Case%11:%Inflammatory%Bowel%Disease:%Crohns%Disease%

Sam!Ballard!
9.15.2015!
!
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!defined!as!an!autoimmune,!chronic!inflammatory!
condition!of!the!gastrointestinal!tract!(Nelms,!380)!and!consists!of!two!diagnoses:!
ulcerative!colitis!and!Crohns!disease.!!Although!the!exact!etiology!for!IBD!is!unknown,!
it!is!hypothesized!that!the!interaction!of!environmental!and!clinical!factors!trigger!an!
inappropriate!immune!response!in!genetically!predisposed!individuals!(Nelms,!418).!!
This!inflammatory!process!leads!to!the!wellRknown!mucosal!damage!and!therefore!a!
further!disturbance!of!the!epithelial!barrier!function,!resulting!in!an!increased!influx!of!
bacteria!into!the!intestinal!wall,!even!further!accelerating!the!inflammatory!process!
(Schmidt,!2005).!!Smoking,!infections,!intestinal!flora,!diet,!and!physiological!changes!in!
the!small!intestine!are!all!examples!of!environmental!factors!that!can!contribute!to!IBD.!!
Genes,!similar!to!those!of!other!autoimmune!diseases,!have!been!identified!that!seem!to!
be!associated!with!IBD!susceptibility!(Nelms,!418).!!!
!
2.#Mr.#Sims#was#initially#diagnosed#with#ulcerative#colitis#and#then#diagnosed#with#Crohns.##
How#could#this#happen?##What#are#the#similarities#and#differences#between#Crohns#disease#
and#ulcerative#colitis?#
!
Both!ulcerative!colitis!and!Crohns!disease!have!similar!signs!and!symptoms.!!Both!
forms!of!IBD!cause!abdominal!pain,!diarrhea,!and!tenesmus,!which!is!the!feeling!that!
you!need!to!pass!stools,!even!though!your!bowels!are!already!empty!(MedlinePlus,!
2014).!!There!are!also!many!subtle!differences!between!Crohns!disease!and!ulcerative!
colitis.!!One!difference!is!that!diarrhea!from!ulcerative!colitis!contains!blood,!while!
diarrhea!from!Crohns!disease!is!much!less!likely!to!do!so.!!Crohns!disease!will!also!
cause!more!abdominal!pain!and!cramping!than!ulcerative!colitis!(Nelms,!420).!!Another!
difference!between!Crohns!disease!and!ulcerative!colitis!is!that!Crohns!disease!can!
affect!any!portion!of!the!gastrointestinal!tract!and!all!layers!of!the!bowel!wall,!while!
ulcerative!colitis!only!affects!the!lining!of!the!colon!(Crohns!&!Colitis!Foundation!of!
America,!2015).! !
!
3.#A#CT#scan#indicated#bowel#obstruction#and#the#Crohns#disease#was#classified#as#severeD
fulminant#disease.##CDAI#score#of#400.##What#does#a#CDAI#score#of#400#indicate?##What#does#
a#classification#of#severeDfulminant#disease#indicate?#
#
The!acronym!CDAI!stands!for!Crohns!Disease!Activity!Index.!!A!CDAI!score!of!400!
indicates!that!the!patient!has!a!moderate!form!of!the!disease.!!A!patient!is!classified!as!
in!remission!with!a!CDAI!score!of!less!than!150,!has!a!response!with!a!score!decrease!
greater!than!70!points,!has!a!mild!form!of!the!disease!with!a!score!of!150R220,!has!a!
moderate!response!to!the!disease!with!a!score!of!220R450,!and!has!a!severe!form!of!the!
!

1!

disease!with!a!score!greater!than!450.!!A!classification!of!severeRfulminant!disease!
indicates!that!the!patient!has!persisting!symptoms!despite!the!introduction!of!steroids!
as!outpatients,!or!individuals!presenting!with!high!fever,!persistent!vomiting,!evidence!
of!intestinal!obstruction,!rebound!tenderness,!cachexia,!or!evidence!of!an!abscess!
(Hanauer!&!Sandborn,!2001).!!!
# #
#
4.#What#did#you#find#in#Mr.#Sims#history#and#physical#that#is#consistent#with#his#diagnosis#
of#Crohns?#Explain.#
#
Mr.!Sims!history!indicates!that!he!has!been!experiencing!severe!diarrhea,!abdominal!
pain,!and!he!is!now!running!a!fever.!!He!also!mentions!that!he!switched!medication!after!
he!began!to!experience!diarrhea!and!abdominal!pain.!!He!felt!better!for!a!while,!but!now!
his!abdominal!pain!is!unbearable.!!He!was!also!hospitalized!this!past!September!with!an!
abcess.!!His!physical!examination!determined!he!has!distension,!extreme!tenderness!
with!rebound!and!guarding,!and!minimal!bound!sounds!in!his!abdomen.!!When!
referring!back!to!the!definition!of!severeRfulminant!disease,!it!is!characterized!by!
persisting!symptoms!despite!the!introduction!of!steroids!as!outpatients,!or!individuals!
presenting!with!high!fever,!persistent!vomiting,!evidence!of!intestinal!obstruction,!
rebound!tenderness,!cachexia,!or!evidence!of!an!abscess!(Hanauer!&!Sandborn,!2001).!!
Mr.!Sims!is!having!persisting!symptoms!despite!the!introduction!of!steroids!or!
medication,!he!has!a!high!fever,!rebound!tenderness,!and!there!is!evidence!of!an!abcess.!!
The!presence!of!diarrhea!and!abdominal!pain!is!also!consistent!with!inflammatory!
bowel!disease!and!the!fact!that!there!is!no!evidence!of!blood!in!his!stool!makes!his!
diagnosis!of!Crohns!disease!more!logical.#
#
#
#
5.#Crohns#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?#
!
Extraintestinal!symptoms!are!those!that!occur!outside!of!the!intestines.!!Examples!of!
extraintestinal!symptoms!may!include!diarrhea,!abdominal!pain,!fever,!weight!loss,!
abdominal!masses,!anemia,!osteoporosis,!inflammatory!arthropathies,!scleritis,!
nephrolithiasis,!cholelithiasis,!and!erythema!nodosum!(American!Academy!of!Family!
Physicians,!2011).!!Mr.!Sims!is!presenting!with!extraintestinal!symptoms!that!include!
diarrhea,!abdominal!pain,!fever,!a!weight!loss!of!about!20R25!pounds,!and!anemia!as!
evidenced!by!low!levels!of!hemoglobin!(12.9g/dL),!hematocrit!(38%),!transferrin!(180!
mg/dL),!ferritin!(16!mg/mL)!and!high!ZPP!(85!umol/mol)!in!the!blood.! !
!
!
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#Crohns.#
#
Corticosteroids!are!used!in!the!treatment!of!inflammation.!!These!include!prednisone!
and!budenoside!and!are!used!when!the!signs!and!symptoms!of!a!disease!become!
severely!worse.!!These!would!have!been!the!case!for!Mr.!Sims!when!his!history!
described!he!had!switched!medicine!in!September,!felt!a!little!better!and!went!back!to!
work,!and!now!feels!significantly!worse.!!Corticosteroids!are!also!utilized!for!severe!
!

2!

fulminant!disease,!which!the!patient!is!classified!as!having,!but!these!put!him!at!risk!for!
becoming!steroid!dependent!(Nelms,!420).!!Mesalamine!is!an!antiRinflamatory!agent!
that!stops!the!body!from!producing!substances!that!cause!inflammation.!!It!is!primarily!
used!to!treat!ulcerative!colitis!and!maintain!improvement!of!ulcerative!colitis!
symptoms!(MedlinePlus,!2015).!!Although!an!antiRinflammatory!agent!would!help!in!the!
treatment!of!Crohns!disease,!this!medication!was!most!likely!prescribed!to!him!when!
he!was!believed!to!have!ulcerative!colitis.!!Mesalamine!is!released!in!the!intestines!and!
because!Crohns!disease!can!occur!in!any!portion!of!the!digestive!tract,!this!medication!
may!not!be!as!useful!to!him!as!it!would!be!with!ulcerative!colitis.!!Humira,!also!known!
as!adalimunab,!is!used!in!biologic!therapy!for!Crohns!disease!(Nelms,!420).!It!is!a!tumor!
necrosis!factor!inhibitor!that!blocks!the!action!of!tumor!necrosis!factor,!which!is!a!
substance!that!causes!inflammation,!a!main!component!of!Crohns!(MedlinePlus,!2015).!!#
#
7.#Which#laboratory#values#are#consistent#with#an#exacerbation#of#his#Crohns#disease?##
Identify#and#explain#these#values.#
Mr.!Sims!has!low!protein!and!low!albumin!and!prealbumin!levels.!!This!is!a!common!
nutrition!deficiency!seen!with!Crohns!disease!and!is!due!to!losses!from!the!GI!tract!
caused!by!inflammation!and!muscle!catabolism!that!is!induced!by!steroids!or!when!an!
infection!or!abcess!is!present!(Nelms,!420).!!The!patients!cBreactive%protein!level!is!
high,!indicating!inflammation!(Nelms,!421).!!Mr.!Sims!also!tested!positive!for!ASCA,!
which!is!an!acronym!for!antiRsaccharomyces!cerevisiae!antibodies.!!These!antibodies!
have!been!proposed!as!serological!markers,!which!may!differentiate!Crohns!disease!
(CD)!from!ulcerative!colitis!(UC)!and!predict!disease!phenotype!(Walker!et!al.,!2004).!!
An!ASCA!test!is!ordered!when!a!patient!presents!signs!and!symptoms!that!suggest!IBD,!
such!as!abdominal!pain,!diarrhea,!rectal!bleeding,!fever,!and/or!fatigue.!!A!positive!
ASCA!test!indicates!that!#the!person!is!likely!to!have!Crohns!disease!(American!
Association!for!Clinical!Chemistry,!2014).!!The!patient!also!has!low!levels!of!
hemoglobin,!hematocrit,!transferrin,!and!ferritin.!!These!low!values!in!the!blood!may!
indicate!anemia.!!Low!levels!of!hemoglobin!and!hematocrit!indicate!low!levels!of!red!
blood!cells!and!this!prevents!cells!from!getting!enough!oxygen!to!the!bodys!tissues.!!
This!can!also!cause!low!blood!iron!levels,!indicated!by!his!low!transferrin,!ferritin,%
and%ZPP!levels!(National!Institute!of!Diabetes!and!Digestive!and!Kidney!Diseases,!
2013).!!Transferrin!is!a!blood!protein!that!picks!up!iron!absorbed!by!the!intestines!and!
transports!it!from!one!location!to!another!(CDC,!2015).!Ferritin!is!a!protein!that!stores!
iron!and!ZPP!(zinc!protoporphyrin)!is!usually!low!in!the!blood!because!it!binds!with!
iron!to!form!heme.!!If!ZPP!levels!are!elevated,!this!indicates!that!there!is!not!enough!
iron!in!the!blood!for!it!to!bind!with.!!He!also!has!low!levels!of!the!fatRsoluble!vitamins!D!
and!vitamin!A!as!well!as!low!levels!of!the!waterRsoluble!vitamin,!vitamin!C.!!Low!levels!
of!fatBsoluble%vitamins!may!be!caused!by!steatorrhea,!which!is!excess!fat!in!the!stool!
(>6!g/24!hrs.)!and!low!levels!of!waterBsoluble%vitamins!may!be!due!to!surgical!
resections!or!loss!of!the!terminal!ileum!(Nelms,!420).!

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

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Crohns!patients!are!at!risk!for!deficiencies!of!calcium,!vitamin!D,!vitamin!B12,!iron,!
zinc,!and!magnesium.!!These!deficiencies!are!due!to!malabsorption!and!losses!in!blood!
and!diarrhea!(Nelms,!421).!!Mr.!Sims!lab!values!indicate!that!he!has!low!levels!of!fatR
soluble!vitamins!A!and!D,!low!levels!of!the!waterRsoluble!vitamin!C,!and!he!is!iron!
deficient.!!Vitamin!D!and!calcium!deficiencies!can!be!caused!by!longRterm!steroid!use!
and!a!decreased!intake!of!dairy!foods!as!a!result!of!lactoseRrestricted!diets.!!FatRsoluble!
vitamin!(A,D,E,!and!K)!deficiency!can!be!caused!by!steatorrhea,!or!excess!fat!in!the!stool.!!
WaterRsoluble!vitamin!(B!and!C)!deficiency!may!be!due!to!surgical!resections!and!the!
loss!of!the!terminal!ileum!(Nelms,!420).!!This!may!be!true!for!Mr.!Sims!since!he!has!had!
200!cm.!of!his!jejunum!and!proximal!ileum!resected.!!Mr.!Sims!high!ZPP!lab!value!
indicates!that!he!is!iron!deficient.!!This!lab!test!measures!the!amount!of!zinc!in!the!
blood!and!when!these!levels!are!high,!this!means!there!is!not!enough!iron!in!the!blood!
for!the!zinc!to!bind!to!so!there!is!an!excess!of!ZPP!(American!Association!for!Clinical!
Chemistry,!2015).!!His!transferrin!and!ferritin!levels!are!also!low,!meaning!that!there!is!
less!iron!to!bind!to!blood!plasma!glycoproteins!and!less!iron!to!store.!!The!presence!of!
his!diarrhea!is!also!a!cause!for!concern!regarding!vitamin!and!mineral!deficiencies.#
# #
#
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!is!defined!as!decreased!digestion!and!absorption!that!result!
from!a!large!resection!of!the!small!intestine!(Nelms,!380).!!Another!definition!proposed!
by!OKeefe!et!al.!states!Short!bowel!syndrome!intestinal!failure!results!from!surgical!
resection,!congenital!defect!or!diseaseRassociated!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,!426).!!
Based!on!this!secondary!definition!of!short!bowel!syndrome,!I!believe!that!Mr.!Sims!is!a!
likely!candidate!for!this!diagnosis.!!His!lab!values!show!low!levels!of!total!protein,!
albumin,!and!prealbumin!and!his!energy!intake!has!been!insufficient!due!to!his!
intestinal!discomfort!when!eating,!diarrhea,!and!malabsorption!and!is!evidenced!by!his!
unintended!weight!loss.!!He!is!also!having!difficulty!maintaining!his!fluid!and!electrolyte!
balance!due!to!his!diarrhea.!
# #
#
10.#What#type#of#adaptation#can#the#small#intestine#make#after#resection?#
#
After!resection,!there!are!three!phases!to!the!postRoperative!period.!!The!first!phase!
lasts!from!7R10!days!where!the!patient!is!dependent!on!parenteral!nutrition!to!manage!
fluid!and!electrolyte!balance.!!This!phase!is!characterized!by!extensive!fluid!and!
electrolyte!losses!within!large!volumes!of!diarrhea!(Nelms,!427).!!The!second!phase!
lasts!for!several!months!and!this!is!when!enteral!nutrition!is!introduced!followed!by!a!
gradual!transition!to!an!oral!diet.!!This!phase!is!characterized!by!reduction!in!diarrhea!
volumes!with!the!initial!stages!of!adaptation!of!the!remaining!bowel!(Nelms,!427).!!The!
third!and!final!phase!ranges!from!1!to!2!years!and!there!is!continued!adaptation!of!the!
remaining!bowel.!!This!phase!is!characterized!by!increased!blood!flow,!secreations,!
and!mucosal!cell!growth!and!the!inner!lumen!of!the!remaining!small!intestine!
!

4!

increases!in!diameter!and!this,!along!with!an!increase!in!villous!height,!allows!for!
increased!absorptive!surface!area!(Nelms,!427).!!Nutritional!support!for!short!bowel!
syndrome!includes!oral!rehydration,!parenteral!nutrition,!enteral!nutrition,!vitamin!and!
mineral!supplements,!and!adherence!to!a!special!diet!that!may!include!small,!frequent!
feedings,!avoiding!foods!that!cause!diarrhea!(such!as!foods!high!in!sugar,!protein,!and!
fiber),!and!avoiding!high!fat!foods!(National!Institute!of!Diabetes!and!Digestive!and!
Kidney!Diseases,!2014).# #
#
11.#For#what#classic#symptoms#of#short#bowel#syndrome#should#Mr.#Sims#health#care#team#
monitor?#
#
Classic!symptoms!of!short!bowel!syndrome!that!Mr.!Sims!health!care!team!should!
monitor!include!bloating,!cramping,!fatigue!or!feeling!tired,!foulRsmelling!stool,!
heartburn,!too!much!gas,!vomiting,!and!weakness.!!They!should!also!monitor!Mr.!Sims!
to!see!if!he!starts!to!react!to!certain!foods.!!Food!allergies!and!intolerances,!such!as!
lactose!intolerance,!are!more!likely!to!develop!in!individuals!with!short!bowel!
syndrome.!!There!are!also!multiple!complications!to!look!for!after!resection,!including!
malnutrition,!peptic!ulcers,!kidney!stones,!and!small!intestinal!bacterial!growth!
(National!Institute!of!Diabetes!and!Digestive!and!Kidney!Diseases,!2014).!#
#
12.#Mr.#Sims#is#being#evaluated#for#participation#in#a#clinical#trial#using#highDdose#
immunosuppression#and#autologous#peripheral#blood#stem#cell#transplantation#
(autoPBSCT).##How#might#this#treatment#help#Mr.#Sims?#
Autologous!peripheral!blood!stem!cell!transplantation!means!transplanting!blood!stem!
cells!that!were!obtained!from!the!same!individual!to!a!different!area!in!that!same!
individual.!!If!healthy!blood!stem!cells!were!taken!from!healthy!areas!of!the!body!and!
transplanted!in!the!area!of!his!small!intestine!(the!site!of!his!resection!and!source!of!his!
abdominal!pain),!they!may!have!an!increased!ability!to!heal!or!replace!cells!that!are!
susceptible!to!inflammatory!bowel!disease.!!Although!there!have!been!advances!in!
immunosuppressive!therapy,!there!is!still!limited!evidence!from!pilot!trials!
suggest[ing]!that!highRdose!immunosuppressive!and!autologous!peripheral!blood!stem!
cell!transplantation!(autoPBSCT)!may!induce!remission!in!these!patients,!but!there!is!
substantial!controversy!regarding!the!safety!and!efficacy!of!this!approach!(Hasselblatt!
et!al.,!2012).!!!

II.! Understanding%the%Nutrition%Therapy%
13.#What#are#the#potential#nutritional#consequences#of#Crohns#disease?!
!
Potential!nutritional!consequences!of!Crohns!disease!include!weight!loss,!muscle!
wasting,!malnutrition,!and!specific!nutritional!deficiencies.!!These!nutritional!
deficiencies!may!include!deficient!calories,!protein,!fluid!and!electrolytes,!iron,!
magnesium,!zinc,!calcium,!vitamin!D,!vitamin!B12,!folate,!waterRsoluble!vitamins,!and!
fatRsoluble!vitamins!(Nelms,!420).!!!

5!

! A!calorie!deficiency!can!be!caused!by!insufficient!intake,!anorexia,!increased!
energy!requirements,!or!fear!of!abdominal!pain!and!diarrhea!after!eating.!!The!
direct!effect!of!this!deficiency!is!weight!loss.!!!
! A!protein!deficiency!can!be!caused!by!increased!protein!needs!due!to!losses!
from!the!GI!tract!caused!by!inflammation,!muscle!catabolism!that!is!steroidR
induced!or!occurs!when!infection!or!abscesses!are!present,!or!healing!from!
surgery.!!The!direct!effect!of!this!deficiency!is!muscle!wasting.!!
! !A!deficiency!of!fluid%and%electrolytes!can!be!caused!by!short!bowel!syndrome!
or!highRvolume!diarrhea.!!!
! Low!iron!levels!may!be!due!to!blood!loss!or!malabsorption.!
! Low!magnesium%or%zinc!levels!can!be!caused!by!intestinal!losses,!especially!
from!short!bowel!syndrome!or!highRvolume!diarrhea.!
! A!deficiency!of!calcium%or%vitamin%D!can!be!caused!by!longRterm!steroid!use!or!
a!decreased!intake!of!dairy!foods!as!a!result!of!lactoseRrestricted!diets.!
! A!B12!deficiency!can!be!caused!by!surgical!resections!of!the!stomach,!which!can!
cause!loss!of!intrinsic!factor.!!It!can!also!be!caused!by!terminal!ileum,!which!is!
the!site!of!absorption.!
! A!folate!deficiency!can!be!caused!by!medications!that!are!used!to!treat!irritable!
bowel!syndrome,!so!is!very!likely.!
! A!deficiency!of!the!waterBsoluble%vitamins!(B!and!C)!can!be!caused!by!surgical!
resections!and!the!loss!of!terminal!ileum,!as!in!a!B12!deficiency.!
! Lastly,!a!deficiency!of!the!fatBsoluble%vitamins!(A,D,E,!and!K)!can!be!caused!by!
steatorrhea,!which!is!excess!fat!in!the!stool!(>6!g/24!hrs.).!
(Nelms,!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!average!small!intestine!in!humans!over!the!age!of!five!is!about!23!feet,!or!700!
centimeters,!long.!!If!Mr.!Sims!had!200!cm!of!the!middle!section!of!his!small!intestine!
resected,!he!has!about!500!centimeters!remaining.!!The!normal!length!of!the!jejunum!is!
2.5!meters,!or!250!cm,!long!and!the!normal!length!of!the!ileum!is!3.5!meters,!or!350!cm,!
long!(New!World!Encyclopedia,!2011).!!Taking!this!into!account,!if!200!cm!of!the!
jejunum!and!proximal!ileum!were!resected,!only!about!400!cm!of!jejunum!and!ileum!
combined!remain.!!This!would!not!be!considered!a!significant!resection!because!more!
than!50%!of!the!small!intestine!has!to!be!removed!before!any!significant!reduction!in!its!
capability!is!observed!(Nelms,!381).!!Also,!the!duodenum!and!jejunum!can!perform!
each!others!role!in!both!digestion!and!absorption!and!the!ileum!can!also!adapt!in!this!
wayup!to!a!certain!point!(Nelms,!381).!!So!although!a!good!portion!of!the!jejunum!
was!removed,!there!is!still!more!than!half!of!the!small!intestine!remaining!and!the!
duodenum!will!be!able!to!adapt!and!assist!in!the!absorption!that!is!lost!from!this!
resection.!!!
!
!

6!

15.#What#nutrients#are#normally#digested#and#absorbed#in#the#portion#of#the#small#
intestine#that#has#been#resected?#
!
Mr.!Sims!surgery!resected!portions!of!his!jejunum!and!proximal!ileum.!!The!jejunum!
makes!up!the!middle!section!of!the!small!intestine.!!The!nutrients!that!are!absorbed!in!
this!middle!section!include!carbohydrates,!proteins,!fats,!and!most!vitamins.!!The!ileum!
makes!up!the!lower!end!of!the!small!intestine.!!The!nutrients!that!are!absorbed!in!this!
lower!section!include!bile!acids!and!vitamin!B12!(National!Institute!of!Diabetes!and!
Digestive!and!Kidney!Diseases,!2014).!!The!resection!of!his!jejunum!can!be!used!to!
explain!the!patients!weight!loss.!!If!carbohydrates,!protein,!and!fats!are!not!being!
absorbed!as!efficiently!as!they!would!be!if!the!jejunum!that!was!resected!was!present,!
then!Mr.!Sims!is!not!receiving!the!energy!necessary!to!carry!out!his!daily!life!and!he!
would!begin!to!lose!weight!and!possibly!waste.!
!
III.!Nutrition%Assessment%
16.#Evaluate#Mr.#Sims#%#UBW#and#BMI.#
!
%UBW!=!(Current!BW!/!UBW)!x!100!
%UBW!=!(140!lbs.!/!166!lbs.)!x!100!
%UBW!=!(0.843)!x!100!
%UBW%=%84%%
%
BMI!=!wt.!(kg)!/!ht.!(m2)!
BMI!=![(140!lbs.!/!2.2!kg)!/!(69!in.!x!2.54!cm)2]!
BMI!=!63.6!kg!/!175.26!cm2!
BMI!=!63.6!kg!/!1.75!m2!
! BMI%=%20.8%
! !
A!%UBW!of!84%!indicates!that!Mr.!Sims!weighs!84%!of!his!usual!body!weight!of!166!
lbs.,!meaning!he!weights!140!lbs.!!A!BMI!of!20.8!classifies!Mr.!Sims!as!having!a!normal!
or!healthy!weight.!
# #
17.#Calculate#Mr.#Sims#energy#requirements.#
!
Hamwi!Method:!
!
IBW!=!106!lbs.!+!(6!lbs.!x!every!inch!over!5!ft.)!
IBW!=!106!lbs.!+!(6!lbs.!x!9!in.)!
IBW!=!106!lbs.!+!54!lbs.!
IBW%=%160%lbs.%/%2.2%=%72.7%kg%
!
ABW!=!IBW!+!0.25!(UBW!!IBW)!
ABW!=!160!lbs.!+!0.25!(166!lbs.!!160!lbs.)!
ABW!=!160!lbs.!+!0.25!(6!lbs.)!
ABW!=!160!lbs.!+!1.5!
ABW%=%161.5%lbs.%/%2.2%=%73.4%kg%
!

7!

!
MifflinRSt.!Jeor:!
!
EER!=![10!x!ABW!(kg)!+!6.25!x!ht!(cm)!R!5!x!age!(yrs)!+!5]!x!PAL!
EER!=![10!x!73.4!kg!+!6.25!x!(69!in.!x!2.54!cm)!!5!x!35!+!5]!x!1.6!
EER!=![734!+!6.25!x!175.26!!175!+!5]!x!1.6!
EER!=![734!+!1,095.375!!175!+!5]!x!1.6!
EER!=!1,659.375!x!1.6!
EER%=%2,655%kcal%
EER%=%2,600%%2,700%kcal
! !
!
18.#What#would#you#estimate#Mr.#Sims#protein#requirements#to#be?#
!
PRO!=!Factor!x!ABW!
PRO!=!1.0!g/kg/day!x!73.4!kg! !
PRO!=!1.5!g/kg/day!x!73.4!kg!
PRO!=!73.4!g/kg/day! !
!
PRO!=!110.1!g/kg/day!
PRO%=%73.4%%110.1%g/kg/day% %
%
!
19.#Identify#any#significant#and/or#abnormal#laboratory#measurements#from#both#his#
hematology#and#his#chemistry#labs.#
!
Chemistry%
Abnormal%Lab%
Ref.%Range%(Male)% Lab%Value%
High%or%Low%
Protein,!total!(mg/dL)!
6R8!
5.5!
Low!
Albumin!(g/dL)!
3.5R5!
3.2!
Low!
Prealbumin!(mg/dL)!
16R35!
11!
Low!
CRreactive!protein!(mg/dL)!
<1.0!
2.8!
High!
HDLRC!(mg/dL)!
>45!
38!
Low!
ASCA!
Neg!
+!
High!
*PT!(sec)!
12.4R14.4!
15!
High!
*Coagulation:!Prothrombin!Time!
!
Hematology%
Abnormal%Lab%
Ref.%Range%(Male)% Lab%Value%
High%or%Low%
Hemoglobin!(Hgb,!g/dL)!
14R17!
12.9!
Low!
Hematocrit!(Hct,!%)!
40R54!
38!
Low!
Transferrin!(mg/dL)!
215R365!
180!
Low!
Ferritin!(mg/mL)!
20R300!
16!
Low!
ZPP!(umol/mol)!
30R80!
85!
High!
Vitamin!D!25!hydroxy!(ng/mL)! 30R100!
22.7!
Low!
Free!retinol!(vitamin!A;!ug/dL)! 20R80!
17.2!
Low!
Ascorbic!acid!(mg/dL)!
0.2R2.0!
<0.1!
Low!
! !
!
IV.!Nutrition%Diagnosis%

8!

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

Inadequate!oral!intake!(NIR2.1)!related!to!Crohns!disease!as!evidenced!by!unintended!
weight!loss!of!about!28!lbs.!in!6!months!and!patient!admission!of!knowing!what!he!
needs!to!do!nutritionally,!but!abdominal!pain!and!diarrhea!decrease!his!appetite!and!
make!it!hard!for!him!to!eat.!
!
Unintended!weight!loss!(NCR3.2)!related!to!Crohns!disease!and!short!bowel!syndrome!
as!evidenced!by!loss!of!about!28!lbs.!in!6!months,!even!after!working!hard!to!regain!
weight!and!return!to!usual!weight!of!166R168!lbs.!!
!
Bonus!PES:!Altered!GI!function!(NCR1.4)!related!to!Crohns!disease!and!short!bowel!
syndrome!as!evidenced!by!low!levels!of!total!protein!(5.5!g/dL),!albumin!(3.2!g/dL),!
prealbumin!(11!mg/dL),!vitamin!D!25!hydroxy!(22.7!ng/mL),!free!retinol!or!vitamin!A!
(17.2!ug/dL),!and!ascorbic!acid!or!vitamin!C!(<0.1!mg/dL)!indicating!lack!of!absorption.!
V.! Nutrition%Intervention%
21.#The#surgeon#notes#Mr.#Sims#probably#will#not#resume#eating#by#mouth#for#at#least#7D10#
days.##What#information#would#the#nutrition#support#team#evaluate#in#deciding#the#route#
for#nutrition#support?#
!
The!nutrition!support!team!must!identify!his!energy!and!macronutrient!needs!as!well!
as!any!reasons!he!may!be!unable!or!unwilling!to!ingest!food!orally.!!They!must!take!into!
consideration!that!he!has!been!experiencing!unintended!weight!loss,!has!just!
underwent!an!intestinal!resection!of!the!jejunum!and!proximal!ileum,!and!experiences!
abdominal!pain!and!diarrhea.!!Parenteral!nutrition!would!be!more!suitable!for!Mr.!Sims!
than!would!enteral!nutrition.!!Enteral%nutrition!is!for!adult!patients!who!have!a!
functioning!gastrointestinal!tract!and!who!present!with!inadequate!oral!intake!for!7R14!
days,!or!in!whom!inadequate!oral!intake!is!expected!to!continue!over!a!7R!to!14Rday!
period!(Nelms,!90).!!Parenteral%nutrition!is!used!to!describe!the!administration!of!
drugs!or!nutrients!by!vein!and!is!for!individuals!with!severe!gastrointestinal!
impairment!(Nelms,!103).!!Because!of!Mr.!Sims!intestinal!resection!and!healing,!
parenteral!nutrition!via!IV!will!allow!nutrients!to!reach!parts!of!the!body!and!bypass!his!
temporarily!impaired!gastrointestinal!tract.!!This!type!of!feeding!will!also!allow!staff!to!
carefully!calculate!his!exact!nutrient!needs,!which!may!be!more!beneficial!to!his!
recovery!than!trying!to!receive!emergency!nutrients!from!orally!ingested!food!alone.! !
!
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!phosphorus!and!serum!magnesium!levels!are!related!to!refeeding!
syndrome.!!Refeeding!syndrome!describes!metabolic!alterations!that!occur!during!
nutritional!repletion!of!patients!who!are!malnourished.!!With!days!of!starvation,!liver!
gluconeogenesis!slows,!free!fatty!acids!produce!ketones!for!energy,!and!basal!metabolic!
rate!declines.!!Reintroducing!carbohydrates,!in!any!form,!shifts!the!bodys!primary!
energy!source!form!ketones!to!glucose.!!Glucose!metabolism!requires!large!amounts!of!

9!

phosphorus!and!to!meet!anabolic!needs,!magnesium,!potassium,!and!thiamin!
requirements!may!also!increase.!!This!results!in!a!drop!in!serum!phosphorus!levels,!
which!may!result!in!hemolysis,!impaired!cardiac!function,!impaired!respiratory!
function,!and!even!death.!!Low!serum!magnesium!levels!(hypomagnesemia)!may!cause!
tremors,!muscle!twitching,!cardiac!arrhythmias,!and!even!paralysis!(Nelms,!103).!
!
!
23.#What#is#refeeding#syndrome?##Is#Mr.#Sims#at#risk#for#this#syndrome?##How#can#it#be#
prevented?#
!

Refeeding%syndrome!is!defined!as!metabolic!alterations!that!may!occur!during!
nutritional!repletion!of!starved!patients!(Nelms,!89).!!Populations!that!are!at!risk!for!
this!syndrome!include!those!who!present!with!malnutrition,!those!who!have!a!history!
of!longRterm!inadequate!oral!intake,!and!those!who!have!had!minimal!intake!for!several!
days!as!a!result!of!NPO!status!or!poor!appetite!(Nelms,!103).!!Mr.!Sims!is!at!risk!for!this!
syndrome!because!he!is!currently!malnourished,!has!had!inadequate!oral!intake!due!to!
intestinal!discomfort,!and!has!had!minimal!intake!for!several!days!due!to!his!NPO!order.!!
Strategies!to!prevent!refeeding!syndrome!include!beginning!feedings!slowly!and!
avoiding!overfeeding!(Nelms,!103).! !
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#teams#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.#
!
50!cc/hr!x!24!hrs.!=!1,200!cc/day!=!1.2!L/day!
! PRO!=!1.2!L/day!x!42.5!g!amino!acids/L!=!51%g%amino%acids/day!
o! 51!g!amino!acids/day!x!4!kcal/g!=!204%kcal/day%from%amino%acids!
! CHO!=!1.2!L/day!x!200!g!dextrose/L!=!240%g%dextrose/day!
o! 240!g!dextrose/day!x!4!kcal/g!=!960%kcal/day%from%dextrose!
! FAT!=!1.2!L/day!x!30!g!lipid/L!=!36%g%lipid/day!
o! 36!g!lipid/day!x!9!kcal/g!=!324%kcal/day%from%lipid!
85!cc/hr!x!24!hrs.!=!2,040!cc/day!=!2.04!L/day!
! PRO!=!2.04!L/day!x!42.5!g!amino!acids/L!=!86.7%g%amino%acids/day!
o! 86.7!g!amino!acids/day!x!4!kcal/g!=!346.8%kcal/day%from%amino%acids!
! CHO!=!2.04!L/day!x!200!g!dextrose/L!=!408%g%dextrose/day!
o! 408!g!dextrose/day!x!4!kcal/g!=!1,632%kcal/day%from%dextrose!
! FAT!=!2.04!L/day!x!30!g!lipid/L!=!61.2%g%lipid/day!
o! 61.2!g!lipid/day!x!9!kcal/g!=!550.8%kcal/day%from%lipid!
According!to!Mr.!Sims!estimated!energy!requirements,!he!requires!2,600R2,700!
kcal/day.!!The!total!kcal/day!he!is!receiving!from!carbohydrates,!fat,!and!protein!at!50!
cc/hr!is!1,488%kcal/day.!!At!50!cc/hr.,!his!protein!intake!(51%g%amino%acids/day)!falls!
short!of!the!estimated!protein!intake!range!of!73.4B110.1%g/day.!!His!goal!of!85!cc/hr!

10!

would!provide!him!with!2,530%kcal/day.!!At!85!cc/hr.,!his!protein!intake!(86.7%g%
amino%acids/day)!would!fall!within!the!estimated!protein!intake!range!of!73.4R110.1!
g/day.!!Although!he!is!not!currently!meeting!his!estimated!nutritional!needs,!he!will!be!
very!close!to!meeting!them!once!he!reaches!his!goal!of!85!cc/hr.!!I!agree!with!the!teams!
decision!to!initiate!parenteral!nutrition.!!It!is!good!that!PN!was!started!at!50!cc/hr.!
because!even!though!it!didnt!satisfy!his!estimated!energy!needs,!it!was!set!so!low!in!
hopes!of!preventing!refeeding!syndrome.!!PN!was!also!necessary!because!of!the!
resection!of!the!patients!small!intestine!and!his!intestinal!discomfort!when!attempting!
to!ingest!foods!orally.!
!
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).#
(NIR2.1):!Based!on!his!admission!of!knowing!what!he!should!be!doing!nutritionally,!but!
having!a!lack!of!appetite!due!to!abdominal!pain!and!diarrhea,!it!would!not!be!necessary!
to!provide!Mr.!Sims!with!lengthy!nutrition!education.!!As!is!currently!being!employed,!
parenteral!nutrition!via!an!IV!will!closely!control!the!amount!of!nutrients!he!receives.!!
This!volume!of!nutrients!would!be!gradually!increased!in!order!to!prevent!refeeding!
syndrome.!!Ideally,!once!he!has!returned!to!oral!nutrient!intake,!we!would!use!nutrition!
counseling!sessions!to!help!him!identify!foods!that!cause!him!little!intestinal!
discomfort.!!This!will!increase!his!oral!nutrient!intake!and!hopefully!allow!him!to!gain!
weight!and!return!to!his!ideal!body!weight.!
!
(NCR3.2):!An!ideal!goal!would!be!for!Mr.!Sims!to!gain!back!the!weight!he!has!lost!in!the!
past!6!months!in!order!to!return!to!his!ideal!body!weight!of!160!lbs.!!In!order!to!combat!
Mr.!Sims!unintended!weight!loss,!there!would!be!an!increase!in!his!daily!caloric!intake!
and!supplements!would!be!provided!to!offset!nutrition!losses!he!may!experience!due!to!
his!intestinal!resection!and!malabsorption!issues!from!Crohns!disease.!!The!increase!in!
daily!caloric!intake!may!be!gradual!at!first!while!he!is!on!PN!to!prevent!refeeding!
syndrome,!but!would!eventually!increase!to!his!calculated!estimated!energy!
requirements!of!2,600R2,700!kcal/day.!!Another!goal!would!be!to!wean!him!off!of!PN!
and!have!him!transition!back!to!oral!intake.!!Again,!nutrition!counseling!would!be!
utilized!over!nutrition!education!in!order!to!help!him!identify!which!foods!he!could!
ingest!orally!while!avoiding!foods!that!cause!him!intestinal!discomfort!or!diarrhea.!
!

!
VI.!Nutrition%Monitoring%and%Evaluation%
26.#Indirect#calorimetry#revealed#the#following#information:!!(p.!64)!
!
Measure%
Oxygen!consumption!(mL/min)!
CO2!production!(mL/min)!
RQ!
RMR!

Mr.%Sims%data%
295!
261!
0.88!
2022!

!
What#does#this#information#tell#you#about#Mr.#Sims?#

11!

Mr.!Sims!indirect!calorimetry!test!reveals!that!he!consumes!more!oxygen!than!the!CO2!
he!produces.!!A!respiratory!quotient!of!0.88!was!calculated!by!dividing!the!CO2!
production!(261!mL/min)!by!the!oxygen!consumption!(295!mL/min).!!The!different!
macronutrients!have!approximate!values!that!correspond!with!respiratory!quotients.!!A!
value!of!0.88!corresponds!with!protein.!!This!means!that!Mr.!Sims!is!metabolizing!
protein!and!it!is!being!exhaled!with!his!CO2!(Open!Anesthesia,!2015).!!This!also!means!
he!may!require!more!kcal!of!other!macronutrients!so!his!body!will!use!other!sources!of!
energy!before!it!uses!protein!as!this!can!lead!to!muscle!wasting.!!Mr.!Sims!RMR!(resting!
metabolic!rate)!measure!indicates!that!he!needs!2,022!kcal!for!his!body!systems!to!
function!when!he!is!at!rest.!!Any!type!of!daily!activity!would!raise!this!kcal!need!and!this!
EER!(estimated!energy!requirement)!was!calculated!to!be!2,600R2,700!kcal/day.!
27.#Would#you#make#any#changes#to#his#prescribed#nutrition#support?##What#should#be#
monitored#to#ensure#adequacy#of#his#nutrition#support?#Explain.#
#
I!would!only!slight!increase!his!total!caloric!intake!of!PN!at!his!goal!of!85!cc/hr.!to!align!
with!his!estimated!energy!requirements!of!2,600R2,700!kcal/day.!!His!protein!needs!at!
this!PN!goal!are!already!adequate!and!fall!within!the!estimated!protein!range!of!73.4R
110.1!g/day.!!Mr.!Sims!calorie,!protein,!iron,!magnesium,!calcium,!zinc,!phosphorus,!
vitamin!D,!vitamin!B12,!waterRsoluble!vitamins!(B!and!C),!fatRsoluble!vitamins!(A,!D,!E,!
and!K),!hydration!status,!and!weight!should!be!monitored!to!ensure!adequacy!of!his!
nutrition!support.!!These!nutrients!are!common!deficiencies!with!Crohns!disease!due!
to!the!nature!of!the!intestinal!disorder!and!the!small!intestines!role!in!digestion!and!
absorption.!!If!neglected,!these!deficiencies!can!lead!to!further!complications.#
#
#
#
28.#What#should#the#nutrition#support#team#monitor#daily?#What#should#be#monitored#
weekly?##Explain#your#answers.#
#
Nutrients!that!are!of!concern!for!Crohns!disease!patients!should!be!monitored!daily.!!
Vitamins!and!minerals!of!concern!include!iron,!magnesium,!calcium,!zinc,!phosphorus,!
vitamin!D,!vitamin!B12,!waterRsoluble!vitamins!(B!and!C),!and!fatRsoluble!vitamins!
(A,D,E,!and!K).!Mr.!Sims!protein!levels,!including!his!total!protein,!albumin,!and!
prealbumin,!should!be!given!special!consideration!due!to!its!role!in!wound!healing!and!
to!prevent!using!protein!as!energy.!!Because!the!patient!has!had!frequent!diarrhea,!his!
hydration!status,!fluid!intake,!and!fluid!output!should!also!be!monitored!daily.!!His!
weight!should!be!monitored!weekly,!only!because!there!may!be!little!change!from!day!
to!day!and!weight!gain!is!a!secondary!goal!after!balancing!his!nutrient!intake.!!Daily!
weight!monitoring!is!also!less!important!because!his!BMI!of!20.8!classifies!him!as!being!
at!a!normal!or!healthy!weight.!!Weight!gain!would!be!preferred!to!get!closer!to!his!ideal!
body!weight,!but!it!is!not!necessary!for!him!at!this!time.#
#
#
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?#
!

12!

Mr.!Sims!serum!glucose!increased!because!his!body!was!undergoing!physiological!
stress.!!This!physiological!stress!is!most!likely!due!to!his!malnutrition,!intestinal!
resection,!and!the!parenteral!nutrition!used!to!correct!his!malnutrition.!!As!the!bodys!
stress!response!subsides,!so!will!the!hyperglycemia.!!Intensive!insulin!therapy!should!
not!be!used!to!correct!this!spike!in!serum!glucose!(Nelms,!103).!!If!the!serum!glucose!
level!was!to!increase!any!more!or!the!hyperglycemia!was!not!subsiding!on!its!own,!it!
may!be!beneficial!to!adjust!the!amount!of!carbohydrate,!or!dextrose,!the!patient!is!
receiving!through!PN.!
!
30.#Evaluate#the#following#24Dhour#urine#data:##24Dhour#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.#
#

N2!balance!=!(dietary!protein!intake!/!6.25)!!urine!urea!nitrogen!!4!!
N2!balance!=!(86.7!g/6.25)!!18.4!g!!4!!
N2!balance!=!13.9!g!!18.4!g!!4!
N2%balance%=%B8.5%g%
%
Assuming!Mr.!Sims!has!reached!his!PN!goal!of!85!cc/hr.!by!postoperative!day!4,!he!has!a!
negative!nitrogen!balance!of!B8.5%g.%%A!negative!nitrogen!balance!indicates!that!his!
nitrogen!excretion!is!greater!than!his!nitrogen!intake!(Nelms,!57).!!This!means!that!he!is!
in!a!state!of!catabolism!where!his!proteins!(muscles)!are!being!broken!down!and!
excreted!because!there!is!insufficient!intake!of!nitrogen,!or!protein,!from!the!diet.!!A!
negative!nitrogen!balance!is!cause!for!concern,!especially!in!a!malnourished!patient!
who!is!already!experiencing!unintended!weight!loss!and!trying!to!recover!from!an!
intestinal!resection.!!However,!there!are!limitations!of!measuring!nitrogen!balance.!!
These!limitations!include!the!inherent!error!of!24Rhour!urine!collection,!failure!to!
account!for!renal!impairment,!and!inability!to!measure!nitrogen!losses!from!some!
wounds,!burns,!diarrhea,!and!vomiting!(Nelms,!58).!!Mr.!Sims!has!been!experiencing!
diarrhea!and!could!be!losing!nitrogen!from!his!surgery!wounds.!!These!factors!could!
have!an!effect!on!his!nitrogen!balance!study.! !
!
31.#On#postDop#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?#
#
First,!Mr.!Sims!should!be!allowed!to!try!a!lowRresidue,!lactoseRfree!diet!with!small,!
frequent!meals!(Nelms,!421).!!Fat!intake!should!be!monitored!and!reduced!if!
steatorrhea!is!present.!!Small!amounts!of!fiber!and!lactose!can!be!added!as!the!patient!
can!tolerate!it!and!this!will!advance!the!diet.!!GasRproducing!foods,!spicy!or!fried!foods,!
caffeinated!beverages,!or!other!foods!that!may!irritate!the!patient!should!be!initially!
restricted!(Nelms,!421).!!If!this!is!successful,!the!parenteral!nutrition!can!be!weaned!
according!to!the!patients!progress!with!oral!feeding.!!It!is!important!for!patients!to!be!

13!

weaned!off!of!parenteral!nutrition!before!complications!occur,!such!as!electrolyte!
imbalance,!underfeeding!and/or!overfeeding,!hyperglycemia,!and!refeeding!syndrome!
(Nelms,!111).!# #
#
#
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.#
!
The!primary!goal!of!rehabilitation!would!be!maximizing!energy!and!protein!intakes.!!
Rebuilding!protein!stores!will!be!accomplished!through!healthy!weight!gain!and!
physical!activity.!!It!will!also!be!important!to!consume!foods!high!in!antioxidants!and!
omegaR3!fatty!acids!to!protect!against!inflammation.!!This!means!that!increased!
consumption!of!fruits,!vegetables,!oils,!nuts,!and!fish!will!be!beneficial.!!Kidney!stones!
and!urolithiasis!can!also!occur!in!IBD!and!the!risk!of!experiencing!these!complications!is!
increased!by!the!consumption!of!foods!high!in!oxalate.!!These!foods!include!cocoa,!tea,!
wheat!germ,!strawberries,!nuts,!spinach,!beets,!baked!beans,!peanut!butter,!tofu,!and!
high!doses!of!vitamin!C!supplements.!!Probiotics!and!prebiotics!enhance!the!normal!
flora!of!the!GI!tract!and!have!been!associated!with!decreased!IBD!symptoms!and!a!
positive!change!in!antiRinflammatory!markers!(Nelms,!423).!!Two!nutritional!outcomes!
from!rehabilitation!would!include!weight!gain!and!adequate!protein!intake.!!Mr.!Sims!
currently!weighs!140!lbs.!and!would!like!to!gain!20R25!lbs.!to!return!to!his!ideal!and/or!
usual!body!weight!of!160R166!lbs.!!His!lab!values!will!be!evaluated!at!his!followRup!
visits!to!ensure!his!total!protein,!albumin,!and!prealbumin!levels!have!increased!to!
normal!levels.!!His!energy!and!protein!intake!is!vital!for!the!rebuilding!of!his!muscles!
and!for!his!overall!rehabilitation!and!physical!strength.!!
!
! !
!
!

14!

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