Case Study #11

Inflammatory Bowel Disease: Crohns Disease

Brooke Bryant
KNH411
09-15-15

Understanding the Disease and Pathophysiology

1. What is inflammatory bowel disease? What does current medical literature indicate
regarding its etiology?
Inflammatory bowel disease is an auto immune, chronic inflammatory condition
of the gastrointestinal tract; IBD is actually the term designating a syndrome
consisting of two diagnoses: ulcerative colitis and Crohns disease (pg.380).
According to Nelms it is unknown the exact etiology but there are hypothesis that
involve the interaction of both environmental and clinical factors that cause an
inappropriate immune response in genetically predisposed people. Some of these
factors include environmental factors such as smoking, infectious agents,
intestinal flora, diet and physiological changes in the small intestine that trigger
the inflammation in the small intestine (pg.418).
2. Sims was initially diagnosed with ulcerative colitis and then diagnosed with
Crohns. How could this happen? What are the similarities and differences between
Crohns and ulcerative colitis?
Both ulcerative colitis and Crohns disease have similar symptoms when the
disease is first diagnosed so often times it is a misdiagnosis until further testing is
done and symptoms begin to change with the disease states. UC shows severe
inflammation of large bowel with thickened walls and superficial ulcerations, and,
over time, the haustra become edematous and thickened. There is often bloody
stool and diarrhea with the urgency to have to defecate and abdominal pain. With
Crohns disease the radiology testing will show small bowel and terminal ileum
abnormalities with evidence of strictures. Crohns disease has similar symptoms
to UC but differ in a few ways, there is extreme abdominal pain, diarrhea and

tenesmus. They are much less likely to have blood in the stool but are more likely
to have more severe abdominal pain and cramping Crohns disease is also
classified as having bowel obstruction unlike UC (pg.419).
3. A CT scan indicated bowel obstruction and the Crohns disease was classified as
sever fulminant disease. CDAI score of 400. What does a CDAI score of 400
indicate? What does a classification of severe-fulminant disease indicate?
The CDAI score of 400 is an index created to rate the amount of pain and the
activity level of the disease state that a patient is undergoing. CDAI stands for
Crohns disease activity index (Dretze, 2011). A score of 400-450 to 600 is
considered sever Crohns disease. The index is used to show how quality of life is
affected by the disease (Medscape, 2001). Severe-fulminant disease refers to
patients with persisting symptoms despite the introduction of steroids as
outpatients, or individuals presenting with high fever, persistent vomiting, and
evidence of intestinal obstruction, rebound tenderness, cachexia, or evidence of
abscess. The classification of sever-fulminant disease indicates that the patient is
suffering from a type of irritable bowel syndrome or Crohns disease (Hauner,
2001).
4. What did you find in Mr. Sims history and physical that is consistent with his
diagnosis of Crohns? Explain

Mr. Sims was initially diagnosed with inflammatory bowel disease three years
ago and was then changed to ulcerative colitis and re-diagnosed six months later
as Crohns disease. He has noticed more diarrhea and unbearable abdominal pain.
Mr. Sims has also started running a fever of 101.5 F and has extreme tenderness

with rebound and guarding around his abdomen and minimal bowel sounds. Mr.

Sims complains of fatigue, reduced appetite, and weight loss.

According to Nelms the symptoms with the increased bowel movements that are
not solid in form and the severe abdominal pain are consistent with the diagnosis
of Crohns disease. The tenderness around the abdomen is directly related to the
damage of the layers of the GI tract and the gastrointestinal mucosa. The
inflammation from this damage would also cause tenderness throughout the
external abdomen (pg.419). The temperature that Mr. Sims is running is due to the
bodys response to the inflammation in the GI tract. Mr. Sims is also experience
fatigue, loss of appetite and weight loss. These are symptoms related to Crohns
disease because of the abdominal pain and cramping and the inflammatory
reaction in the wall of your bowel can affect both your appetite and
your ability to digest and absorb food (Mayo Clinic, 2014).

5. Crohns patients often have extra intestinal symptoms of the disease. What are some

examples of these symptoms? Is there evidence of these in his history and physical?
Patients may experience diarrhea, abdominal pain, fever, weight loss, abdominal masses,
and anemia. Extra intestinal manifestations of Crohns disease include osteoporosis,
inflammatory arthropathies, scleritis, nephrolithiasis, and erythema nodosum (American
Family Physician, 2013). The physical appearance of his abdomen is one of the extra
intestinal symptoms that Mr. Sims is experiencing because it is rounded and soft to the
touch.

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.

Corticosteroid is a steroid formed from the adrenal gland that contains two sets of
hormones. One is the glucocorticoids which are produced to help with stress and
metabolizing fats, proteins and carbohydrates. The other is mineralocorticoids which
helps balance salt and water which would help with the inflammation that Mr. Sims is

experiencing with the Crohns disease (Medicine, 2014).

Mesalamine is used to treat UC and to maintain improvements of UC. It works by
stopping the body from producing a certain substance that may cause inflammation (Medline,
2015).

Humira is used to treat Crohns disease injecting a protein (antibody) into the body to
help reduce inflammation and stop it so that healing can begin (Medicine, 2014).

7. Which laboratory values are consistent with an exacerbation of his Crohns disease?

Identify and explain these values.

One of the laboratory values that is consistent with Crohns disease is his protein,
albumin, and prealbumin are all extremely low. According to Nelms this shows that the
body is using the protein to try to repair the damaged tissue that is caused from the
Crohns disease and that the small intestine is not absorbing enough protein to meet the
needs of Mr. Sims to heal or function normally (pg.420-421). Another level that is
significantly low on Mr. Sims laboratory results is his HDL, hemoglobin, and Iron values.
This shows malabsorption in the small intestine which is directly related to the villi being
damaged from Crohns disease. Other levels that show malabsorption related to Crohns
disease are low Transferrin, Ferritin, Vitamin D, Vitamin A and Ascorbic acid (pg.419420).

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 is at risk for vitamin and mineral deficiencies because of malabsorption in the
intestines. Since his intestines are inflamed from the Crohns disease they are not working
properly to take in the proper amount of nutrients that he needs to support himself. Mr.
Sims fear of diarrhea and abdominal pain after eating may also be another reason he is
not taking in enough vitamins and minerals because of lack of consumption of nutrients.
Mr. Sims is also at risk for vitamin and mineral deficiencies because when he consumes
food it is excreted by diarrhea before it gives the body time to absorb the proper nutrients
(pg.420).

9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel

syndrome, and provide rationale for your answer.

Mr. Sims is a likely candidate for short bowel syndrome because it is a disorder caused
by significant damage in the small intestine. Short bowel syndrome is when the small
intestine cannot absorb enough vitamins, minerals, water, protein, fat, and calories from
food (NIDDK, 2015). Mr. Sims shows deficiencies in his proteins, cholesterol,
Hemoglobin, Transferrin, Ferritin, Vitamin D, Vitamin A, and Ascorbic acid. This all
relates to malabsorption caused by the short bowel syndrome. According to Mr. Simms
history it indicates that he has some damage to his GI tract which is also related to short
bowel syndrome as stated above. Mr. Sims also has lost almost 25 pounds from going
from his normal weight of 168-140 pounds. This shows symptoms of short bowel
syndrome because he is not absorbing the proper calorie intake.

10. What type of adaptation can the small intestine make after resection?
The type of adaptation the small intestine can make is by increasing its surface area. It
will sometimes grow in length or diameter so that the small intestine can absorb more

nutrients and minerals. This also helps to absorb the amount of calories, protein and fat to
maintain a healthy body mass (Buchman, 2006).
11. For What classic symptoms of short bowel syndrome should Mr. Sims health care

team monitor?
Mr. Sims health care team should monitor the amount of bowel movement he has per day
and how long it takes for him to have a bowel movement after he has finished consuming
breakfast, lunch, and dinner. They should monitor his urine output and check to make
sure he is not getting dehydrated. They should also monitor his lab values for his Vitamin
D, Iron, Magnesium, Zinc, B12, Folate, Protein, Calories, and fat. The health care team
needs to keep a food diary for Mr. Sims to make sure he is taking in the proper amount of
calories for his dietary needs. Keeping track of his weight so he does not continue to lose
weight (pg.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?

If Mr. Sims was to participate in this clinical trial using high- dose immunosuppression
and autologous transplant it could send his Crohns disease into remission. The patients
that have participated have seen remission but some exhibit gaining back signs and
symptoms of the Crohn disease later on. Mr. Sims could benefit from this by potentially
bringing his Crohns disease into remission and that participants in this study receive free
medication for their Crohns disease (Annaloro, 2009).

II. Understanding the Nutrition Therapy

13. What are the potential nutritional consequences of Crohns disease?

According to Nelms a significant amount of people diagnosed with active Crohns
disease experience weight loss, muscle wasting, and malnutrition. Some nutrition
consequences with patients with Crohns disease are Anorexia, short bowel syndrome,

Anemia, and Intestinal loss.

Anorexia is caused by inadequate energy intake caused by the excretion of waste before

the small intestine has time to absorb the calories the body needs.
Short bowel syndrome caused by the damage done to the villi in the small intestine
caused by Crohns disease. This makes it to where the small intestine cant absorb the

adequate amount of nutrients.

Anemia by loss of blood in stool, and malabsorption of iron into the body.
Intestinal loss because of surgery done to remove some of the damaged intestines that are
causing problems that were onset by the Crohns disease (pg.420).

14. Mr. Sims underwent resection of 200cm of jejunum and proximal ileum with
placement of jejuostomy. 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 seven meters long or 700cm and is on average three and a half
times longer than your body length (CHP, 2012). This resection is very significant
because a normal resection is about 100cm and it causes absorption problems after the
surgery. Taking out 200cm of intestines will need the aid of extra vitamins and minerals
so that they do not drop to low and become extremely malnourished. Vitamin B12 is
required and often times patients having 200cm removed have problems digesting food
orally so a liquid diet may be used to start with after the procedure (Jeejeebeho, 2007).
The small intestine can make adaptations to help absorb the proper nutrients it needs but
it will take nutrition therapy to get it to where there will be no malnourishment.

15. What nutrients are normally digested and absorbed in the portion of the small

intestine that has been resected?

One nutrient that is normally digested and absorbed in this portion of the small intestine
is vitamin B12. And it helps aid in nervous system function, brain function, and blood
formation. Patients with the resected surgery require large amounts of vitamins A, D, and
E to maintain normal levels. They have to be given in liquid form because pills will just
be passed through the GI tract without being digested (Jeejeebeho, 2007).

III. Nutrition Assessment

16. Evaluate Mr. Sims% UBW and BMI
BMI=64(kg)/1.75(meters)^2=21
%UBW= (100x140)/168= 83%
The evaluation of Mr. Sims body mass index is that he is close to being underweight but
is at a normal BMI but if he was to go under 18.5 he would be considered underweight.
As for Mr. Sims usual body weight percentage shows that he is moderately malnourished
and if he went to 75% or lower he would be sever malnourished. These two calculation
supports that Mr. Sims is suffering from Crohns disease.
17. Calculate Mr. Sims energy requirements.
Calories=64(kg)x24x1.2(PAL)=1,843kcal/day
Protein=1,843kcal/dayX15%=277kcal/day ( This may need to be increased to 300kcal

per day due to the deficiency and healing of Mr. Sims intestines from surgery)
Carbohydrate= 1,843kcal/dayX50%-60%= 922-1,100kcal
Fat=1,843kcal/dayX25%-30%=460-553kcal

Values were found using the Mifflin-St.Jeor resting energy expenditure method.
18. What would you estimate Mr. Sims protein requirements to be?
The estimated amount of protein requirements for Mr. Sims is 277kcal/day but this is if
his intestines and GI tract were functioning properly. According to Mr. Sims labs he is

low on his protein; it would need to be increased to about 300-350kcals a day and a
reduction in his carbohydrates due to the high fiber content of some carbohydrates. This
would help raise his levels and having the lower fiber diet would help with digestion and
reduce the excretion of nutrients in his waste (CCF, 2014).
19. Identify any significant and/or abnormal laboratory measurements from both his

hematology and his chemistry labs.

Mr. Sims Total protein was down by .5grams when his levels should be between 6-8g/dl.
His albumin was at 3.2g/dl .3g/dl under what his levels should be between 3.5-5g/dl.
According to his laboratory results his prealbumin mg/dl was at 11 down 4mg/dl than
where the levels should be between 16-35mg/dl. ASCA and PT (sec) were all above
normal. The Hemoglobin level was 1g down compared to the normal 14-17g/dl. Mr. Sims
Hematocrit was at 38% when his levels should be between 40%-54%.Transferin was at
180mg/dl and levels should be between 215-365mg/dl. Ferritin was at 16mg/ml and
levels should be 20-300mg/ml. ZPP was increased it was at 85 range is 30-80. Vitamin D,
Vitamin A and Ascorbic acid were all deficient.

IV. Nutrition Diagnosis

20. Select two nutrition problems and complete the PES statement for each.
Inadequate oral intake (Ni 2.1) related to exacerbation of Crohns disease as evidence by

malnutrition and excessive weight loss.

Inadequate fluid intake (Ni 3.2) related to dehydration as evidence by malabsorption
because of inflammation in the small intestine.

V. Nutrition Intervention

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
rout for nutrition support?

For the first 7 to 10 days they would want to do injection of vitamins and minerals like
B12, folate, vitamin D and iron so that they would be directly put into the body instead of
having to go through the GI tract and just get excreted through a bowel movement.
Vitamins in pill form cannot be given because the pill would just be excreted and not
absorbed. For his caloric intake needs and protein he will get his food through

intravenous feeding (CCF, 2010).

After the 7-10 days of not receiving food orally the nutrition support team should receive
labs on how his intestines is healing and then should consider changing Mr. Sims to a
clear liquid diet but have him still receiving the vitamins and minerals he is deficient in.
If the clear liquid diet shows no complication then moving him to a dark thicker liquid
diet will be started. Once his intestines are healed enough to consume solid foods he will
be placed on a puree diet that will be a low-residue, lactose-free, and low fiber diet. Small
frequent meals will be given and through the therapy lactose and fiber can be added in as
small quantities. Mr. Sims will then move up to mechanical/regular diet that will continue
to be low-residue, and have some lactose and fiber added in until the adequate amounts

are tolerable (pg.421-422).

21. 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?
This would be of concern because it supports blood, bone and muscle health and if it is
low it indicates a vitamin D deficiency and can show some liver damage. Low
phosphorus and serum magnesium will be of concern to the nutrition support team

because it means the diet they have Mr. Sims on is not working properly because these
low levels show that he is malnourished and still not receiving the adequate amount of
nutrition he needs(Health line, 2015).
22. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be

prevented?
Refeeding syndrome is a metabolic complication that occurs when nutritional support is
given to someone who is severely malnourished. The patients metabolism shifts from a
catabolic to an anabolic state. Insulin is released on carbohydrate intake, triggering

cellular uptake of potassium, phosphate, and magnesium (Manual, 2009).

Mr. Sims is at risk for this syndrome because of how malnourished he was from not being
able to absorb the adequate amount of nutrients. It can be prevented by initially
delivering a maximum of 10 kcal/kg/day and raised gradually to full needs within a week.
In extreme cases this energy intake is limited to 5 kcal/kg/day (Manual, 2009).

24. Mr. Sims was placed on parenteral nutrition support immediately postoperatively, and
a nutrition support consult was ordered. Initially, he was prescribed to receive 200g
dextrose/L, 42.5g amino acids/L, and 30g lipid/L. His parenteral nutrition was initiated at
50 cc/hr. with a goal rate of 85cc/hr. Do you agree with the teams decision to initiate
parenteral nutrient? 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 to initiate parenteral nutrient because Mr. Sims cannot be on an
oral diet. PN is normally required right after surgery to ensure proper nutrition intake is received
to help with the healing process (pg.421).

(200 g dextrose/L) x (1L/1000ml) = 0.2 g dextrose/ml or 0.2 g dextrose/cc

(42.5 g amino acids/L) x (1L/1000ml) = 0.0425 g amino acids/ml or 0.0425 g amino

acids/cc
(30 g lipid/L) x (1L/1000ml) = 0.03 g lipid/ml or 0.03 g amino acids/cc
(0.2 g dextrose/cc) x (85 cc/hr) = 17 g/hr x 24 hr = (408 g dextrose per day) x (3.4

kcal/g) = 1632 kcal

(0.0425 g AA/cc) x (85 cc/hr) = 3.61 g/hr x 24 hr = (86.7 g AA per day) x (4 kcal/g) =

346.8 kcal from protein

(0.03 g lipid/cc) x (85 cc/hr) = 2.55 g/hr x 24 hr = (61.2 g lipid per day) x (10 kcal/g) =
550.8 kcal from lipid

These calculations were done using the Miffilin St. Jeor. These calculations show that Mr. Sims
energy needs will be met while on the PN.
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).

To get Mr. Sims rehydrated and get him the adequate nourishment a 7-10 day
period where he will receive no oral intake of food he will receive intravenous
feeding (CCF, 2010). After this the ideal goal is to get Mr. Sims on an oral diet of
low-residue, lactose-free diet with small frequent meals throughout the day to see
how it is tolerated. As time goes on small amounts of fiber and lactose will be
added to the diet to increase tolerance. Some foods that may also be restricted are
spicy foods, fried, caffeinated beverages and any other foods that Mr.Sims says he
has digestive problems with(pg.421).Vitamin B12 will be administered in a higher
dosage of 1000-2000mcg daily and a Vitamin D will be orally given 50,000IU
once per week for a total of 8 weeks(pg.422). The goal is to get him back to a
regular diet and to help he understand foods that may be problematic so he can cut

them out of his diet. Mr. Sims water intake will also be increased to help
rehydrate him from all the excretion of waste he was having before the surgery
was completed. An IV may be needed the first 7-10 days.
26. Indirect calorimetry revealed the following information:
Measure
Mr. Sims data
Oxygen consumption (mL/min)
CO2 production (mL/min)
RQ
RMR
What does this information tell you about Mr. Sims?

295
261
0.88
2022

What this information tells about Mr. Sims is that his oxygen intake and his
carbon dioxide intake are increased. These two measures make up the respiratory
quotient of 0.85 and shows metabolism for mixed one which is showing all
carbohydrates. This indicates that Mr. Sims is carb heavy and that he should be in
taking less of the carbohydrates (Krause, 22-27).

27. Would you make any changes to his prescribed nutrition support? What should be
monitored to ensure adequacy of his nutrition support? Explain

According the Krause for his nutrition support I would lower Mr. Sims
carbohydrate intake since the chart above shows he is carb heavy. His protein
should be increased and the carbohydrate should be decreased to help his Oxygen
and carbon dioxide levels return to normal. The primary goal is to maximize his
energy intake and protein to facilitate rehabilitation. Also adding foods high in
antioxidants, carotenoids, vitamin E,vitamin C, selenium and omega-3 fatty
acids(422).

What should be monitored to ensure adequate nutrition support is a food diary of

everything he eats each day so that it is made sure that Mr. Sims is meeting all
nutritional needs each day. Mr. Sims fluid intake will also need to be monitored to
ensure proper absorption of all water soluble vitamins. Mr. Sims will also need to
chart all bowel movements throughout the day to monitor how his intestines are
healing after the surgery. Mr. Sims weight will need to be monitored to ensure that
he is gaining the proper amount of weight and not having any more muscle
wasting (421-422).

28. What should the nutrition support team monitor daily? What should be monitored
weekly? What should be done about it?

Mr. Sims bowel movements should be monitored daily to ensure there is no abnormal
stool and that he is not going as frequently like he was before the surgery. Mr. Sims diet
and food should be monitored daily to make sure all nutritional needs are being made.
His weight and muscle measurements should be monitored weekly to ensure he is gaining
the adequate amount of weight and to check for any more muscle wasting. Each week
Mr. Sims should have labs done to check and see if all the nutrients he was deficient in
are increasing and no longer decreasing (pg.420-421).What should be done if anything
abnormal is occurring is to establish what is causing excessive bowel movements, muscle
wasting, or nutrient deficiencies. Once the problem is found changes to the diet should be
altered to fit Mr. Sims needs.

29. Mr. Sims serum glucose increased to 145mg/dL. Why do you think this level is now
abnormal? What should be done about it?

This level is now abnormal because of refeeding syndrome caused by Mr. Sims
malnourishment. Since his body is taking in the nutrients he needs now his bodys
metabolism is beginning to release more insulin (Manual, 2009). What should be done to
help lower this level is to reduce his energy intake by 50% for around 5 days and then
increased slowly to see if refeeding comes back. Once refeeding does not start back up
then full energy requirements can be taken in(Mehanna,2008).

30.Evaluate the following 24-hour urine data:24-hour urinary nitrogen for 12/20:
18.4grams.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

Mr. Sims is only keeping 110(mL/kg) of urine on 12/20. This means he is not receiving
enough fluids to meet his nutrient needs. The nutrition support team should be concerned
some about this because they will not want Mr. Sims dehydrating and not keeping the
amount of fluid in his system the water soluble vitamins will not be absorbed properly.
This will cause him to decrease in his nutrients and he will stay malnourished. A positive
about Mr. Sims urine test is that his are all in positive values which means he is not
pulling muscle protein out of his body. There are problems with accuracy of nitrogen
balance because it accounts for all nitrogen in the system and does not accurately depict
what values are really needed(Mayo Clinic, 2000).

31. On post-op day 10, Mr. Sims team notes he has had bowel sounds for the previous
48hours and has 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 be allowed to try clear liquids first and non-caffeinated beverages. If
regular solid food is to be given it should consist of low-residue, lactose free diet that
should be given in small amounts. His tolerance as his diet progresses should be
monitored for gluten and lactose intolerances. If these tolerances do show then they
should be reduced and reintroduced after the small intestine has had more time to heal
(pg.421). If the oral diet is successful the parenteral nutrition should be weaned once the
oral diet is a success and once nutritional levels start to elevate to normal.

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.

A nutrition concern would be that Mr. Sims would not continue on his diet and will not
eat the adequate amount of nutrients he needs. Another concern is that if he starts to have
complications that he wont come in and discuss the issues he is having and then the
Crohns disease will flare back up and cause nutritional problems and other health
problems. Mr. Sims also needs to continue to take his supplements to help keep his
nutrient levels where they need to be. If Mr. Sims continues his rehabilitation at home he
should start to have regular bowel movements with no abdominal pain or fever. Mr. Sims
should also start to gain back the weight that he has lost from the malabsorption and
muscle growth should be seen instead of muscle wasting.

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