
Loss of appetite,
nausea, vomiting
(less common)

Protonix

Proton Pump inhibitor;

treats reflux
symptoms; inhibits
gastric acid secretion

May inhibit folic acid,

B-12, iron and betacarotene absorption,
avoid alcohol with use.

Carafate

treats ulcers

Can cause
constipation

Xanax

anti-anxiety

Changes in
weight/appetite,
constipation
(less common)

Colestid

reduces cholesterol

Constipation,
diarrhea, nausea,
vomiting

Zofran

anti-nausea/vomiting

Can cause
constipation or
diarrhea
(less common)

Atenolol

beta blocker

Can cause
hypoglycemia

In-Patient Medications
Medication

Function

Nutritional Implications

Colestid

Helps lower cholesterol

May interfere with fat soluble

vitamin absorption causing
deficiency; increased chance of
bleeding due to possible vitamin
K deficiency

(bile acid binding resin)

Heparin
17

anticoagulant

N/A

Humalog (SSI)

Sliding scale insulin

May cause hypokalemia, avoid

use in patients using potassiumlowering medications

Pentasa

treats/prevents flare-ups of
Crohns

Loss of appetite, nausea,

vomiting
(less common)

Prednisone

Corticosteroid, treats
inflammation

Can cause hyperglycemia, limit

sodium intake, steroids increase
bone loss-increase calcium and
vitamin D intake.

Protonix

Proton Pump inhibitor;

treats reflux symptoms;
inhibits gastric acid
secretion

May inhibit folic acid, B-12, iron

and beta-carotene absorption,
avoid alcohol with use

Carafate

Treats and prevents ulcers

Avoid antacid use 30 minutes

before and after use which may
less the effect of Carafate,

Entocort

steroid/anti-inflammatory/
treats Crohns symptoms

Can cause hyperglycemia,

steroids increase bone lossincrease calcium and vitamin D
intake.

Questran
light/prevalite

Helps lower cholesterol (bile

acid binding resin)

May interfere with fat soluble

vitamin absorption causing
deficiency; increased chance of
bleeding due to possible vitamin
K deficiency

Zoysn

Antibiotic

Can cause diarrhea

Vancocin

antibiotic

Can cause diarrhea

GLOSSARY
1. Clostridium difficile: bacteria that can cause symptoms ranging from
diarrhea to severe, life-threatening inflammation of the colon.
2. Extraluminal abscess- a localized collection of pus in the tissues of the
body, often accompanied by swelling and inflammation and frequently
caused by bacteria.
3. Fistula- an abnormal connection between an organ, vessel, or intestine and
another structure. Fistulas are usually the result of injury or surgery. It can also
result from infection or inflammation. CD leads to fistulas between different loops
of intestines.
18

4. Guided Aspiration- the removal of fluid from a part of the body.

19

REFERENCES
1. CDC
2. Donnellan, Clare F., Lee H. Yann, and Simon Lal. Nutritional
Management of Crohn's Disease. Therapeutic Advances in
Gastroenterology. (2013): 6(3): 231-42.
3. Fazio, Victor W., Floriano Marchetti, James M. Church, John R.
Goldblum, Ian C. Lavery, Tracy L. Hull, Jeffery W. Milsom, Scott A.
Strong, John R. Oakley, and Michelle Secic. Effect of Resection
Margins on the Recurrence F Cohn's Disease in the Small Bowel.
Annals of Surgery. 1996: 224(4): 563-73.
4. Ferguson, Anne, Michael Glen, and Subrata Ghosh. Crohn's Disease:
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Gastroenterology. 1998: 12(1): 93-114.
5. Knight, C., Wael El-Matary, Christine Spray, and Bhupinder K. Sandhu.
Long-term Outcome of Nutritional Therapy in Pediatric Crohn's
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8. Morain, C.O., A.W. Segal, A.J. Levi. Elemental Diet as Primary
Treatment of Acute Crohn's Disease: a Controlled Trial. British
Medical Journal Clinical Research. 1984: 288: 1859-1862.
9. Triggs, Christopher M., Karen Munday, Rong Hu, Alan G. Fraser,
Richard B. Gearry, Murray L. Barclay, and Lynnette R. Ferguson.
Dietary Factors in Chronic Inflammation: Food Tolerances and
Intolerances of a New Zealand Caucasian Crohn's Disease Population.
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Mutation Research/Fundamental and Molecular Mechanisms of

Mutagenesis. 2010: 690(1-2): 123-38.
10.
University of Maryland.
http://umm.edu/health/medical/altmed/condition/crohns-disease)
11. Veloso, F. T., Ferreira, J. T., Barros, L. and Almeida, S. Clinical

Outcome of Crohn's Disease: Analysis According to the Vienna

Classification and Clinical Activity. Inflammatory Bowel Diseases.
2001:7(4): 306313.
12.
Verma, S., B. Kirkwood, S. Brown, and M.h. Giaffer. Oral
Nutritional Supplementation Is Effective in the Maintenance of
Remission in Crohn's Disease. Digestive and Liver Disease. 2000:
32(9):769-74.

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