Amanda Cravinho

3/27/15
Case #11
Inflammatory Bowel Disease: Crohn s Disease
1. Inflammatory Bowel Disease is categorized as Ulcerative Colitis of Crohns Disease and is
defined as chronic inflammation of the digestive tract. Symptoms include abdominal pain,
distension, bloating, diarrhea, bloody diarrhea, unintended weight loss, fever, fatigue and
reduced appetite. Previously, IBD was thought to be brought on by stress and diet. Now medical
literature states that stress and diet are factors that will aggravate the disease but in no way cause
the onset of IBD. It is now known that IBD can be caused by a bacteria/virus resulting in an
inflamed digestive system. This as well as other immune systems malfunctions can lead to IBD.
In addition genetics may play a role in the onset of the disease. Research has shown that IBD
occurs more commonly in people who have a family member with the disease.
2. The way in which Ulcerative Colitis and Crohns Disease present could have given Mr. Sims
a misdiagnosis of Ulcerative Colitis during an initial evaluation. Ulcerative Colitis is classified
according to the severity of symptoms and location of inflammation. It is specific to the inner
most lining of colon and is continuous inflammation throughout the region. In addition, bleeding
is more common in ulcerative colitis when compares to Crohns. In comparison, Crohns causes
inflammation in different parts of the digestive tract and can include any segment of the GI from
the mouth to the anus. It is not continuous and usually presents as splotchy inflamed segments.
Different from UC it can occur in all layers of the bowel lining. Crohns can include the small
bowel (jejunum, duodenum) where most of absorption takes place and can create more severity
and thus, more severe interventions.
Knowing this, Mr. Sims may have presented with location of inflammation just in the colon and
the inflammation must have appeared to be continuous in nature. In addition, the symptoms of
UC and Crohns are very similar and it may be hard to decipher the condition with the
appearance of a continuous inflammation of the colon. Perhaps as his symptoms worsened the
inflammation moved to other regions of the digestive tract AEB the case study citing
inflammation affecting the jejunum and ileum. With this evidence it was necessary to rediagnosis Mr. Sims with Crohns Disease.
9. In my opinion, Mr. Sims would not be a candidate for short bowel syndrome. SBS is a
condition resulting in reduced absorptive capacity caused by surgical resection of the small
intestine. The result of the surgery reduces the length or decreased function of the bowel after
resection. To have short bowel syndrome a pt will be left with less than 200cm of small bowel
that is viable or the pt will have lost 50% or more of the small intestine. Mr. Sims has only lost
200 cm of his small bowel and still has his colon and ilieocecal valve so he does not meet the

requirements for SBS. However, he should be monitored as his resection is severe enough to
warrant watching for signs and symptoms of SBS.
10. After resection, the small bowel can adapt. Adaptation pertains to nutrient absorption and
when part of the bowel is removed, the part left adapts to take on the job of specific nutrient
absorption and liquids that would have previously been absorbed by the resected portion. The
body adaptions in order to decrease nutrient deficiencies resulting from the resection.
Enterocytes in the remaining portion will adapt as they have the ability to reabsorb other
nutrients. This adaptation can take 1 to 3 months to determine how much reabsorption will occur.
To account for this delay, TPN may be administered to account for adequate micronutrient
absorption and hydration for the pt. Once lab values reflect appropriate nutrient levels and
absorptive capacity of the small bowel the pt can be slowly weaned off of TPN. At this point,
consumption PO can begin and progress to regular food intake is the goal. TPN should be
adjusted during this period to account for normal food intake and absorption. REC of
supplementation of a multivitamin should be given to these pts once off TPN.
14. The small intestine is approximately 600 cm or about 20 ft in length. Knowing that Mr.
Smiths resection resulted in removal of 200 cm of his small intestine gives us an estimate of
about 30% of his small intestine that was removed. This is a significant portion removed and due
to this, the pt should be evaluated for signs and symptoms of SBS. However, it is not enough to
be categorized as severe and thus is more moderate of a resection. Nutrient absorption will be a
major issue for the pt with 200 cm removed. The pts lab values should be monitored for nutrient
deficiencies and if they are occur TPN should be given until the small intestine adapts
19. After viewing Mr. Sims lab values it is clear that total protein, albumin and pre-albumin are
all low. Low Hgb and Hct, ferritin, transferrin, Vit D, Vit A and Vit C are also low values AEB
Mr. Sims hematology report. This points to compromised absorption of nutrients due to
inflammation of the jejunum and ileum due to the Crohns. Elevated chemistry lab values include
CRP (indicating inflammation) and a pos. value for ASCA, which is an indication of Crohns.

What are Mr. Sims Estimated needs for energy, protein and fluid?
Pt Weight: 140 lbs (64 kg)
Energy Needs:
Goal of 20 25 kcals/kg/d in hospital: 1280 1600 kcal/d
Goal of 30 35 kcals/kg/d at home: 1920 2240 kcals/d

Protein Needs:

Goal of 1.2 1.5 g/kg/d (severe abdominal surgery) = 76.8 96 g/d

Fluid Needs:
Goal of 25 35 ml/kg/d = 1600 2240 ml/d
23. Refeeding syndrome is classified as a metabolic complication occurring when nutrition
support is given to severely malnourished pts. This syndrome typically occurs after a state of
malnutrition when low levels of K, Phosphorus and Mg develop and is when a pts intracellular
electrolytes are not supplied in sufficient quantity to keep up with tissue growth upon refeeding.
Due to this, CHO metabolism causes a shift of electrolytes to the intracellular space. This
stimulates insulin release and reduces salt and water excretion from the body. In turn, fluid
overload can cause a chance of cardiac and pulmonary complications. To remedy this, nutrient
supplementation gradually should be increased in order to allow the body to adapt and prevent
the refeeding syndrome.
It is my opinion that Mr. Sims is at risk for refeeding syndrome. Mr. Sims nutrition assessment
highlights that he has had a lack of appetite prior to be admitted and prior to starting on PN
intake indicating poor eat habits. Preventive steps for refeeding syndrome include an initial diet
that is moderate in CHOs. In addition, K, Mg and P should be supplemented gradually to allow
time for the body to adapt.
24.
Initial Order
200 g dextrose/L

42.5 g AA/L 30 g lipid/L,

50 cc/hr

= 50 ml/hr x 24 hr = 1200 ml (1.2 L)

Goal rate - 85 cc/hr
= 85 ml/hr x 24 hr = 2040 ml (2.04 L)

Current Rate

Goal Rate

AA42.5 g/L x 1.2 L = 51 g/d

42.5 g/L x 2.04 L = 86.7 g/d

51 g x 4 kcal/g = 204 kcal/d

86.7 g x 4 kcal/g = 346 kcal/d

Dextrose-

200 g/L x 1.2 L = 240 g/d

200 g/L x 2.04 L = 408 g/d

240 g x 3.4 kcal/g = 816 kcal/d

408 g x 3.4 kcal/g = 1428 kcal/d

30 g/L x 1.2 L = 36 g/d

30 g/L x 2.04 = 61.2 g/d

36 g x 10 kcal/g = 360 kcal/d

61.2 g x 10 kcal/g = 612 kcal/d

Lipid-

Total Calories
204 kcal + 816 kcal + 360 kcal = 1380 kcal/d

346 kcal + 1428 kcal + 612 kcal = 2386 kcal/d

The teams decision to initiate parental nutrition is justified, I do agree with their decision. Mr.
Sims is at high risk for nutrient deficiencies based on poor eating habits prior to his admission.
Furthermore, his dx of Crohns disease and recent surgical resection put the pt at an even higher
risk due to reduce absorption of nutrients. Deciding to start the pt on a PN intake will supply
enough nutrients to hopefully reach a nutritional status in which he is meeting his estimated
needs. The above calculations show that the PN provided meets Mr. Sims estimated PRO
requirements. Calorie needs reflect that the PN being supplied is slightly high so an adjustment
may want to be considered once the patient reaches a decreased catabolic state post-op. This will
further help to prevent re-feeding syndrome
26. Please see article on Blackboard in course documents.
Indirect calorimetry assesses estimated energy expenditure needs by measuring oxygen
consumption and carbon dioxide production. In turn, this will determine nutritional needs. The
Weir Equation is used to calculate energy expenditure (kcal/d) by using VO2 and VCO2. RQ
(respiratory quotient) is the ratio of the volume of CO2 given off by the lungs to the volume of
O2 absorbed by the lungs. RQ should be between 0.67 and 1.2. An RQ larger than 1.0 indicates
lipogenesis or overfeeding, an RQ less than 0.85 suggests underfeeding and an RQ of 0.85 0.9
suggests mixed substrate utilization. RQ also can help to distinguish the energy sources and fuel
mix being used by the person. The RQ can decipher this because each macronutrient has a
specific RQ number associated with it. RMR (resting metabolic rate) is the amount of calories
needed to maintain the body at rest and is used to design/alter a feeding regimen. 70 75% of
total daily calories is comprised by RMR. It is important to remember that is RMR was taken
during intermittent feeding or during fasting period 5% needs to be added to account for
thermogenesis of food. If working with pts in intensive care a continuous feeding regime is
generally used and therefore the thermogenesis factor is not needed. In the ICU, as long as
sufficient protein of 1.5 2 g/kg/d is provided, it is appropriate to feed at or below the measured
RMR without adding a stress factor. This will preserve lean body mass and prevent the negative
effects of overfeeding. Overfeeding is a major complication that could jeopardize the healthy
and recovery of a pt, the RMR is important to use in the ICU to ensure that pts are not overfed.

O2 consumption = 295 ml/m

CO2 production = 261 ml/m

RQ: 261 / 295 = 0.88

Mr. Sims RQ = 0.88 - This RQ level indicates a normal range. It also indicates the that adequate
nutrition is being given and the use of mixed substrates for fuel.
Mr. Sims RMR = 2022 This number demonstrates that the pt uses 2022 kcals at rest. This
value is the golden standard of measurement for energy utilization for ICU pts, assuming it is
tolerated by the pt. For pts who are unstable in the ICU, such as surgery pts, a trend should be
looked for and the test should be given 2x/week to account for any variance and to monitor the
malnutrition risk.

30.
18.4 g N2 in urine
2040 ml/hr
PRO - 42.5 g/L x 2.04 L = 86.7 g/PRO/d
86.7 g / 6.25 g = 13.8 g N2 is in PN
13.8 g 18.4 g = -4.6 N2 balance (add 3 4 for insensible losses for pt) = -7.6 -8.6 N2 balance
These numbers indicated a negative nitrogen balance and that there is a need more increased
daily PRO. For UUN it is ideal that the protein should be +2-4.
Current PRO order- 86.7 g PRO / 64 kg BW = 1.3 g/kg
PRO goal - increase to 1.5 2 g/kg of protein.
UUN: is a measure of end products of PRO in urine. This can be affected by hydration, the
function of the kidneys, and at what time and how well the urine is collected. During stress Mr.
Sims could be utilizing the break down of endogenous stores of PRO. This could skew UUN
results. To prevent this, lab values of CRP should be monitored and when they have decreased
indicating less stress and inflammation the UUN study should be resumed to reflect more reliable
results.
31. Client Education Material on Blackboard in course documents.
When considering a PO diet, Mr. Sims should be allowed to try eating foods that are low in fiber
to decrease bloating and uncomfortable distension. To alleviate the pts symptoms, the ideal food
sources would be ready to eat/cooked grains and foods with less than 2 g of fiber/serving. Gut
health is extremely important for health and well-being of the patient and because of this foods
high in prebiotics should be given as well as probiotics to increase the amount of commensal

bacteria. To monitor the tolerance of PO foods, the pts bowel function, stool, and commensal
bacteria should be monitored. In addition it is important to monitor CRP, weight, iron and I/Os.
These markers will indicate readiness to wean the pt off of TPN. Weaning of PN should
gradually progress over 2-3 weeks. When tolerance of the PO diet is achieved, usually within 3
mo, orders of TPN can be discharged.
32. As Mr. Sims prepares for rehabilitation the primary nutrition concerns would be to monitor
his micronutrient levels to ensure a return to normal and to increase his weight. Folate, iron, B6,
B12 as well as Vit C, Vit A and Vit D are the nutrients of most concern. Future adaptation of the
small intestine will allow for further absorption of these nutrients and deficiencies will be less of
a concern. In addition, it is important to REC a multivitamin until Mr. Sims is able to eat a
regular diet and evidence of normal lab values are seen. Protein is also a primary nutrition
concern and educating the patient on the importance of protein after discharge for healing postop due to the body being in a catabolic state is paramount. Finally, high fat foods should be
avoided as well as certain fruits and veggies as they may cause gas which can be very
uncomfortable for a pt with an impaired bowel. Usually give 200-500kcal max and then wait for
everything to stabilize. May cause hyperglycemia if not absorbing fast enough (esp if stressed), hypo can
also occur. More you feed the worse the response (K drops) see the most in anorexic pts. Look out for
severely malnourished pts.