Medical and Nutritional

Implications of Crohn's
Disease
Hilary Raciti, Sodexo Dietetic Internship

Objectives
1. Anatomy of GI tract
2. Discussion of Crohns
disease
3. Diagnosis and Treatment
4. Review of Medical Nutrition
Therapy for Crohns disease
5. Presentation of the Patient
6. Critical Comments

Anatomy of the Gastrointestinal

Tract

Mouth
Esophagus
Stomach
Small Intestine
o Duodenum
o Jejunum
o Ileum

Large Intestine= Colon

o Cecum, ascending, transverse,
descending, sigmoid

Rectum
Anus

What is Crohns disease?

Crohns Disease is an
Inflammatory Bowel Disease
(IBD)
Chronic inflammatory
condition of the
gastrointestinal tract.
IBDs include Crohns disease,
Ulcerative Colitis and
Indeterminate Colitis

Gastrointestinal Tract with IBD

Crohns disease can affect any
part of the GI tract- most often the
small intestine and the colon
Inflammation occurs in segments
and has transmural involvement

Ulcerative Colitis ONLY affects

the colon and rectum. The
inflammation is continuous and
only affects the lining of the
colon.

Inflammation of GI Tract
Small Intestine

Colon

Crohns Statistics
780,000 Americans have Crohns disease
33,000 new cases of Crohns disease each year
Industrialized countries have greater prevalence
The average age of onset is 15-35 years

Geographic prevalence

Classification by location of
inflammation
-Most

common form of Crohns Disease

Ileocolitis -Affects the colon and the ileum
-

Ileitis

Gastro
duodenal
Crohns
disease

-Only affects the ileum

-Risk of developing fistulas, may affect
the stomach/duodenum

-Affects the stomach and beginning of the

small intestine

Classification by location of
inflammation
Jejunoileitis

-Patchy areas of inflammation in the

upper half of the small intestine
-Abdominal pain and cramps after
meals
-Fistulas common

-Affects only the colon. Most similar to

Crohns
Granulomatous Ulcerative Colitis
Colitis

Classification by
Complication
Inflammatory
Fibrostenotic

Penetrating

Causes
Genetics
Immune
system
disturbance

Environmental
factors

Crohns
Disease

Pathogenesis

Genetics
Up to 20% of patients have a first
degree relative
North Eastern European DescentAshkenazi Jews
Associated with genetic mutations on
CARD15 and ATG16L1 and
Chromosome 5 and 10
o Play a role in providing instructions
for creating proteins needed for
immune response.

Environmental Factors

Industrialization
Diet high in saturated/Trans fat
Diet low in fiber and vegetables/fruits
Tobacco use
Smoke exposure
Prolonged antibiotic use
NSAIDs
Oral contraceptives
Appendectomy

Signs & Symptoms

Abdominal Pain

Diarrhea

Rectal Bleeding

Fatigue

Loss of Appetite

Fever

Weight Loss

Loss of Menstrual Cycle

Extraintestinal Symptoms
Crohns disease can impact the skin, joints, eyes,
mouth, kidneys, liver and lungs
Arthritis
Erythema nodosum
Oral ulcerations
Pyroderma
gangrenosa
Conjunctivitis
Osteopenia

Osteoporosis
Iritis
Sclerosing cholangitis
Jaundice
Kidney stones
Thromboembolic
event

Extraintestinal Symptoms

Complications of Crohns disease

Bowel
Obstruction
Strictures
Anorectal
fistulas
Anal Fissures
Pouchitis
Short Bowel
Syndrome

Ulcers
Intestinal Bleeding
Colon Cancer
Abscesses
Toxic Megacolon
Malnutrition
Anemia
Vitamin/mineral
deficiencies

Diagnosis

Physical exam

Lab Tests

Barium X-Rays/CT Scans

Biopsy

Endoscopy/Colonoscopy

Lab Tests
Markers of Inflammation

WBC
RBC
Platelet Count
CRP
Sedimentation Rate
Albumin
Calproctectin (Stool test)

Markers of Anemia

Markers of Vitamin Deficiencies

Vitamin D-25 hydroxy

Serum Tocopheral
Vitamin K
Vitamin C
Zinc

Hemoglobin
Hematocrit
Ferritin
B12
Folate

Antibodies

OmpC
ASCA- Biomarker
Anti-CBir1
Anti-flagellin

Colonoscopy and Biopsy

CDAI
Crohns Disease Activity Index

Treatment

Medication

Surgery

Lifestyle/Nutrition

Crohns Step Up Therapy

Treatment - Medications
CLASS
5-ASAs

MEDICATIONS

IMPLICATION

SIDE EFFECT

Sulfasalazine,
Mesalamine, Asacol,
Apriso, Balsalazide

Work locally on GI tract.

Effective for mild
Crohns with colonic
disease.

Abdominal pain,
nausea, hair loss,
dizziness, headache,
diarrhea.

Corticosteroids

Prednisone,
Methylprednisone,
Budesonide

Mainstay treatment for

active flares. Exert an
anti-inflammatory and
immunosuppressive
effect.

Can cause osteoporosis,

DM, HTN, cataracts,
psychosis, risk of
infection and weight
gain.

Immunomodulators

Athioprine (Imuran), 6Mercaptopurine

(Purinethol), and
Methotrexate

Alter the body's

immune response by
inhibiting the
inflammatory action of
white blood cells.

Nausea, pancreatitis,
upper abdominal pain,
low blood counts,
altered liver function,
infection

Medications
CLASS

MEDICATONS

IMPLICATION

SIDE EFFECTS

Anti-TNF alpha Infliximab, Adalimumab, Binds to cytokines (like

Fever, chills,
therapies
Natalizumab
TNF) and causes
nausea, headache,
(Biologic
programmed cell death
itching or rash
Therapies)
of macrophages and T
during infusion.
lymphocytes
Provided via
Used for luminal or
infusions.
fistulizing CD.
Antibiotics

Metronidazole,
Ampicillin,
Ciprofloxacin

Treat bacterial
infections that may
exacerbate symptoms
of CD. Help treat
abscesses and fistualas

GI distress,
diarrhea, greater
likelihood to
develop IBD
(prolonged use).

Treatment - Surgery
Strictureplasty
Bowel Resection
Subtotal colectomy

Proctocolectomy
Ileostomy/Ostomy pouch

Lifestyle Treatment Options

Nutrition

Stress
Reduction
Exercise

Medical Nutrition Therapy

Assessment
1. Physical Findings (PD)
2. Client History (CH)
3. Food History (FH)
4. Biochemical Data (BD)

5. Anthropometric Measurements (AD)

Nutrition Indicators
Abdominal
Pain

Compromised
Oral Intake

Inadequate
Growth
(Children +
Teens)

Unintentional
Weight Loss

Diarrhea

Emesis

Evidence of
Malabsorption
(Gas and
Bloating)

Anemia

Diagnosis
Intake

Clinical
BehavioralEnvironmental

Malnutrition (NI-5.2)
Inadequate oral intake (NI-2.1)
Inadequate vitamin/mineral intake (NI5.10.2)
Unintended weight loss (NC-3.2)
Altered GI function (NC-1.4)
Food/Nutrition related knowledge deficit
(NB-1.1)
Disordered eating pattern (NB-1.5)

Intervention - Energy
Condition
Nutritional repletion, weight gain

Energy Needs

35-45 kcal/kg

BMI < 15

BMI 15-19

30-35 kcal/kg

BMI 20-29

25-30 kcal/kg

BMI >30

15-25 kcal/kg

Intervention cont.
Protein

Fluid

Vitamins/Minerals

1.0-1.2 g/kg
1.5 g/kg (fistulas or strictures present)

1 ml/kcal
30-35 ml/kg
64-80 ounces/day if ostomy is present (extra for fluid loss)
B-12 (ileum removed)
Iron
Folate
Calcium/Vitamin D
Zinc + Magnesium

Diet Progression

NPO/Bowel
Rest

Clear Liquids

GI Soft
Low Residue

Intervention cont.
Oral Supplements

Ensure Complete, Health shake,

Magic cup etc.

Vitamins/Minerals

MVI, Omega-3 Fatty Acid, Probiotics

Nutrition Support

Compromised oral intake/GI

Function

Recent Insight on Enteral Nutrition

Study by Alimentary Pharmacology & Therapeutics evaluated if long
term enteral nutrition reduces clinical and endoscopic reoccurrence
after resection for Crohns disease.
o provided nocturnal EN and restricted to low fat diet during the day
o received no EN and and had no diet restrictions

1 patient in the EN group and 7 patients in the control group

experienced clinical reoccurrence
6 patients in the EN group and 14 patients in the control group
experienced endoscopic reoccurrence 1 year after surgery

Monitoring & Evaluation

Disease
Activity

Oral Intake

GI Symptoms

Weight

Lab
Tests/Vitamin
Deficiencies

Calproctectin,
CRP, Albumin

Presentation of the Patient

H.T. Patient Information

Client
Information

52 year-old Caucasian female

Lives with husband
Height: 59 inches; Weight 69.3 kg
BMI 30
Smoker

Past Medical
Hx

Crohns disease (dx 2009), Arthritis, Chronic

Pain, TIA, COPD, Deep Vein Thrombosis,
Pneumonia, GERD, HTN, Small bowel
obstructions

Surgical
History

Small bowel resections, subtotal colectomy

w/ lysis of adhesion, appendectomy,
cholecystectomy, Hysterectomy, Evacuation
of Hematoma

Initial Nutrition Assessment

Initial Assessment
Admitted April 12
2015
Seen on April 13
Kennedy University
Hospital-Cherry
Hill Campus
Surgical Floor

Chief
Complaint:
Abdominal pain,
intractable
vomiting
secondary to
partial small bowel
obstruction

Current Diet
Order
4/12: NPO
4/13: Clear
Liquids
(Not Tolerating)

Initial Assessment
Weight Hx
CBW: 67.03 kg
UBW: 73.8 kg
BMI: 30- Obese Class I
IBW: 45.4 kg +/- 10%

Nutrition Indicators
Poor Po 3 weeks
NPO for last week
NO BM >3 days
K+, HGB
WBC + Platelet Count

Trace Lower Ext

Edema

Medications
Name

Indication

Heparin

Anticoagulant

K-Rider
Apresoline

Morphine ER
Lyrica

Nexium

Name

Indication

Ranitidine

H2 Antagonist

Potassium Chloride
Infusions

Pepcid

H2 Antagonist

Antihypertensive

Reglan

Antiemetic

Analgesic

Miralax

Osmotic laxative

Antiemetic

Colace

Stool Softener

Proton Pump
Inhibitor

Zofran

Antiemetic

Labs
Laboratory Test
WBC
Hgb
Hct
Plt
Na
K
Cr
BUN
Albumin
CRP
Glucose

Charted Value
13.5
11.8
35.8
402
142
3.2
0.90
12
4.4
4.0
108

Value Level (High/Low)

High
Low
Low
High
Low
High
-

Diagnosis

Inadequate calorie and protein energy intake

Related to:
Poor appetite secondary to abdominal pain and
intractable vomiting

As evidenced by:
NPO status prior to admission
Clear liquid diet restriction
Reported weight loss of 10 lbs. in 10 days (6.5%
of UBW)= severe weight loss.

Intervention
Energy
Protein
Diet Order
Supplement

20-25kcal/kg CBW= 1386-1732 kcal

1.0-1.2 g/kg CBW= 69.3-83.16 g/day

Advance to full liquids when medically

appropriate.
Discontinue Ensure Clear- Advance to Ensure Complete
TID

Vitamins/Minerals

Multivitamin, Fe supplement recommended. Provide

electrolytes as needed.

Other

Enteral Nutrition should be considered if poor Po

continues for > 5-7 days

Monitoring & Evaluation

Oral
Intake

Weight

GI
Symptoms

Labs

Nutrition Reassessment
April 14, 2015
Diet
Full Liquids with
Ensure Clear TID

Nutritional Indicators:

Patients pain/GI
symptoms improved.
Has not vomited since
9 pm the night before.
Tolerating Po now but
does not like full
liquid diet.

I want real food!!

Clinician Notes:
Obstruction series
completedrevealed partial
small bowel
obstruction.
No surgical
procedures
planned
Skin intact
IV fluids and KRider

Laboratory Test

April 12th April 14th

Value Level (High/Low)

WBC
Hgb
Hct
Plt
Na
K
Cr
BUN
Albumin

12.9
11.8
35
402
142
3.2
0.90
12
4.4

10.9
10.5
32.4
402
142
3.2
0.73
8
4.4

High
Low
Low
High
Low
-

CRP
Glucose

4.0
108

2.8
103

High
-

Diagnosis

Inadequate oral intake

Related to:
Diet restriction and patient not accepting
supplements

As Evidenced by:
Intake of 50% of meals and diet restriction
still in place

Intervention
Energy
Protein

20-25kcal/kg CBW= 1386-1732 kcal

Diet Order

Advance to GI Soft (low fat/low fiber)

Supplement
Vitamins/Minerals

Other

1.0-1.2 g/kg CBW= 69.3-83.16 g/day

Discontinue all oral supplements; add liquid protein

to applesauce
Multivitamin, Fe supplement recommended.
Provide electrolytes as needed.
Discuss adding probiotic to diet
Provided IBD diet education for Crohns
exacerbation symptoms

Patient discharged on GI soft diet on April 15, 2015

Readmission
April 28, 2015
Chief Complaint:

Abdominal pain, vomiting, diarrhea lasting 1 week.

Pain localized in right lower quadrant

Clinician Update:

Sent for X-Ray by primary physician on April 25th and it revealed another
partial small bowel obstruction

PO Status:

NPO status for 3 days; No solid foods for 10 days (per pt. reports)
Hospital diet upon admission: NPO

Weight

Patients CBW: 67.03 kg; BMI 29

Total weight loss of 4.5 kg between two admissions (<2 weeks)

Labs & Medications

Laboratory
Test
WBC
Hgb
Hct
Plt
Na
K
Cr
BUN
Albumin
CRP

Charted
Value
14.3
11.2
34.7
402
142
3.3
1.06
8
3.4
4.5

Value Level
(High/Low)
High
low
High
Low
High

Glucose

100

Medication
Name

Indication

Heparin

Anticoagulant

Nicotine Patch

smoking
deterrent

Vancomycin

Antibiotic

Morphine ER

Analgesic

Naloxone

Opioid antagonist

Zofran

Anti-emetic

K-Chloride

Potassium
Chloride Infusions

Diagnosis

Inadequate oral intake

Related to:
GI distress secondary to partial SBO

As Evidenced by:
Nausea, vomiting, and diarrhea; poor Po for
1.5 weeks and reported 5 lb. weight loss in 3
weeks, 10 lb. weight loss in 1.5 months

Intervention
Energy

20-25 kcal/kg of patients CBW= 1340-1676 kcal/day

Protein

1.0- 1.5 g/kg IBW due to inflammation= 45.4-68 g/day

Diet Order

Advance diet to Clear Liquids when medically

appropriate- gradually advance to GI soft once stable

Snack
Supplement
Vitamins/Minerals

Other

Yogurts with meals once diet advanced to GI soft

Liquid protein in applesauce TID

MVI; Iron supplement
Discuss adding probiotic to diet
Provided IBD diet education for Crohns exacerbation
symptoms

Critical Comments
Short Hospital Duration
o Why readmitted just 2 weeks later?

Involvement in Interdisciplinary Team

Importance of Bowel Rest
Smoking and CD Exacerbation
Nutrition Education

Thank you to the dietetic team

at Kennedy Health, my Sodexo
program directors, and my
fellow co-interns!

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The End