Patrick Burrows

KNH 411
Prof. Matuszak
9/15/15

Case Study #11 Inflammatory Bowel Disease: Chrons Disease

1. What is inflammatory bowel disease? What does current
medical literature indicate regarding its etiology?

Inflammatory bowel disease (IBD) is an autoimmune condition that is

characterized by chronic inflammation of the gastrointestinal tract. The
term IBD is a designation of a syndrome of two conditions ulcerative
colitis and Chrons disease. IBD has a higher prevalence in countries
within the northern hemisphere. Newer evidence is showing its
prevalence increasing in countries where rates were before lower. The
current hypothesis for IBD is that there are genetically predisposed
individuals where environmental and clinical factors trigger an
inappropriate immune system response. The exact etiology is unknown
at this time but in approximately 5%-15% of patients there is a positive
family history of IBD (418).

2. Mr. Sims was initially diagnosed with ulcerative colitis and then
diagnosed with Chrons. How could this happen? What are the

similarities and differences between Chrons disease and

ulcerative colitis?

Chrons disease and ulcerative colitis are both generalized under the
term inflammatory bowel disease because both diagnoses are similar
but have distinct differences. Approximately 40%-50% of patients
diagnosed with UC have the disease only involving the rectum. The
damage associated with UC to the intestinal mucosa usually only
involves the first two layers. UC typically affects one section of the
intestinal tract at a time whereas Chrons disease can skip around and
can affect any portion of the gastrointestinal tract (419). Since both
diseases possess similar clinical symptoms (abdominal pain and
tenesmus) it is possible that someone could have Chrons but be
diagnosed with UC.

3. A CT scan indicated bowel obstruction and the Chrons disease

was classified as severe-fulminant disease. CDAI score of 400.
What does a CDAI score of 400 indicate? What does a
classification of severe-fulminant disease indicate?

CDAI stands for Chrons Disease Activity Index. The CDAI was
established in an effort to measure the clinical response in patients
suffering from Chrons disease. A CDAI score of 400 indicates moderate

disease (Cohen). A classification of severe-fulminant disease indicates

that the patient continues to have symptoms despite being placed on a
corticosteroid or continue to experience vomiting, intestinal
obstructions, high fever, and abdominal tenderness (American College
of Gastroenterology).

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

Mr. Sims admits to experiencing abdominal pain, diarrhea, and

tenesmus. All of the symptoms listed are clinical manifestations of
Chrons disease (419). Mr. Sims also admits to taking mercaptopurine,
which is an immunosuppressive medication that is used to treat
Chrons disease (Mercaptopurine).

5. Chrons 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?

Patients suffering from Chrons may also experience extraintestinal

symptoms including osteopenia, osteoporosis, dermatitis,
rheumatological conditions suck as ankylosing spondylitis, ocular
symptoms, and hepatobiliary complications (420). There is no evidence

in the history that Mr. Sims provided showing that he experienced any
extraintestinal symptoms.

6. Mr. Sims has been treated previously with corticosteroids and

mesalamine. His physician had planned to start Humira prior to
this admission. Explain the mechanism for each of these
medications in the treatment of Chrons.

Corticosteroids main purpose are to reduce inflammation. Chrons

disease is an inflammatory disease process so the corticosteroids are
used to reduce the inflammation caused by Chrons disease. They are
also an immunosuppressant so they block the inappropriate immune
reaction that is a characteristic of Chrons symptoms. They are not
used as a maintenance drug (Crohn's & Colitis). Mesalamine is a drug
that falls into the category of anti-inflammatory. Mesalamine is
prescribed to treat the inflammation caused by UC by keeping the body
from producing substances that cause inflammation (Mesalamine).
Humira is a TNF blocker and patients with Chrons produce too much
TNF. (Adalimumab Injection)

7. Which laboratory values are consistent with an exacerbation of

his Chrons disease? Identify and explain these values.

Upon review of Mr. Sims laboratory values it was determined that his
hematocrit, hemoglobin, protein and albumin levels are all decreased
and his ACSA was elevated. ACSA is identified as an acute-phase
reactant and has been found indicative of Chrons exacerbation. The
low hemoglobin and hematocrit levels confirm anemia and in severe
exacerbations low albumin levels are found (419).

8. Mr. Sims is currently on several vitamin and mineral

supplements. Explain why he may be at risk for vitamin and
mineral deficiencies.

Mr. Sims may be at risk for vitamin and mineral deficiencies for several
reasons. He may be at risk for iron deficiency due to blood loss and
malabsorption, magnesium and zinc due to intestinal losses, calcium
and vitamin D due to long term steroid use, folate due to medications
used to treat IBD, and lastly fat soluble vitamins due to steatorrhea
(420).

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 a result of a large resection of the small

intestine resulting in nutritional deficiencies (427). Mr. Sims is not a
likely candidate because he has not had an intestinal resection.

10.

What type of adaptation can the small intestine make

after resection?

Post resection the small intestine adapts in three phases. The first
phase ranges anywhere between 7 to 10 days and is characterized by
diarrhea resulting in large fluid and electrolyte losses. The second
phase may last for several months but exhibits a reduction in diarrhea
volume and enteral nutrition and be introduced. Lastly the third phase
can last 1-2 years and during this phase the bowel receives increased
blood flow, secretions, and mucosal cell growth (427).

11.

For what classic symptoms of short bowel syndrome

should Mr. Sims health care team monitor?

The health care team for Mr. Sims should monitor large fluid and
electrolyte loss. They should also monitor for magnesium and zinc
deficiencies, B12 malabsorption, and water-soluble vitamin
malabsorption (420).

12.

Mr. Sims is being evaluated for participation in a clinical

trial using high-dose immunosuppression and autologous

peripheral blood stem cell transplantation (autoPBSCT). How
might this treatment help Mr. Sims?

It has been shown that high-dose immunosuppression and autologous

peripheral blood stem cell transplantation is safe and induces
remission in patients experiencing refractory Chrons disease
(Hasselblatt).

13.

What are the potential nutritional consequences of

Chrons disease?

Chrons disease can affect a patients intake of calories, protein, fluid

and electrolytes, iron, magnesium, zinc, calcium and vitamin D,
vitamin B12, folate, water soluble vitamins, and fat soluble vitamins
(420). These can be shown by inadequate energy intake, inadequate
oral intake, increased nutrient needs, and impaired nutrient utilization.

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 jejunum is approximately 2-3 meters long and Mr. Sims only had
200cm of it removed. Most absorption occurs in the first 100cm of the
intestine so nutritional deficiencies typically occur when the distal ilium
is removed. Mr. Sims did not have any of his ilium removed and his
colon remained intact so his small intestine should be able to adapt to
perform the duties of the portion that was removed (427)(Organs).

15.

What nutrients are normally digested and absorbed in the

portion of the small intestine that has been resected?

The nutrients that are normally digested in the portion that was
resected are sugars, starch, fiber, lipids, and fluids. (Organs)

16.

Evaluate Mr. Sims % UBW and BMI.

%UBW= (current body weight/usual body weight) x 100

%UBW= (140/166)x100= 84%
%UBW= (140/168)x100= 83%
%UBW= 83%-84%

BMI= weight (kg)/(height (m))2

BMI= 63.6kg/(1.77m)2=20.3

17.

Calculate Mr. Sims energy requirements.

Mifflin-St. Jeor
((10x63.6)+(6.25x175.26)-5x35+5)1.2= 1873
Energy requirments= 1800-1900 kcal/day

18.

What would you estimate Mr. Sims protein requirements

to be?

ASPEN guidelines recommend 1-1.5g protein/kg for adults (421).

1(63.6)=63.6g protein/day
1.5(63.6)= 95.5g protein/day
63-96g protein/day

19.

Identify any significant and/or abnormal laboratory

measurements from both his hematology and his chemistry

labs.

Below is a chart containing all of Mr. Sims abnormal laboratory

measurements from his hematology and chemistry labs.

Chemistry
Protein
Albumin
Prealbumin
C-reactive Protein
HDL-C
ASCA
PT
Hematology
Hemoglobin
Hematocrit
Transferrin
Ferritin
ZPP
Vitamin D
Free retinol
Ascorbic acid
20.

Ref. Range
6-8
3.5-5
16-35
<1.0
>45
Neg
12.4-14.4
Ref. Range
14-17
40-54
215-365
20-300
30-80
30-100
20-80
0.2-2.0

2/15 1952
5.5
3.2
11
2.8
38
+
15
2/15 1952
12.9
38
180
16
85
22.7
17.2
<0.1

Select two nutrition problems and complete the PES

statement for each.

Unintended weight loss (NC-3.2) as related to inability to consume

enough energy due to Chrons exacerbation as evidenced by a weight
loss of 16%-17% in the past 6 months.

Inadequate protein energy intake (NI-5.4) as related to decreased

ability to consume sufficient protein due to exacerbation of Chrons
disease as evidenced by his low protein level reflected in his lab
results.

21.

The surgeon notes Mr. Sims probably will not resume

eating by mouth for at least 7-10 days. What information

would the nutrition support team evaluate in deciding the
route for nutritional support?

Since the patient will not be eating by mouth the nutritional support
team should be looking to give the patient PN until the small intestine
has adapted adequately (421). As the small intestine adjusts for the
first 7-10 days Mr. Sims will experience large fluid and electrolyte loss
due to diarrhea (427). The nutritional support team will have to take
that into consideration.

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?

Both values being low are indicative of malnutrition (Phosphorus blood

test). This is of concern because this shows that Mr. Sims has modified
GI absorption and he is going to need increased PN in order to increase
these values.

23.

What is refeeding syndrome? Is Mr. Sims at risk for this

syndrome? How can it be prevented?

Refeeding syndrome occurs in starving patients when metabolic

alterations occur during nutritional repletion. Mr. Sims is at risk for
refeeding syndrome because he will be subjected to PN post surgery.
Feeding the patient slowly to avoid overfeeding him can prevent
refeeding syndrome.

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.

I agree with the teams decision because Mr. Sims small intestine
needs to have some time to adapt post operation. I calculated his EER
to be 1800-1900kcal/day and his protein requirements to be 6396g/day.

At 50cc/hr:

50cc(24hr)= 1200cc/day=1.2L/day
1.2(200g dextrose)= 240g dextrose/day(4 cal/g)= 960 kcal/day
1.2(42.5g amino acids)= 51g amino acids/day(4 cal/g)= 204 kcal/day
1.2(30g lipid)= 36g lipid/day(9 cal/g)= 324 kcal/day

Total kcal/day at 50cc/hr= 1488kcal

At 85cc/hr:
85cc(24hr)= 2040cc/day= 2.04L/day
2.04(200g dextrose)= 408g dextrose/day(4 cal/g)= 1632 kcal/day
2.04(42.5g amino acids)= 86.7g amino acids/day(4 cal/g)= 346.8
kcal/day
2.04(30g lipid)= 61.2g lipid/day(9 cal/g)= 550.8 kcal/day

Total kcal/day at 85cc/hr= 2530kcal

At a rate of 50cc/hr the nutritional needs of Mr. Sims will not be met. At
a rate of 85cc/hr the nutritional needs of Mr. Sims will be met but they
will be exceeded. Giving him this much could increase his risk of
refeeding syndrome (109).

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 etiology).

An ideal goal to increase his weight would be to increase his caloric

intake as soon as he can tolerate it without exposing him to refeeding
syndrome. A goal to increase his protein levels would be to increase
the amount of amino acids that he is being given via PN daily.
26.

Indirect calorimetry revealed the following information:

Measure
Mr. Sims Data
Oxygen consumption (mL/min)
295
CO2 production (mL/min)
261
RQ
0.88
RMR
2022
What does this information tell you about Mr. Sims?
The RMR value is obtained from indirect calorimetry and reflects the
patients energy expenditure over a period of 24 hours (64). This
information tells me that at the initial 50cc/hr of PN the energy needs
of Mr. Sims will not be met therefore his caloric intake will need to be
increased.
27.
Would you make any changes to his prescribed nutrition
support? What should be monitored to ensure adequacy of his
nutrition support? Explain.
If Mr. Sims is being given the goal rate of 85cc/hr of PN I would
decrease his intake of dextrose in order to decrease his overall caloric
intake. I would decrease dextrose because I would not want to alter his

protein intake because his lab values for protein were low and he also
needs adequate amount of protein to recover from surgery.

28.

What should the nutrition support team monitor daily?

What should be monitored weekly? Explain your answers.

The nutrition support team will want to monitor the caloric intake of Mr.
Sims daily and compare it to his RMR value to insure that he is
receiving proper nutrients. They will need to monitor his previously
abnormal lab values weekly to insure that he is properly absorbing
nutrients as his small intestine adapts.

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?
This increase of serum glucose to 145 mg/dL could be caused by PN
overfeeding (109). In order to bring the serum glucose level back down
the amount of glucose that Mr. Sims is receiving should be decreased
until the desired serum glucose level is achieved.
30.

Evaluate the following 24-hour urine data: 24-hour

urinary nitrogen for 12/20: 18.4 grams. By using the daily

input/output record for 12/20 that records the amount of PN
received, calculate Mr. Sims nitrogen balance on

postoperative day 4. How would you interpret this

information? Should you be concerned? Are there problems
with the accuracy of nitrogen balance studies? Explain.

31.

On post-op day 10, Mr. Sims team notes he has had

bowel sounds for the previous 48 hours and had his first bowel
movement. The nutrition support team recommends
consideration of an oral diet. What should Mr. Sims be allowed
to try first? What would you monitor for tolerance? If
successful, when can the parenteral nutrition be weaned?

Mr. Sims should first be allowed to try sugar free isotonic clear liquids
first (428). All food would be monitored for tolerance and if they were
not tolerated they would be instantly removed from the diet and added
again later depending on the patients adaptation continues (429).

References
Adalimumab Injection: MedlinePlus Drug Information. (n.d.). Retrieved
September 10, 2015.
American College of Gastroenterology. (n.d.). Retrieved September 8, 2015.
Crohn's & Colitis. (2009, January 16). Retrieved September 10, 2015.
Cohen, R. (n.d.). Should Mucosal healing Be used Instead? Retrieved
September 10, 2015.

Hasselblatt, P. (n.d.). Result FiltersRemission of refractory Crohn's disease by

high-dose cyclophosphamide and autologous peripheral blood stem cell
transplantation. Retrieved September 15, 2015.
International dietetics and nutrition terminology (IDNT) reference manual:
Standardized language for the nutrition care process. (2014). Chicago, IL:
American Dietetic Association.
Mercaptopurine: MedlinePlus Drug Information. (n.d.). Retrieved September
9, 2015.
Mesalamine: MedlinePlus Drug Information. (n.d.). Retrieved September 10,
2015.
Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed.). Belmont,
CA: Wadsworth, Cengage Learning.
Organs: Small and Large Intestines. (n.d.). Retrieved September 12, 2015.
Phosphorus blood test: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved
September 11, 2015.