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Ellie Flum KNH413Diet InstructionFebruary 12, 2013Inflammatory Bowel Disease1) Description of patient and diagnosis Matthew Sims is a 35-year-old Caucasian high school math teacher. He was diagnosed with inflammatory bowel disease, specifically Crohn’s disease, 2 ? years ago, when he lost 25 pounds. Initial diagnostic workup indicated acute disease within the last 5-7 cm of the jejunum and first 5 cm of the ileum. After hospitalization, he was able to regain the weight back to his usual body weight, which is 166-168 pounds. Mr. Sims has recently had recurring symptoms, which include unbearable abdominal pain, diarrhea, and fever. He has also lost all of the weight that he was able to regain, now being back at 140 pounds. A CT scan indicated a bowel obstruction, and Crohn’s disease was diagnosed as severe-fulminant disease. Mr. Sims underwent a resection of 200 cm of the jejunum and proximal ileum with placement of a jejunostomy. Mr. Sims was put on PN immediately post-operatively, and a nutrition support consult was ordered. (Medical Nutrition Therapy Case Study 14)2) Discussion of the disease: Inflammatory Bowel DiseaseEtiology Inflammatory bowel disease (IBD) is characterized as an autoimmune, chronic inflammatory condition of the gastrointestinal tract. IBD is the general term for either of two diagnoses: ulcerative colitis and Crohn’s disease. The complete etiology of both ulcerative colitis and Crohn’s disease is unknown at the present time, however it is understood that many factors play a role in the conditions. These include diet, smoking, infectious agents, physiological changes in the small intestine from which an abnormal inflammatory response is triggered, and genetics. (Pathophysiology of Inflammatory Bowel Disease: An Overview)Diagnostic Measures There are several tests that can be done in order to diagnose inflammatory bowel disease. These include abdominal ultrasound, MRI, CT scan, and antiglycan antibodies (ASCA/ANCA). The most prevalent way to diagnose and describe Crohn’s disease is using the CDAI. A score of over 150 indicates a flare-up of the disease, and a score over 300 means the patient is experiencing a severe exacerbation of the disease. Calprotectin, lactoferrin, and polymorphonucler nuetrophil electase levels in the stool have been found to be indicative of exacerbations of Crohn’s disease as well. Low albumin levels and elevated WBC are also common. In the case of ulcerative colitis, more than 5 daily bowel movements, large amounts of hematochezia, temperature above 37.5°C, pulse above 90/min, and hemoglobin less than 10 g/dL are all indicative of severe activity of ulcerative colitis. (Nutrition Therapy and Pathophysiology Ch. 15)TreatmentMedical, surgical and/or psychological treatment Treatments for inflammatory bowel syndrome include antibiotics, immunosuppressive medications, immunomodulators, and biologic therapies as well as surgical intervention. Medical treatment for UC has used combinations of both antibacterial coverage and anti-inflammatory therapy. Immunomodulators work to inhibit inflammatory cell proliferation by interrupting cellular RNA and by inhibiting overall immune response. Antibiotics are used in UC only when there is an acute infection. Treatment for Crohn’s disease can utilize all of these same medical treatments. Corticosteroids are often used to treat acute exacerbations, especially in severe-fulminant disease, but patients are at risk for becoming steroid dependant. Antibiotics and biological therapies such as anti-adhesion molecules and anti-interleukin antibodies are also used. Treatment by surgery is required for over 60% of patients with inflammatory bowel disease. The most common procedure in ulcerative colitis patients is a total colectomy, and in Crohn’s disease patients, an ileostomy. Sugery is typically performed when a patient is unresponsive to medications or disease-related complications begin to occur. (Nutrition Therapy and Pathophysiology Ch. 15)Medical Nutrition Therapy Most individuals with Inflammatory Bowel Disease experience weight loss and nutritional deficits. Nutritional therapy is often required during times of exacerbation or recovery from surgery, in the form of enteral or parenteral nutrition. IBD can affect normal digestion and absorption, increase caloric and protein needs, or result in protein-energy malnutrition. When inflammation is present in the patient, they could need up to 150% of their normal protein requirements. During times of exacerbation of the disease, Enteral Nutrition is usually necessary to help maintain or improve the patient’s nutritional status and weight. Most researchers say that Parenteral Nutrition is not necessary and does not provide benefits, however PN may be required post-operatively or until there is adequate intestinal adaptation. Protein requirements may be as high as 1.5-1.75 g/kg for adults. If oral intake is initiated, it should be made up of low-residue, lactose-free items. Fiber and lactose should be introduced gradually as the patient’s GI function begins adapting. All patients should receive a multivitamin that meets 100% of the RDA for all nutrients. During times of remission, maximizing energy and protein intake should be the primary goal. This is needed to restore function and facilitate rehabilitation. In the case of Mr. Sims, he has been prescribed to parenteral nutrition post-operatively. His parenteral nutrition prescription is as follows: ?1,500-1,600 kcals ?(20 kcals*76.6kg) (Refeeding must start with fewer kcals/kg)?115 grams protein (460 kcals)?(1.5 g/kg)? 33 grams fat (297 kcals)?(100 cc’s 30% intralipid; 3kcals per cc)?210 grams CHO (843 kcal)?Remaining calories?150 milliequivalents of sodium and potassium EACH?(2 mEq/kg)?16 mEq magnesium ?(8-24 mEq daily)?1,600 cc’s fluid ?1 Multivitamin vile and 1 trace element vileThe reduction of diarrhea volumes predicts the beginning of adaptation of the remaining bowel. At this point, I would begin enteral nutrition with Mr. Sims, and gradually transition into an oral diet. At this point, Mr. Sims should also be taking a multivitamin daily that fulfills all of his RDA needs for all nutrients. During his remission, Mr. Sims should maximize energy and protein intake to facilitate rehabilitation. Physical activity will also help to rebuild muscle mass and protein stores. Mr. Sims should consume foods high in antioxidants and omega-3 fatty acids, as these have been shown to reduce inflammation. (Sample Adult PN Order Form, Figure 7.9 & Nutrition Therapy and Pathophysiology)() Prognosis Typically, IBD is characterized by a sequence of remissions and exacerbations, with acute attacks lasting weeks to months. The mortality rate for inflammatory bowel disease ranges from approximately 1.4 times the general population (Sweden) to 5 times the general population (Spain). Most of this increase appears to be in the Crohn’s disease population, while the ulcerative colitis population appears to have the same mortality rate as the general population. An average patient with ulcerative colitis has a 50% probability of having another episode during the next 2 years. However, patients may have only one flare over 25 years and some may never have another flare again. Ulcerative colitis is considered to be cured once a colectomy takes place.The course of Crohn’s disease is much more viable than that of ulcerative colitis. Remission and exacerbations are sure to occur in Crohn’s patients, with the relapse rate over 10 years being 90%. Surgical intervention is a treatment option for Crohn’s disease, it is not curative and the disease recurrence rate after surgery is high. () () Specific Instructions: Low-ResidueThe point of this diet is to decrease the work that the digestive tract is having to perform in order to promote healing and decrease the symptoms of pain related to Inflammatory Bowel DiseaseHigh fiber foods should be avoided Milk should be drank in moderation An oral supplement is neededEat small meals, take breaks Eat frequently at regular intervalsAdd only one new food to the diet at a time, this way you are able to determine what foods are irritating to the stomach Avoid caffeine and alcohol Avoid spicy foodsIn the case if IBD, it is really a matter of creating an individual plan for the specific patient and finding out what types of foods are irritants in that specific caseFoods to AVOID: Whole grainsChocolateJuices with PulpRaw VegetablesNuts/SeedsSpicy foodsExcess pepper or hot sauceFoods ALLOWED: White or refined breadTender meatButter/MargarineOatmeal Fruits and Vegetables without the skin References: Nelms, Sucher, Lacey, Roth. 2011. Published by Wadsworth, Cengage Learning. Baltimore, CA. Nutrition Therapy & Pathophysiology Nelms, Long, Lacey. 2009. Published by Wadsworth, Cengage Learning. Baltimore, CA. Medical Nutrition Therapy: A Case Study Approach.Pathophysiology of Inflammatory Bowel Disease: An Overview by Rebecca Thoreson and Joseph Cullen. Inflammatory Bowel Disease. (2012). E-Medicine Health. Retrieved from and Managing IBD. (April 30, 2011). Crohn’s and Colitis Foundation of America. Retrieved from Chen-Maynard, PhD. (n.d.) Calculating Parenteral Nutrition. Retrieved from , Joe. Low Residue Diet. Retrieved from Plan. Low Residue Diet. Retrieved from Tine, Jess. 2007. Changes in clinical characteristics, course, and prognosis of inflammatory bowel disease during the last 5 decades. Retrieved from . MedLine Plus. 2013. Low-residue Fiber Diet. Retrieved from ................
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