Answer Guide for Medical Nutrition Therapy: A Case Study ...



Case Questions for Medical Nutrition Therapy: A Case Study Approach 4th ed.

Title: Case 11 – Inflammatory Bowel Disease: Crohn’s Disease

Instructions: Answer the questions below. Please print the questions out with your answers and bring to class on the due date.

Questions:

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

IBD is an autoimmune, chronic inflammatory disease. Clinical characteristics include diarrhea, fever, weight loss, anemia, food intolerances, malnutrition, growth failure, arthritis, and dermatitis. Some of the recent medical literature indicates that there are three characteristics that define the etiology of IBD. These include: genetic predisposition, an altered, dysregulated immune response, and altered response to gut microorganisms.

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?

Both Crohn’s and ulcerative colitis are types of inflammatory bowel disease and are very similar in their signs and symptoms. Crohn’s disease is also hard to identify and therefore can be mistaken for ulcerative colitis at first. Crohn’s disease can affect any part of the GIT, it has skip lesions, transmural inflammation, strictures are more common with high inflammation and shallow ulcers, and perianal disease, abdominal pain and mass in abdomen are more common. Ulcerative colitis however affects only the rectum and colon part of the GIT. It’s continuous from the rectum, has mucosal inflammation, strictures are uncommon with UC and has low inflammation and deep ulcers. It’s also associated with bloody diarrhea.

3. A CT scan indicated bowel obstruction and the Crohn’s 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 is used in clinical practices to determine the characteristics of patients with Crohn’s disease and to evaluate the effect of drug treatment. A CDAI of 400 falls within the moderate disease range of 200-449. Severe-to-fulminant disease applies to patients who have the specific characteristics of high fevers, persistent vomiting, evidence of intestinal obstruction, or cachexia which is wasting syndrome of weight loss, muscle atrophy, fatigue, weakness, and significant loss of appetite.

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

Mr. Sims’ has a high fever of 101.5 which is common in Crohn’s disease. He has also lost 25 lbs of weight since his initial diagnosis. He has symptoms of increased diarrhea and abdominal pain to the point where the pain is unbearable and he constantly has diarrhea. His physical shows that his abdominal area has distention, and extreme tenderness with rebound and guarding. The abdominal pain and diarrhea make it difficult for him to eat so he has also had decreased appetite.

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?

Some examples of extraintestinal symptoms include: redness, pain and itchiness of the eyes, mouth sores, swelling and joint pain, tender bumps, painful ulcerations and other sores/rashes associated with the skin, osteoporosis, kidney stones, and liver problems such as primary sclerosing cholangitis, hepatitis and cirrhosis. However the liver extraintestinal symptoms are very rare. Mr. Sims was hospitalized in September with an abscess which could have been associated with the Crohn’s disease; however, other than the abscess he shows no other 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 Crohn’s.

Humira is a TFN blocker (tumor Necrosis Factor). It’s used for arthritis and when other medications for Crohn’s is not effective. It will also block the cytokine-direct inflammatory activity. Mesalamine will be used to help control the inflammatory response, and corticosteroids will do the same by inhibiting the overall inflammatory response.

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

Mr. Sims has low protein, albumin, and prealbumin levels which could be related to his decreased appetite. His vitamin D, A, and C levels are also very low as well. This could be due to the excessive diarrhea and also indicate that he isn’t absorbing enough of the nutrients he needs. He tests positive for ASCA, anti-Saccharomyces cerevisiae antibodies, which is a test used to distinguish between Crohn’s and ulcerative colitis. And lastly his c-reactive protein is elevated which could be related to inflammation.

8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why he may be at risk for vitamin and mineral deficiencies.

The excessive amount of diarrhea that Mr. Sims is experiencing can put him at increased vitamin and mineral deficiencies. The diarrhea makes it hard for the GIT to digest and absorb the needed nutrients. Mr. Sims also stated that abdominal pains and diarrhea are keeping him from eating, and this could lead to vitamin and mineral deficiencies as well. The corticosteroid medication could potentially pose an issue towards deficiencies as well.

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 when part of an individual’s small intestine is missing or has been surgically removed. Malabsorption can occur because there isn’t enough area to absorb nutrients from food. Mr. Sims could a candidate for short bowel syndrome. He is already having malabsorption difficulties related to his diarrhea and his acute disease is noticeable in the last potion of the jejunum and first part of the ileum. Short bowel syndrome can also be clinically defined by diarrhea and the common cause in many people is from Crohn’s disease.

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

With part of the small intestine being gone, the remaining small intestine will want to increase the number of villi and size of the villi. This will allow for nutrient digestion and absorption to be more thorough. Consuming the correct amount of calories will also help make this possible.

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

Diarrhea is the main symptom of short bowel syndrome, so that could be monitored closely. Other symptoms that should be monitored include weight loss, malnutrition, dehydration/fluid intake and loss, cramping, bloating, heartburn, weakness, and fatigue. Any oral medications getting received need to be monitored as well.

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?

Immunosuppression will help decrease the activity of the immune system. This is helpful to Mr. Sims because Crohn’s disease is an autoimmune disease. The autoimmune response won’t be as severe with the immunosuppressants. autoPBSCT will put stem cells back into Mr. Sims’s body after they have been radiated. This will help the immune system from attacking itself.

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

Potential nutritional consequences include cachexia, vitamin deficiency, anemia, total parenteral nutrition, physical retardation of children, and malabsorption. Specific vitamin deficiency include vitamin B12 and the fat soluble vitamins. Children who suffer from Crohn’s disease have been shown to suffer from growth retardation and retardation of sexual maturity.

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 small intestine is around 20 feet which is roughly 600 cm in length. Therefore, Mr. Sims now has only 400 cm of his small intestine still intact. Therefor this resection isn’t extremely significant because he still has more than half of it remaining.

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

The ileum is usually a main site of absorption for vitamin C, D, K, and B12. It also absorbs magnesium and folate. The jejunum also absorbs vitamin C, D, K, in addition vitamin A, E, and B6. The jejunum also absorbs folate, calcium, lipids, zinc, phosphorus, and magnesium.

16. Evaluate Mr. Sims’ % UBW and BMI.

His current BMI is 20, which falls in the normal range. His BMI prior to weight loss is 24.6 which is still in the normal weight range but very close to the overweight category. Therefore, his UBW percentage is 83%. This means that he has lost 17% of his weight in 6 months which is classified as being severe weight loss.

17. Calculate Mr. Sims’ energy requirements.

(10 X 63.6) + (6.25 X 175.3) – (5 X 35) + 5 = 1561 X 1.4 = 2185 kcal

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

The protein requirements for Crohn’s disease at 1.5 – 1.75 g/kg. Therefore, Mr. Sims needs would be 95 – 110 grams of protein/day

19. Identify any significant and/or abnormal laboratory measurements from both his hematology and his chemistry labs.

Some of Mr. Sims significant and abnormal lab measurements include the following: his protein is at 5.5 g/dL which is less than the reference range of 6-8. His albumin and prealbumin as also low at 3.2 and 11 g/dL compared to the reference ranges of 3.5-5 and 16-35. His c-reactive protein is elevated to 2.8 mg/dL and his ASCA is recorded to be positive, which indicates Crohn’s disease. His hemoglobin and hematocrit levels are also decreased, as are his transferrin, ferritin, and vitamin D, A, and C.

20. Select two nutrition problems and complete the PES statement for each.

Altered nutrition-related laboratory values RT abdominal cramping leading to lack of appetite and decreased ingestion AEB low protein, albumin and prealbumin of 5.5, 3.2 and 11 g/dL and decreased hematocrit, transferrin, ferritin, and vitamin D, A, and C levels

Increased nutrient needs RT decreased functional length of intestine AEB vitamin D, A, and C deficiencies, severe weight loss of 17% within 6 months, and diagnosis of Crohn’s disease

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 nutrition support?

Bowel function, and fluid and electrolyte balance would be the top priorities to be evaluated. The nutrition support team would also want to evaluate what nutritional needs are essential for transitional feedings. Because he will only be on the nutrition support for a short amount of time, the team will want to evaluate that safe progression to an oral diet is ensured.

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?

The jejunum is a main site of vitamin and mineral absorption. During Mr. Sims surgery he had the jejunum removed which is the primary site for phosphorus and magnesium absorption. Therefore, these low levels could indicate an electrolyte imbalance or the presence of short bowel syndrome.

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

Refeeding syndrome is usually present in patients receiving artificial feeding. It is related to the lethal shifts in electrolytes and fluid that can occur in malnourished individuals. The shifts result from the metabolic and hormonal changes and can lead to a very serious clinical condition. Refeeding syndrome is more commonly found in individuals who are malnourished or have had long-term inadequate intake. Mr. Sims could be potentially at risk as he shows symptoms of being malnourished. Also, if his serum magnesium and phosphorus levels aren’t continually checked refeeding can occur. Refeeding can also be prevented by providing small feedings at first and monitoring his serum levels.

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 team’s 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.

Yes, I agree. Mr. Sims will have had to adjust to the resection surgery. Incorporating PN will give time for the adaptation of the ileum to understand the absorption of nutrients once done by the jejunum.

50 cc/hr x 24 hr = 1200 cc/day = 1.2 L/d

1.2 L x 200 g dextrose/L = 240 g dextrose/d x 3.4 kcal/g = 816 kcal dextrose

1.2 L x 42.5 g a.a./L = 51 g a.a./d x 4 kcal/g = 204 kcal amino acid

1.2 L x 30 g lipids/L = 36 g lipids/day x 9 kcal/g = 324 kcal lipids

TOTAL = 1344 kcal

85 cc/hr x 24 hr = 2040 cc/day = 2.04 L/d

2.04 L/d x 200 g dextrose/L = 408 g dextrose/d x 3.4 kcal/g = 1632 kcal dextrose

2.04 L/d x 42.5 g a.a./L = 96.7 g a.a./d x 4 kcal/g = 346 kcal amino acid

2.04 L/d x 30 g lipids/L = 61.2 g lipids/day x 9 kcal/g = 550 kcal lipids

TOTAL = 2528 kcal

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).

Vitamin and Mineral Supplements

Goal: Incorporate a multivitamin supplement into the diet every day to increase the absorption and amount of Vitamin A, D, and C into the diet

Nutrition Education: nutrition relationship to SBS

Goal: educate the patient and family on how digestion will be different related to the short bowel syndrome. Also educate on the increased nutritional needs related to the surgery and ways to help with symptoms

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?

A normal RQ value is 0.7 to 1, with the average usually being around 0.88. This value is the ratio of the amount of carbon dioxide given off by the body related to the amount of oxygen absorbed by them. The RMR also provides a patient’s energy expenditure over a 24 hour time frame. Therefore, Mr. Sims needs at least 2,022 calories to meet his body’s energy needs.

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

The amount of PN that Mr. Sims is receiving is a little higher compared to his estimated required needs however because he lost a some much weight previously I would be okay with him receiving the increased amount of 2428 kcal compared to the estimated amount of 2185. I would however increase the amount of protein that he is receiving because of his surgery he would want to have increased protein needs. To ensure the adequacy of his nutrition support his intake and output should be monitored especially on hydration status, magnesium, phosphorus, and calcium levels.

28. What should the nutrition support team monitor daily? What should be monitored weekly? Explain your answers.

One of the main things that the team should monitor daily would be his serum phosphorus and magnesium levels. This will help to ensure that refeeding syndrome will be prevented. Because Mr. Sims lost so much weight they would want to work towards him regaining that weight to reach his normal weight range. Therefore, weight should be monitored weekly. Vitamin and mineral values would want to be measured weekly to ensure that he is absorbing the correct amount and not deficient on certain ones. Hydration/fluid status, bowel function, and intake/output should be monitored daily to ensure and verify that Mr. Sims is receiving the correct prescribed parenteral feeding.

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?

Patients receiving PN are usually at significantly increased risk for hyperglycemia. Therefore, increased serum glucose levels can result from the PN overfeeding, dehydration, or metabolic stress. If the concentration of dextrose becomes decreased the serum glucose levels could be returned back to normal. The value should be decreased until blood sugars become stabilized.

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.

Dietary protein intake / 6.25 – urine urea nitrogen – 4

(86.7 / 6.25) – 18.4 – 4 = -8.5 grams

Mr. Sims nitrogen balance is -8.5 grams which means that the amount of nitrogen excreted is greater than the amount of nitrogen intake. This is a concerning value related to Mr. Sims nutritional status. The additional nitrogen loss can potentially lead to protein malnutrition. One complication related to the accuracy of nitrogen balance studies specifically related to this case could be the inability to measure the nitrogen loss from diarrhea or vomiting. Any form of renal impairment could affect the accuracy as well.

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?

Some of the first items that Mr. Sims would be allowed to eat could be a lactose-free, low-residue diet with small, frequent meals. Fat levels shouldn’t need to be adjusted unless if steatorrhea is present. Once the beginning lactose-free, low-residue diet with small, frequent meals small amounts of fiber can be gradually added in.

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.

I would recommend that Mr. Sims take a multivitamin that meets his recommend daily allowance. A good multivitamin to take would include one that has vitamin B12, zinc, calcium, copper, and magnesium. These are some of the main deficiencies that can arise from such a surgery. Other areas of nutrition concern would be protein malnutrition. Two possible nutritional outcomes would be for Mr. Sims to maximize his total energy and total protein intake. In order to fully understand what Mr. Sims is consuming overall I would recommend that he keep a food log to look at his overall intake. To measure his protein intake, I would do all of the necessary lab work to measure albumin, prealbumin, and overall protein levels.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download