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Zach Pfirrman

9/15/13

KNH 411

Inflammatory Bowel Disease: Crohn's Disease

What is inflammatory bowel disease? What does current medical literature indicate regarding it's etiology?

“Inflammatory Bowel Diseases (IBD) is a broad term that describes conditions with chronic or recurring immune response and inflammation of the gastrointestinal tract. The two most common inflammatory bowel diseases are ulcerative colitis and Crohn’s disease”(CDC). Based on studies done, some believe that the cause of IBD could be a change in the intestinal flora. “a change in the gut flora in industrialized countries compared with places in which Crohn’s disease is rare, such as rural Africa, result in an increase in certain bacteria, such as Bacteroides, and a decrease in Bifido-bacteria. This shift in bacteria, better studied in association with periodontitis, has greater concentrations of bacteria,

which can penetrate the epithelium and produce leukotoxins capable of impairing function of neutrophils and other innate immune cells”(Korzenik, p.S62). Smoking has also been thought to be a factor in the etiology.

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?

Ulcerative colitis is a chronic gastrointestinal disorder that only occurs in the large intestine. Ulcerative colitis does not affect all layers of the bowel, but only the top layers of the colon in an even and continuous distribution. While in Crohn’s disease, potentially any location of the gastrointestinal tract can be involved, but it frequently affects the end of the small intestine and the beginning of the large intestine. In Crohn's disease, all layers of the intestine can be involved and there could be normal healthy intestine between patches of diseased intestine. The signs and symptoms of both Crohn's disease and ulcerative colitis seem to be about the same with diarrhea, cramping abdominal pain, skin lesions, joint pain, eye inflammation, and liver disorders. It would be very easy to diagnose one for the other. The main difference between the two would be the location of the disease. If disease is found in the upper layers of the large intestine, it would be hard to tell which it is. If later the disease spread to the small intestine, it would be a for sure Crohn's disease diagnosis.

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?

A CDAI score of between 200-449 indicates moderate disease activity. This is defined as having failed to respond to treatment for mild-moderate disease or those with more major symptoms of fevers, significant weight loss, abdominal pain or tenderness, nausea or vomiting, or significant anemia.

Sever-fulminant disease is characterized as persisting symptoms in spite of introduction of steroids or biologic agents as outpatients, or those presenting with high fever, persistent vomiting, evidence of intestinal obstruction, rebound tenderness, cachexia, or evidence of an abscess.

Nutrition Therapy & Pathophysiology p.419

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

He complained of chronic diarrhea and abdominal pain, switched medicine which relieved the symptoms for a short time, then experienced strong abdominal pain and constant diarrhea. Also he now has a fever and from is general appearance, seems to be underweight. All of these are prime signs and symptoms of Crohn's.

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?

Extraintestinal symptoms that can appear because of Crohn's would include osteopenia, osteoporosis, dermatitis, rheumatological conditions such as ankylosing spondylitis, ocular symptoms, and hepatobiliary complications. From his history and physical there seems to be no indicator of any of these manifestation occurring in Mr. Sims.

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.

|Corticosteroids |Anti-inflammatory and Immunosuppressive |

|Mesalamine |Contain 5-aminosalicylic acid and interfere with body's ability to control inflammation |

|Humira |Adalimumab in Humira blocks TNF-alpha which reduces inflammation. |

Crohn's & Colitis Foundation of America.

Adalimumab (Humira)

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

Low Protein, albumin and prealbumin, high C-reactive protein levels, low HDL levels, positive ASCA, low hemoglobin, low hematocrit %, low levels of Transferrin and Ferritin, high levels of ZPP, and a decreased level of vitamins D, A, and C. Protein, albumin and prealbumin levels are low due to malabsorption. High levels of C-reactive protein are an indicator IBD. ASCA or Anti-saccharomyces cerevisiae antibodies are much higher in frequency in people with Crohn's. A positive ASCA reading paired with a negative pANCA reading is one of the best indicators of having Crohn's. Anemia is often caused by Crohn's, which for Mr. Sims, is confirmed by his low levels of hemoglobin and his hematocrit percentage. Tranferrin is known to decrease due to inflammation. Ferritin is an iron binder and decreases because of inflammation and anemia. While Tranferrin and Ferritin decrease because of iron anemia, ZPP levels increase because when the body does not have enough iron to use, it turns to Zinc, which is why the levels increase. And since his intestinal tract is not absorbing vitamins and minerals properly, a drop in vitamin (A,D,C) and iron levels. This, or a poor diet, could contribute to the low HDL.

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

Crohn's disease can affect the the small intestine and cause malabsorption. Different parts of the small intestine absorb different vitamins and minerals so depending on how much disease and inflammation there is in particular parts that are the only areas that absorb a certain nutrient, there is always a chance of nutrient deficiencies. The reason for taking the multivitamin is to get extra nutrients in there to be absorbed. The more there is the easier it is to absorb.

Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel syndrome and provide a rationale for your answer.

Short bowel syndrome results from a large resection of the small intestine. Each patient presents a unique situation where the underlying diagnosis, the condition of the ileocecal valve, and the amount of colon that is preserved are important factors affecting the long term prognosis. Short bowel syndrome intestinal failure results from surgical resection, congenital defect or disease-associated loss of absorption and is characterized by the inability to maintain protein, energy, fluid, electrolyte, or micronutrient balances when on a conventionally accepted, normal diet.

Nutrition Therapy & Pathophysiology p.424

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

The small intestine makes adaptations in a way of parts of the small intestine that remain start to absorb the nutrients that would have been absorbed by the area that was removed. This works for the most part. Sometimes, if too much of a certain portion of the small intestine is removed, the rest of it can not adapt to ensure proper absorption.

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

The classic symptoms of SBS include the inability to maintain protein, energy, fluid, electrolyte, and micronutrient balances. In the beginning they need to monitor his fluid intake as well as how much is lost through diarrhea. They need to monitor his every intake and see how his levels of vitamin and mineral levels hold up after his procedure.

Nutrition Therapy & Pathophysiology p. 424

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?

The immunosuppressants would help in treatment by targeting the immune system, specifically the tumor necrosis factor in the bloodstream, removing it before it can cause inflammation in the gastrointestinal tract.

II. Understanding the Nutrition Therapy

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

Many people with active Crohn's disease experience weight loss and nutrient deficits. Calorie deficiencies are caused by low apatite, increased energy requirements, and fear of abdominal pain and diarrhea after eating. Fluid and electrolyte deficiencies can occur due to short bowel syndrome or high volume diarrhea. Iron deficiencies are common due to malabsorption and blood loss. Other vitamins and minerals due to short bowel syndrome and malabsorption.

Nutrition Therapy & Pathophysiology p.420

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 average length of an adult's small intestine is about 6 meters, so if 200 cm were removed then his small intestine is about 5.8 meters now. As far as resections go, this should not prevent Mr. Sims from absorbing any vitamin or mineral completely. He will need to increase to amount of some of the nutrients in his diet to ensure sufficient absorption by the areas of the small intestine that he does have left.

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

Of the areas that have resected, these nutrients are absorbed by the Jejunum:

|Thiamin |Riboflavin |Niacin |Pantothenate |Biotin |Folate |

|Vitamin B6 |Vitamin C |Vitamins A, D, E, K |Calcium |Phosphorus |Magnesium |

|Iron |Zinc |Chromium |Manganese |Molybdenum |Lipids |

|Monosaccharides |Amino Acids |Small Peptides | | | |

As for the proximal Ileum, these nutrients are absorbed:

|Vitamin C |Folate |Vitamin B12 |Vitamin D |Vitamin K |Magnesium |

Nutrition Therapy & Pathophysiology p.380

III. Nutrition Assessment

Evaluate Mr. Sims' % UBW and BMI.

I used the Hamwi Method to calculate Mr. Sims healthy weight:

106 + (6 x 9) = 160lb.

So to calculate his % UBW I did the following equation:

140lb / 160lb = 0.875 x 100 = 87.5%

I then calculated his BMI

140lb x 0.4536 = 63.5 kg

69in x 2.54cm = 175.26cm / 100cm = 1.75m

63.5kg x 1.75m² = 20.7

Although BMI is in the healthy range for a person of his stature, based on his %UBW he is underweight. This is probably due to his poor apatite and malabsorption.

Calculate Mr. Sims' energy requirements.

I calculated this with the Mifflin-St. Jeor equation:

10 x 63.5 + 6.25 x 175.26 – 5 x 35 + 5 = 1550

Since he will be bed bound he will have a PAL of 1.2 and just went through surgery which is a factor of 1.1

1550 x 1.2 x 1.1 = 2046 kcal

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

Because of protein loss from surgery and the needed protein for wound healing, 1.5g/kg of protein is needed.

63.5kg x 1.5 = 95.25 g of protein/day

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

| |Normal Level |Patient's Level |

|Protein |6-8 |5.5 |

|Albumin |3.5-5 |3.2 |

|Prealbumin |16-35 |11 |

|C-reactive Protein |45 |38 |

|ASCA |Neg |+ |

|PT |12.4-14.4 |15 |

|Hemoglobin |14-17 |12.9 |

|Hematocrit |40-54 |38 |

|Transferrin |215-365 |180 |

|Ferritin |20-300 |16 |

|ZPP |30-80 |85 |

|Vitamin D 25 hydroxy |30-100 |22.7 |

|Free Retinol |20-80 |17.2 |

|Ascorbic Acid |0.2-2.0 | ................
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