Case Number 11-Inflammatory Bowel Disease: Crohns

Please answer the following questions from your lab text on Mr. Sims:
1. What is inflammatory bowel disease? What does current medical literature
indicate regarding its etiology?
Irritable bowel disease refers to two rare bowel diseases including Crohns
and ulcerative colitis. The prevalence is approximately 130 cases per
100,000 for Crohns and 100 for per 100,000 for ulcerative colitis. The
onset occurs between the ages of 15 and 30 in most cases.
Current research suggests that the cause of IBD may be genetic in nature
with immunologic and environmental factors. Gene mutations rendering
individuals susceptible to the disease is diverse, which leads scientists to
conclude why there are so many differences in onset, aggressiveness,
complications, location and responsiveness to therapies. Major
environmental factors include transient microorganisms in the GIT and
dietary components.

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?
The location of the ulcer his is in the jejunum
Ulcerative colitis and Crohns disease share common symptoms, which
include diarrhea, fever, unintentional weight loss, food intolerances,
anemia, malnutrition, growth failure, and extraintestinal symptoms.
Because of this, it may be difficult to distinguish one disease from the
other using conservative diagnostic measures.
Similarities: see above
Differences: Only the large intestine and rectum are diseased in
Ulcerative Colitis while any part of the gastrointestinal tract may be
affected with Crohns. Portions of healthy segments with Crohns may
separate diseased segments of the bowel but with UC the infected area is
continuous. Crohns disease affects all layers of the mucosa; alternatively,
only the mucosa is affected in UC. Crohns causes abscesses, fistulas,
fibrosis, submucosa thickening, localized strictures, narrowed segments of
the bowel and partial or complete obstruction of the intestinal lumen. UC
causes more bleeding than in Crohns.
.

Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel
syndrome, and provide a rationale for your answer.
Short-bowel syndrome (SBS) usually results from having a loss of 70-75%
of the small bowel after resection and causes inadequate and decreased
functional bowel after resection.

Mr. Sims only had 200 cm removed from his bowels so is not a likely
candidate or SBS however, some adaptation and absorption issues are
likely. Assessment of functional status and weight will need to be
conducted to determine if SBS has occurred. Assessment should quantify
dietary intake as well as stool and urine output over 24 hours.
Medications and hydration status should also be assessed.

0. What type of adaptation can the small intestine make after resection?
After jejunal resections, the ileum typically adapts to perform the
functions of the jejunum. Because Mr. Sims had the 200cm of the distal
part of the jejunum, he most likely will adapt well to the resection, as
most of digestion and reabsorption occurs within the first 100 cm of the
small intestine.
. 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 small intestine is approximately 20 feet long but can range anywhere
from 8 feet to 32 feet.
Mr. Sims had approximately 6.5 feet of his small bowel removed (200 cm).
Because the resection occurred in the distal part of the jejunum and the
proximal portion of the ileum, the majority portion of the jejunum, which
digests food and absorbs most nutrients, remained intact (the first 100
cm). Because the ileocecal valve remains intact, maximum nutrient
absorption can still take place as will the prevention of reflux of colonic
bacteria.
19. Identify any significant and/or abnormal laboratory measurements from both
his hematology and his chemistry labs.
Laboratory Result
Value
Protein
5.5 d/dL (Low)
Albumin
3.2 g/dl (low)
Prealbumin
11 mg/dL (low)
C-reactive protein
2.8 mg/dL (High)
Hemoglobin
12.9 g/dL (low)
Hematocrit
38% (low)
Transferrin
180 mg/dl (low)
Ferritin
16 mg/mL (low)
Evaluation: Protein, albumin, prealbumin result from trauma obtained during
surgery and c-reactive due to inflammation. This value should be used for
consideration going further for MNT. Hemoglobin, hematocrit, transferrin and ferritin
deficiencies likely due to GI bleeding and hemorrhage during surgery.
What are Mr. Sims Estimated needs for energy, protein and fluid?

Energy = 2156 2669kcal/d

175 cm/1.75m, 140lbs/64 kg
BMI= 21
Harris-Benedict Formula
66 + (13.7 x 64) + 5(175) (6.8 x 35) = 1579.8 x (1.3 activity factor) x (1.05, 1.3
stress factor)
Protein = 80 96 g/kg
Used stress factor 1.25-1.5 g/kg due to major surgery
Fluid = 2156 2669 ml/day

23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it
be prevented?

Refeeding syndrome is a severe electrolyte fluctuation involving metabolic,

hemodynamic, and neuromuscular problems. If energy substrates,
particularly CHO are introduced parentally in anabolic patients, there is a
likelihood of electrolyte imbalances. When cells metabolize CHO, electrolytes
are shifted to intracellular spaces as glucose moves into cells for oxidation.
Further, there is a greater need for K, Mg, P after after an illness/surgery due
to an increased need for tissue generation. Both of these factors can
contribute to drastic electrolyte fluctuations, which lead to refeeding
syndrome.
Being conservative with CHO refeeding can prevent refeeding syndrome.
Continual monitoring and evaluation for electrolyte imbalances should be
performed until estimated needs can be reached safely. Supplemental P, K,
and Mg may be necessary.

24. Mr. Sims was placed on parenteral nutrition support immediately postoperative,
and a nutrition support consult was ordered. Initially, he was prescribed to receive
200g dextrose/L, 42.5 g amino acids/L, and 30 g lipid/L. His parenteral nutrition was
initiated at 50 ml/hr with a goal rate of 80 mL/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.
TPN:
1st step: know the total volume
PRO
o 85 mL/hour x 24hours (2040 mL)
o 1 L = 1000 mL

42.5 g pro
1000ml
42. 5 g

CHO
o 1000 mL
200 g
Lipids
1000 mL
30
Total Kcal

= 2040 mL (42.5x2040/1000)
= X
o = 86.7 g pro x 4 = 346.8 kcal/mL/d AA

= 2040 mL 408 x 3.4 = 1387 kcal/mL/d

=
x
= 2040 mL 61g x 10 = 610 kcal/mL/d
=
x
= 2344 kcal/mL/d

26. Indirect calorimetry revealed the following information:

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?

Indirect calorimetry is a measure of Carbon Dioxide production (VC0 2)

divided by Oxygen consumption (VO2) that results in a respiratory
quotient (RQ). IC is considered the gold standard when evaluating
energy and nutrient requirements. An RQ of below .8 would suggest
underfeeding while an RQ of .85 to .9 suggests mixed substrate
utilization, indicating that the nutrition regimen is adequate. An RQ
above 1 would suggest overfeeding.
Since the patients RQ = .88, one would conclude that Mr. Sims is
receiving adequate nutrition at this time.

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.

UUN study
o

86.7 g/pro divided by 6.25 = N2 = 13.9g N2 IN

o
o
o
o

Nitrogen OUT 18.4g

Add fudge-factor of 3g (due to N2 out in feces, breath, sweat, etc.)
= -21.4g for insensible losses (18.4 + 3g) (-21.4 + 13.9g = -7.5)
= -7.5 g N2 balance
The negative nitrogen balance indicates that Mr. Sims is in a
catabolic state. Usually an UUN would be performed at least 3
weeks post-surgery when the patient is in a stable, non-stressed
state. Regardless, a positive nitrogen balance of 2-4g is ideal. To
get to a positive N2 one could multiply the negative balance by
6.25 to get to a positive state, however simply adding 10 g of
protein would suffice.
Because Mr. Sims is 4 days post-operative one would expect him
to be in a catabolic state, therefore it would be prudent to
reevaluate his UUN in three weeks to determine if additional
protein is required. This is one limitation to the accuracy of the
nitrogen balance study.

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?

Careful consideration should be taken to prevent constipation, bloating

and diarrhea. It may take several days for his gastrointestinal tract to
regain function after a resection; therefore foods should be selected by
ease of digestibility. Mr. Sims should be allowed to try clear liquids first
to monitor how oral feeding will be tolerated. If clear liquids are
tolerated, pureed foods may be introduced at a later date. These foods
should be low in fiber, fat and lactose. Monitor the patient for normal
bowel movements, nausea, vomiting diarrhea and/or constipation to
determine how well CHO and fiber are being tolerated. Parenteral
nutrition can be weaned once 75% of nutrients are met by oral intake
on a consistent basis.

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
measure for evaluation.

Primary nutrition concerns for Mr. Sims would be malnutrition, shortbowel syndrome and tolerance of oral feedings. Because Mr. Sims had
a significant section of his bowel resected, the dietician should monitor
his ability to digest and absorb nutrients. Mr. Sims did not have an
ileostomy, and his entire colon remains intact, therefore SBS is not a

significant risk. Even though B12 intrinsic factor complex and bile salts
are absorbed in the distal ileum, these should be monitored on a
precautionary basis due to the relatively small portion of proximal
ileum removed.
One nutritional outcome would be to aim for a nitrogen balance 2 to 4
g within 3 weeks once he has stabilized post-operatively to determine
adequate protein intake. Protein, albumin, prealbumin and C-reactive
protein should also be monitored to determine if metabolic stress is
still a factor.
Because Mr. Sims is 83% UBW prior to surgery and lost 17% of his UW
within the last 6 months, he is considered in a state of moderate
malnutrition. Therefore, focus should be on getting Mr. Sims weight
greater than 95% of his usual weight. Ideally Mr. Sims would gain 1 2
lbs per week until >95% UW is achieved.
Supplemental P, K, and Mg may be necessary due to increased need
and prevention of refeeding syndrome.