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Libby Sells

Professor Matuszak

KNH 411

September 17, 2013

Case Study 11-Inflammatory Bowel Disease:Crohn’s Disease

I. Understanding the Disease and Pathophysiology

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

its etiology?

a. Inflammatory bowel disease is a group of chronic inflammatory conditions affecting the large and small intestines. It causes the disruption of the normal functioning of the digestive system, and can be very painful and debilitating. Two common types of IBD are ulcerative colitis and Crohn's Disease.

b. Current medical literature indicates that IBD is considered to be autoimmune, meaning the body's immune system is attacking the digestive system. It is thought that IBD occurs due to a combination of genetic(if parent has it that person is more likely to as well) and environmental(smoking, infectious agents, intestinal flora, etc) factors.

I. Nelms pg. 415-416

2.Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with Crohn’s. How could this happen? What are the similarities and differences between Crohn’s disease and ulcerative colitis?

a.Many people suffering from IBD may not have a specific diagnosis at the start of their signs and symptoms. For example, Mr. Sims was misdiagnosed because ulcerative colitis and Crohn's disease have very similar signs and symptoms including weight loss, diarrhea, bloody stools, fever, weakness, fatigue, and abdominal pain and discomfort. Both diseases may also cause an increase risk of intestinal cancer. Mr. Sim's has experienced weight loss, frequent diarrhea,fever, and abdominal pain, as admitted by his account of his medical history; these symptoms could easily be mistaken for ulcerative colitis. The location of the inflammation resulting from the disease are different, however. In Crohn's, inflammation may occur anywhere along the digestive tract, but in ulcerative colitis, typically only the large intestine or occasionally the ileum will be inflamed. While signs and symptoms are similar, the location of the pain may be different. In ulcerative colitis, pain tends to be localized in the lower left abdomen, while pain tends to be in the lower right abdomen in Crohn's:it may have been difficult for Mr. Sim's to identify the location of his pain.Other differences include more gallstones, kidney stones, UTIs, perianal disease, fistulas, fissures, and ulcerations in the bowel wall in Crohn's. Bloody stools are more commonly indicative of ulcerative colitis, as is constipation, dysplasia, arthritis, and dermatological changes. Treating Crohn's disease is often more difficult, as many of the medications used for ulcerative colitis are not a good treatment for Crohn's.

Nelms pg. 416

3. A CT scan indicated bowel obstruction and the Crohn's Disease was classified as severe fulminant disease.What does a CDAI score of 400 indicate? What does a classification of severe-fulminant disease indicate?

a. A CDAI score of 150-220 in a patient indicates mild to moderate activity of Crohn's disease with tolerable pain and no dehydration, a score of 220-450 indicates moderate to severe activity and are unresponsive to treatment, so Mr. Sim's score would likely qualify as severe activity of Crohn’s disease. A score of less than 150 is often given to those considered to be in remission for the disease.

b.A classification of Crohn's severe-fulminant disease is characterized by severe symptoms that are persistent often despite of steroid treatment and is indicated by high fevers, on-going vomiting, signs of intestinal blockage, tenderness of the abdomen, cashexia, or evidence of an abscess. To be classified as this, the CDAI score must be >450.

I. From Nelms, pg 419

4.What did you find in Mr. Sim’s history and physical that is consistent with his diagnosis of Crohn’s? Explain.

a.According to his account of his medical and nutrition history, Mr. Sims has several signs and symptoms of Crohn's disease.While his usual body weight ranges from 166-168 pounds, he has unintentionally lost 25 pounds over the last six months , likely as a result of frequent bowel movements and malabsorption of nutrients. In the past six months, he has reported fever (101.5 F), worsening abdominal pain, and frequent diarrhea, which are all symptoms of Crohn's. The increased frequency and severity of these signs and symptoms is likely due to increased inflammation, and his disease may be worsening, as occurrence of ulcerations, fissures, fistulas for example are possibilities with Crohn's Disease. Distension and extreme tenderness with rebound and guarding (pain from reapplying pressure and tensing of abdomen wall muscles to protect inflamed muscles) have been reported.

Nelm's pg. 416

5.Crohn’s 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?

a. Extraintestinal symptoms occur because other organs and organ systems may be affected by Crohn’s disease. Manifestations of Crohn's Disease may include peripheral arthritis,sacroiliitis, ankylosing spondylitis, osteopina,and osteoporosis which are muscoskeletal implications of Crohn's, erythema nodosum,pyoderma gangrenosum, and aphthous stomatitis which are dermatological implications; uveitis, scleritis,and episcleritis are ocular implications; thromboembolic events may occur in the vascular system, and nephrolithiasis may occur in the renal area. An increased prevalence of gallstones may occur due to lack of bile resorption, and painful, swollen, and stiff joints with loss of joint mobility or function may occur as a result of arthritis due to Seronegative spondyloarthropathy. Neurological complications like seizures, headaches, depression, stroke, myopathy, and peripheral neuropathy may also happen. Clubbing, a deformity of the ends of the fingers, may also take place. None of these are evidenced by Mr. Sim's history and physical.

I. From Evans, 2007 and Nelms pg. 418

6.Mr. Sim's has been treated perviously with corticosteroids and mesalamine. His physician had planned to start Humira prior to this admission. Explain the mechanism for each of these medication in the treatment of Crohn's.

a. Often used to put patients into remission, corticosteroids are potent anti-inflammatory drugs (steroids) used for treating moderate to severe Crohn's disease in adults. They are recommended only for short term, and long term use can cause many side effects. They work by targeting the adrenal gland in order to reduce inflammation and stress associated with illness and injury in the body, which can be the cause of some symptoms (including pain) of the disease. Mesalamine works by works by stopping the body from producing a certain substance that may cause pain or inflammation, but also has potential side effects and can be ineffective if the small intestine is affected. Humira blocks the tumor necrosis factor, a protein produced by the immune system that caused inflammation. It can reduce flare up and the signs and symptoms of Crohn's disease and may cause remission, but also has potential side effects. It is often used for moderate to severe Crohn's Disease.

I. From The Mayo Clinic:Crohn's Disease

7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease? Identify and explain.

a. Mr. Sim's albumin value is low which was is likely due to malnutrition, inflammation, and poor absorption and digestion of protein from food-total protein and pre-albumin (his value at 11 g/dL and the normal range is 16-35 mg/dL) are also low due to this reason.His total protein level is 5.5 g/dL and the normal range is 6-8 g/dL. His albumin level is 3.2 g/dL and the normal range is 3.5-5 g/dL. C-reactive protein is higher than normal because of inflammation, and his osmolality lab value is low due to dehydration caused by diarrhea.Mr. Sim's ESR value is high due to inflammation. His alkaline phosphatase level is also high. This can occur with bile duct obstruction or osteoporosis. Mr.Sim's HDL-C lab value is low because cholesterol levels tend to fall with illness and also with malnutrition. Lab values of transferrin ( Mr. Sims is 180 mg/dL normal is 215-365 mg/dL),hemoglobin and ferritin (proteins that bind and transport iron) are low, and ZPP is high due to iron deficiency because of malabsorption and malnutrition, and low protein levels. The normal range for ferritin is 20-300 mg/dL; Mr. Sim's is 16mg/dL. His vitamin D and A levels are both low, as his vitamin D is 22.7 ng/mLwith normal range of 30-100ng/mL, and his vitamin A is 17.2ug/dL with healthy range of 20-80ug/dLwhich indication inadequate intake or poor absorption.

8.Mr. Sim's is currently on several vitamin and mineral supplements. Explain why he might be at risk for vitamin and mineral deficiencies.

a.If Mr. Sim's had a bowel resection involving the removal of 200 cm of his jejunum and proximal ileum, the small intestine would not able to absorb as many nutrients, vitamins, and minerals (iron, zinc, magnesium) as normal. With Crohn's, inflammation can occur in the small intestine, affecting absorption.Malabsorption and malnutrition are also currently apparent due to his dramatic weight loss and diarrhea. Poor appetite may also occur due to the abdominal pain caused by Crohn's, so he may not be taking in enough vitamins and minerals with his food, and if he is, he may have problems absorbing them.

I.From Nelm's pg. 420

9.Is Mr. Sim’s a likely candidate for short bowel syndrome? Define short bowel syndrome, and provide a rational for your answer.

a. Each part of the small intestine absorbs and digests certain nutrients-short bowel syndrome is a malabsorption syndrome that could occur due to surgical resection of the small intestine, occurring when the remaining intestine does not completely adapt to the bowel resection, and malabsorption of nutrients, vitamins, and minerals can occur as a result. Mr. Sim's will be a likely candidate for short bowel syndrome if he is not careful and intentional about what he eats, especially because he eventually undergoes a resection of part of the jejunum and proximal ileum (almost half of small intestine), which could decrease his absorption for b12 and fat soluble vitamins along with other nutrients.

Nelms pg. 424

10.What type of adaptation can the small intestine make after resection?

a.After resection, the small intestine may undergo a process that can increase absorption. This involves an increase in the intestinal surface area of the mucosa, creating an increase in absorption and digestion.Villi may grow and become longer and thicker.The diameter of the small intestine may also widen, and peristalsis could slow down so that food and nutrients have a longer time to be absorbed. It is thought that the factors influencing this type of adaption includes hormones, intestinal factors, gastrointestinal secretions, and nutrients from both in and outside of the intestines.

From From National Digestive Diseases Information Clearinghouse

11.For what classic symptoms of short bowel syndrome should Mr. Sim’s health care team monitor?

a.Mr. Sim's health care team should monitor the following:frequency and severity of diarrhea, abdominal pain and bloating, fever,dehydration, heart burn, electrolyte balance, symptoms of malnutrition like extreme weight loss, and food tolerance. The health care team should also pay attention to how well Mr. Sim's is able to follow nutrition and diet recommendations, and they should monitor any subsequent lab values that would be abnormal because of Crohn's disease and short bowel syndrome. If part of the ileum is removed, levels of bile acid and b12 should be watched.

12.Mr. Sims is being evaluated for participation in a clinical trial using high dose immunosupression and autologous peripheral blood stem cell transplantation (autoPBSCT). How might this treatment help Mr. Sims?

a.In autoPBSCT, a person with compromised stem cells may receive their own stem cells derived from a peripheral blood source. By replacing these stem cells, it is hoped that a patient's immune system will basically be reset,which could be beneficial to Mr. Sim's, since Crohn's disease is highly considered to be autoimmune. He could potentially have decreased inflammation, lessened severity of symptoms, or go into remission for his disease. Immunosupressive drugs have been used in the treatment of Crohn's disease to suppress or modify the immune system, and some of these drugs work to specifically target the chemicals of the immune system that are involved with inflammation. Again, reduced inflammation would greatly lessen many of Mr. Sim's symptoms.

I. Annaloro, Onida, Deliliers, 2009

II.Understanding the Nutrition Therapy

13.What are the potential nutritional consequences of Crohn's disease?

a. The potential nutritional consequences that Mr. Sim's may experience include inadequacy of protein, folate,iron, calcium, fat, magnesium, zinc, B12, difficulty with fluid retention , food and medical interactions,fat soluble vitamins, and other vitamin and mineral deficiencies resulting from malabsorption, especially due to problems in the small intestine. As a result of malnutrition, Mr. Sim's could have unintentional weight loss,dehydration, growth failure, and muscle wasting. Often times, supplementation like multivitamins are recommended for patients. For extremely severe cases, enteral or parenteral feeding could be required. In some cases, lactose may also not be tolerated. Mr. Sim's may benefit from both supplementation and smaller, well timed meals.

Nelms pg. 420

14.Mr. Sims has had a 200-cm resection of his jejunum and proximal ileum. How long is the small intestine, and how significant is this resection?

a.Normally, the small intestine in an average adult is around 400 cm long. If the terminal ileum is preserved, resection of large sections of jejunum is generally feasible as adaptions of the small intestine may occur. Mr. Sim's resections is very significant, since he had almost half the length of the small intestine resected. He may very likely experience problems like significant malabsorption problems, frequent diarrhea, and malnutrition, with specific absorption problems depending on the area removed, if he does not watch his diet carefully.

15.What nutrients are normally digested and absorbed in the portion of the small intestine that has been resected?

a.Mr. Sims has had a 200-cm resection of his jejunum and proximal ileum Most of the crucial absorption of fat takes place in the ileum. Due to Mr. Sim's resection, nutrients of digestive and absorption concern include calcium, folate, vitamins A, D, E, K, free fatty acids, monoglycerides, and some B12 (absorbed in ileaum), sodium, and water (absorbed all along digestive tract).

I. From National Digestive Diseases Information Clearinghouse

III.Nutrition Assessment

16. Evaluate Mr. Sims’s anthropometric data by evaluating %UBW and BMI. Interpret your calculations.

a.Using %UBW = (100 x Actual Weight)/Usual body weight:166-168 pounds. Using the average of 167 lbs, (100 x 140 (current weight))/167 (UBW)=83.8 or 84% of his UBW. If a person has a % UBW within approximately 70-90% of normal body weight, that means they are at risk of moderate malnutrition. Using BMI = ( Weight in Pounds / ( Height in inches x Height in inches ) ) x 703, Mr. Sim's BMI=(140/(69 x 69))x703=20.6.His BMI is approximately 21 kg/m^2, while healthy weight usually falls in a BMI range of 18.5-25.However, Mr. Sim's weight loss is recent and dramatic, which is of concern, and his BMI could easily fall below the healthy BMI range.

17.Calculate Mr. Sim’s energy requirements.

a. Using the Mifflin-St. Jeor equation for men, where 10 x weight (kg) + 6.25 x height (cm) - 5 x age (y) + 5 determines energy needs: 140x.453=63.42 kg for weight and 2.54x 69=175.26 cm, and (10x63.42)+(6.25x175.26)-(5x35)+5=1559.58 or 1560 kcal for REE for his current, not usual body weight. For his TEE, since physical activity frequency and duration is not specified, I would give the patient a PAL of 1.6 or 1.8, since it depends how much he is standing and moving around while he teaches. 1.6x1560=2496 kcal or 1.8x1560=2808 kcals. When at the hospital, I would give him a PAL of 1.2, which would give 1.2 x 1560=1872 calories.It would, however be an important goal to being increasing total caloric intake necessary for weight gain once he is released from the hospital.

18.What would you estimate Mr. Sim’s protein requirements to be?

a.Using his current body weight of 140 pounds, and 0.8 g x 63.42 kg=50.7 or 51 grams of protein per day. Using his usual body weight of 167 pounds, 0.8 x 75.65=60.5 or 61 grams per day.Since protein is an important part of healing and Mr. Sim's has been malnourished, I would recommend he get anywhere from 1.0 to 1.5g/kg of protein. Using his usual body weight this would be 1.0 x 75.65=60.5 or 1.5x75.65=113.5 for a protein intake of 61-114 grams. Using his current body weight this would be 1.0 x 63.42=50.7 or 1.5x63.42=95.15 g for a protein intake of 51-95 grams.

19.Identify any significant laboratory measurements from both his hematology and his

chemistry labs.

a.

|Lab value |Normal Range |02/15/52 |

|Total Protein g/dL |6-8 g/dL |5.5 g/dL |

|Albumin g/dL |3.5-5 g/dL |3.2 g/dL |

|Pre-albumin g/dL |16-35 g/dL |11 g/dL |

|C-Reactive Protiein mg/dL |55 F, >45 M |38 mg/dL |

|ASCA |Neg |Pos |

|PT (sec) |12.4-14.4 sec |15 sec |

|Hemoglobin g/dL |12-15 F, 14-17 M |12.9 |

|Hematocrit % |37-47 F, 40-54 M |38 |

|Transferrin mg/dL |250-380 F, 215-365 M |180 mg/dL |

|Ferritin mg/dL |20-120 F, 20-300 M |16 |

|ZPP umol/mol |30-80 |16 umol/mol |

|Vitamin D ng/ml |30-100 |22.7 |

|Vitamin A ug/dL |20-80 |17.2 |

|Ascorbic Acid mg/dL |.2-2.0 | ................
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