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Taryn BerryCase Study #11-Crohn’s DiseaseUnderstanding the Disease and PathophysiologyWhat is inflammatory bowel disease? What does current medical literature indicate regarding its etiology?Inflammatory bowel disease (IBD) is a chronic inflammatory condition of the gastrointestinal tract that is also autoimmune. This is a term that generally describes ulcerative colitis (UC) and Crohn’s Disease. The complete etiologies for both of these are unknown but multiple factors are said to contribute. Some factors include environmental factors such as smoking, infectious agents, intestinal flora, and physiological changes in the small intestine, which is where the abnormal inflammatory response starts. A strong association based on family history suggests that there is a 5% to 15% positive chance of IBD. Also, genetic associations have been found with innate and acquired immune response. “The major hypotheses regarding the etiology of UC have included infection, allergy to dietary components, immune responses to bacterial or self-antigens and environmental causes.” (Karagozian, Burakoff). 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?Patients with UC and Crohn’s disease both have symptoms of abdominal pain, bloody diarrhea, and tenesmus, which is the feeling of passing stools when the bowels are empty. Mr. Sims was diagnosed with acute Crohn’s disease 2 ? years ago. First, he was diagnosed with UC 3 years ago. This could be because UC usually only affects one part of the gastrointestinal tract at a time, so when he first started seeing symptoms, it was only in one section. As it progressed, his symptoms of diarrhea and abdominal pain worsened. Crohn’s disease has a “skipping pattern” in which it can affect multiple parts of the gastrointestinal tract, thus having worse symptoms. Patients with Crohn’s disease also have worse cramping then UC patients which is what Mr. Sim’s had at the time of re-diagnoses and currently (Nelms, Sucher, Lacey, Roth, 2011, p. 416).A CT scan indicated bowel obstruction and 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 include? A CDAI score of 400 indicated moderate-severe disease. This is individual that have failed to respond to treatment for mild-moderate disease or those with major symptoms such as fevers, significant weight loss, abdominal pain or tenderness, intermittent nausea or vomiting, or significant anemia. Severe fulminant disease includes a CDAI greater then 450. These patients have persistent symptoms in spite of the addition of steroids or biological agents or those with high fever, persistent vomiting, evidence of intestinal obstruction, rebound tenderness, cachexia, or evidence of an abscess (Nelms, Sucher, Lacey, Roth, 2011, p. 419).What did you find in Mr. Sim’s history and physical that is consistent with his diagnosis of Crohn’s? Explain. Matt Sims was in the hospital last September with an abscess and acute exacerbation of Crohn’s disease. He said that 3 years ago he was diagnosed with inflammatory bowel disease but 6 months later he was diagnosed with Crohn’s disease. A this point he was hospitalized for more then two weeks. He went back to school and switched medication. Currently, he has been hospitalized again because his symptoms have worsened. The part of Mrs. Sim’s history that seems to be consistent with the symptoms of Crohn’s disease is that he has chronic diarrhea, worse abdominal pain, running a fever of 101.5 and the medication does not seem to be working anymore (Nelms, Sucher, Lacey, Roth, 2011, p. 416)Crohn’s 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 with Crohn’s disease often have symptoms outside of the gastrointestinal tract, called extraintestinal. These symptoms include osteopenia, osteoporosis, dermatitis, rheumatoid conditions, such as ankylosing spondylitis, ocular symptoms, and hepatobiliary complications (Nelms, Sucher, Lacey, Roth, 2011, p. 418).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 are used to reduce inflammation. This is accomplished by the medication mimicking the effect of the body’s naturally occurring hormones in the adrenal glands. When given at a dose that exceeds the usual amount in the body, the result is an anti-inflammatory response. The anti-inflammatory responses are accomplished when the steroids enter the cell and bind with steroid receptors, pass through the nuclear membrane, form protein that inhibits phospholipase A2 and allows the supply of arachidonic acid. This acid is needed for inflammatory mediators. In addition to this process, corticosteroids alter which ions are accepted through the cell membrane, thus reducing the autoimmune attack of cells. Corticosteroids are for short-term use, usually around 3-4 month in order to induce remission. Some side effects of corticosteroids are puffy face, excessive facial hair, night sweats, insomnia, hyperactivity, high blood pressure, diabetes, osteoporosis, bone fractures, cataracts, glaucoma, and increased chance of infection.References from and Mesalamine is medication primarily for the treatment and maintenance of mild to moderate ulcerative colitis (UC) and Crohn’s disease. Like corticosteroids, mesalamine is an anti-inflammatory. The anti-inflammatory responses are accomplished when mesalamine enters the cell and bind with receptors, pass through the nuclear membrane, form protein that inhibits phospholipase A2. In addition, mesalamine is also an immunosuppressive drug. The synthesis of inflammatory lipid mediators is influenced by mesalamine, as well as inhibits enzymatic activity, which causes inflammation. In regards to the immunosuppressive response, mesalamine impairs leukocyte function and activation by the release of adenosine. Reference from Humira is a medication for adult patients to achieve and maintain remission with Crohn’s disease. It is primarily used in patients with moderate to severe cases and those who have not responded to conventional treatment. Humira is given as one dose by injection under the skin. It is a biological medicine that block TNF production, which is associated with Crohn’s disease. The result is reduced inflammation in the gastrointestinal tract. A side effect is that this action reduces the immune system, thus increasing susceptibility to disease.Reference from: laboratory values are consistent with an exacerbation of his Crohn’s disease? Identify and explain these values. TestRef. Range2/15ASCANeg+Hemoglobin14-17M12.9C-reactive protein<1.02.8Hematocrit40-54 M38Ferritin20-300 M16Antisaccharomyces cerevisiae antibodies (ASCA) are more particular with Crohn’s disease as oppose to pANCA which are particular to UC. Hemoglobin, c-reactive protein, hematocrit, and ferritin are all abnormal due to intestinal inflammation and blood loss. (Nelms, Sucher, Lacey, Roth, 2011, p. 420)Mr. Sims is currently on several vitamin and mineral supplements. Explain why he may be at risk for vitamin and mineral deficiencies. Patients diagnosed with active Crohn’s disease may experience weight loss and nutrition deficits because normal digestion and absorption of nutrients is disrupted. The symptom of chronic diarrhea is also an indication that nutrition deficit may be of concern because nutrients are not be correctly absorbed due to the reoccurring diarrhea. Also, the loss of appetite from the abdominal pain could cause the patient to not eat due to lack of appetite or fear of worsening the stomach pain. Fat-soluble vitamins are also lost due to the excess fat passed in bowels through steatorrhea, a symptom of Crohn’s disease.Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowl syndrome, and provide a rationale for your answer. Short bowel syndrome is the result of a large resection of the small intestines. Each case is unique with consideration to the ileocecal valve, and the amount of colon to preserve. Long-term implications are also taken into account. This is often characterized by inability to maintain protein, energy, fluid, electrolyte, or micronutrient balances when on a normal diet. I believe that Mr. Sims would be a good candidate for this procedure because he possesses all symptoms of people who need this procedure, including Crohn’s disease (Nelms, Sucher, Lacey, Roth, 2011, p. 424)What type of adaption can the small intestine make after resection?After the resection procedure, the small intestines will decrease the surface area in which it can absorb nutrient. Therefore, malabsorption of nutrients, fluids, and electrolytes will result from decreasing the size of the small intestines (Nelms, Sucher, Lacey, Roth, 2011, p. 424)For what classic symptoms of short bowel syndrome should Mr. Sim’s health care team monitor?The symptoms that the health care team should monitor that correlate with short bowel syndrome are inability to maintain protein and energy, and fluid and electrolyte loss (Nelms, Sucher, Lacey, Roth, 2011, p. 425).Mr. Sims is being evaluated for participation in a clinical trial using high-dose immunosuppression and autogulous peripheral blood stem cell transplantation (autoPBSCT). How might this treatment help Mr. Sims?Autogulous refers to a transplant where the receiver is also a donor. Their cells are taken out, harvested, and returned to the body after the procedure. This could be beneficial to the patient because healthy cells will be transplanted back into his body after the procedure is over (Nelms, Sucher, Lacey, Roth, 2011, p. 173).II. Understanding the Nutrition TherapyWhat are the potential nutritional consequences of Chron’s disease?Crohn’s disease causes many nutritional consequences, such as malnutrition inadequate energy intake, inadequate oral food/beverage intake, increased nutrient needs, inadequate vitamin/mineral intake, impaired nutrient utilization, food-medication interaction, and altered nutrition-related laboratory values. Malnutrition can still be present when Crohn’s disease is in remission. These implications can cause growth deficits in children, anemia, osteoporosis, poor wound healing, and a compromised immune system (Nelms, Sucher, Lacey, Roth, 2011, 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 small intestine is divided into three sections: the duodenum, the jejunum, and the ileum, with respect to order. The whole small intestine is 5.5-7.5m in length. The duodenum is .5m long, the jejunum is 2-3m long, and the ileum is 3-4m long. The chyme first enters the duodenum where gastrin and internal pacemakers signal the segmentational contractions. The chime then moves to the jejunum. Most absorption takes place in the duodenum and jejunum. The ileum does absorb some nutrients that stay in the small intestines long enough to reach the ileum. One exception of this is vitamin B12 which is only absorbed in the ileum. Next is the ileocecal valve which leads to the large intestine. 7.5+3+4=14.5m x 100cm = 1450 cm – 200cm = 1250cm after the resection of the jejunum. Although some absorption will be disrupted by the procedure, only 14% of the small intestines was removed which is not a lot in reality. The duodenum and ileum are still capable of absorbing nutrients.What nutrients are normally digested and absorbed in the portion of the small intestine that has been resectioned?In the duodenum and jejunum the following are absorbed, thiamin, riboflavin, niacin pantothenate, biotin, folate, vitamin B6, vitamin C, vitamins A, D, E, and K, calcium, phosphorous, magnesium, iron, zinc, chromium, manganese, molybdenum, lipids, monosaccharide’s, amino acids, and small peptides. This means that there will be a slight lack of absorption as a result of the resectioning. (Nelms, Sucher, Lacey, Roth, 2011, p. 384)III. Nutrition Assessment Evaluate Mr. Sims’ percent UBW and BMI.Percent Usual Body Weight (UBW)=84%-83%% UBW=(current weight/usual weight) x 100% UBW=(140lb/166lb) x 100=84.3%% UBW=(140lb/168lb) x 100=83.3%Percent Weight Change=16%-17%% change=100-%UBW% change=100-84=16%% change=100-83=17%Body Mass Index (BMI)=21NormalBMI=weight(kg)/ ht(meters2)Weight: 140lb x (1kg/2.2lb)=63.64kgHeight: 69in x (1cm/0.3937in)= 175.26cm/(1m/100cm)=1.75mBMI: 63.64kg/(1.75m2)=20.8Ideal (Hamwi Method): 5’9” male. 106+(6 x 9)=160 lbAdjusted: 140lb-160lb=-20 (.25)=-5+160lb=155 lbCalculate Mr. Sims’ energy requirements. Mifflin-St. Jeor=2445 kcalMen=10 x wt(kg) + 6.25 x ht(cm) – 5 x age(yrs) + 5Adjusted Weight: 155lb x (1kg/2.2lb)=70.45kgHeight: 69in x (1cm/0.3937in)= 175.26cm/(1m/100cm)=1.75m(10 x 70.5kg) + (6.25 x 175.2cm) – (5x 35 yrs) + 5 =1630kcal1.5 stress factor- 1630kcal x 1.5=2445 kcal (Nelms, Sucher, Lacey, Roth, 2011, p. 421). A 1.5 stress factor was chosen because this is his second hospitalization and he has extreme abdominal pain and diarrhea, therefore high stress.What would you estimate Mr. Sims’ protein requirements to be?When looking at lab results for Mr. Sims’ protein, albumin and prealbumin, they are all low. Lab ResultsChemistryRef. Range12/15Protein, total (g/dL)6-85.5Albumin (g/dL)3.5-53.2Prealbumin (mg/dL)16-3511Considering the above result, protein results may be as high as 1.5g to 1.75g protein/kg. (Nelms, Sucher, Lacey, Roth, 2011, p. 421). 1.5g x 63.64kg=94.5 and 1.75g x 63.64kg=111.4gI would suggest 94.5g-111.4g of protein for Mr. Sims at this time. I would also take into account the amount of lean body mass that Mr. Sims has currently.Identify any significant and/or abnormal laboratory measurements form both his hematology and his chemistry labs. Lab ResultsHematology/ChemistryRef. Range12/15Protein, total (g/dL)6-85.5 (low)Albumin (g/dL)3.5-53.2 (low)Prealbumin (mg/dL)16-3511 (low)C-reactive protein (mg/dL)<1.02.8 (high)HDL-C (mg/dL)>45 M38 (low)ASCANeg+ PT(sec)12.4-14.415 (high)Hemoglobin(Hgb, g/dL)14-17 M12.9 (low)Hematocrit (Hct, %)40-54 M38 (low)Transferrin (mg/dL)215-365 M180 (low)Ferritin (mg/mL)20-300 M16 (low)ZPP (umol/mol)30-8085 (high)Vitamin D 25 hydroxy (ng/mL)30-10022.7 (low)Free retinol (Vit. A; ug/dL)20-8017.2 (low)Ascorbic Acid0.2-2.0<0.1(low)Nutrition DiagnosisSelect two nutrition problems and complete the PES statement for each. (Academy of Nutrition and Dietetic, eNCPT, 2013)Unintended Weight Loss- NC-3.2Unintended weight loss related to decreased ability to consume adequate energy due to exacerbation of Crohn’s disease as evidence by 16%-17% weight loss in 6 month and loss of appetite due to severe abdominal pain and diarrhea as stated by client.Inadequate Protein Intake- NI-5.7.1Inadequate protein intake related to decreased ability to consume sufficient protein due to Crohn’s disease as evidence by total protein, albumin, and prealbumin levels and severe abdominal pain and diarrhea as stated by client.Nutrition InterventionThe 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?The nutrition support team would need to monitor the patient’s fluid and electrolyte levels, during parenteral nutrition for the 7-10 days. Due to high amounts of diarrhea, fluid and electrolytes are important to maintain. Bowel rest is very important to mention as well so the healing process can begin during the parenteral nutrition time. Depending on the effected area, some nutrient may not be able to be absorbed, this would be important to mention as well. Also, some IBD medications increase energy needs and exacerbate nutrient losses so making sure he has increased energy, especially protein, when enteral nutrition is introduced. (Nelms, Sucher, Lacey, Roth, 2011, p. 420)The members of the nutrition support team note his serum phosphorous and serum magnesium are at the low end of the normal range. Why might that be of concern?Magnesium is necessary for cellular metabolism and helps to maintain Calcium and Phosphorous homeostasis. For this reason, it would make sense that the phosphorous level is low. Phosphorous is a component of cellular energy, and an important part of DNA and RNA. During parenteral nutrition, these may decrease due to lack of absorption and energy intake (Nelms, Sucher, Lacey, Roth, 2011, p. 132). With parenteral nutrition, refeeding syndrome is at risk, especially with Phosphorous and magnesium levels are low.What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be prevented? Refeeding syndrome describes a common metabolic change that may occur when nutrient are be reintroduced after starvation. When in starvation mode, the body starts using fat as an energy source because glucose is not available. Ketones become present and metabolic rates decline. When carbohydrates are reintroduced, the body shift sback into using glucose, which requires large amount of phosphorous. At this time, magnesium, potassium, and thiamin requirement increase and as a result, phosphorous levels decrease. If severe, this can result in impaired cardiac and respiratory function, or death. Low magnesium levels can result in muscle tremors, or even paralysis. (Nelms, Sucher, Lacey, Roth, 2011, p. 93). Because Mr. Sims’ serum magnesium and serum phosphorous levels are on the lower end, he could be at risk. This can be prevented by making sure these two serum values are watched during parenteral nutrition.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. 50 cc/hr=1200 cc/day x (1L/1000 cc)=1.2 L/dayPro-1.2L x 42.5 g/L = 51 g amino acids/day51g x 4 kcal/g = 204 kcalCHO-1.2L x 200 g/L = 240 g dextrose/day240g x 3.4 kcal/g = 816 kcalLipid-1.2L x 30 g/L = 36 g lipid/day36g x 10 kcal/g = 360 kcalTotal cal- 1380 kcal85 cc/hr=2040 cc/day x (1L/1000 cc)=2.04 l/dayPro-2.04L x 42.5 g/L = 86.7 g amino acids/day86.7 x 4 kcal/g = 347 kcalCHO-2.04L x 200g/L = 408 g dextrose/day408g x 3.4 kcal/g = 1387 kcalLipid-2.04L x 30 g/L = 61.2 g lipid/day61.2g x 10 kcal/g = 612 kcalTotal cal-2346 kcalBased on the above calculations of Mr. Sims parenteral nutrition and my calculations using Mifflin-St. Jeor, I came up with his energy needs to be 2445 kcal and his protein requirement being 94.5g-111.4g of protein. Because of these calculations, I do not agree with the teams decision. It is 100 kcal and 7.8 g protein short of what I calculated as his needs.(Nelms, Sucher, Lacey, Roth, 2011, p. 95-97)For each of the PES statements you have written, establish and ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). Unintended weight loss-In regards to the patients weight loss of 16% of his usual weight in 6 month, the goal is to regain this weight. Making sure all macronutrient and micronutrients are included in the diet, paying close attention to protein. I would suggest increasing calories by 250 kcal when oral nutrition is started. When this can be accomplished, increase to 500 kcal more then required 2445 kcal/day. Education about reintroduction of whole food would be necessary so the gastrointestinal tract is not irritated. A food journal with nutrients and amount of food will be tracked.Inadequate protein intake-In regards to the patient’s inadequate protein intake, the goal would be to increase protein intake to at least 94.5g/day when oral nutrition is started. Gradually increase to the top of the protein range of 111.4g/day. Education on acceptable protein sources and food journal will be explained. Reevaluate protein, albumin, and prealbumin next visit.Nutiriton Monitoring and EvaluationIndirect calorimetry revealed the following information: MeasureMr. Sims’ dataOxygen consumption (mL/min)295CO2 production (mL/min)261RQ0.88RMR2022What does this information tell you about Mr. Sims? Indirect calorimetry is commonly used to measure the required energy needs of critically ill patients. Resting metabolic rate (RMR) is the energy requirements for 24 hours. RQ is found by dividing carbon dioxide production by oxygen consumption, in this case 261/295=0.88. This means that the patient is utilizing 60.8% carbohydrate and 39.2% fat to fuel his metabolism. In his current state, he is still utilizing a lot of fat for energy. (Medeiros, Wildman, 2015, p. 205-206)Would you make any changes to his prescribed nutrition support? What should be monitored to ensure adequacy of his nutrition support? Explain. I would suggest increasing protein to 100g per day, which would also increase calories to 300kcal of protein per day. The total calories would also be increased to 2400kcal, which is closer to my calculation of energy requirement.What should the nutrition support team monitor daily? What should be monitored weekly? Explain your answers. The nutrition support team would monitor serum electrolytes, magnesium, phosphorous, creatinine, and BUN 3-4 times a day. A baseline assessment of lipid tolerance is taken then monitored weekly if abnormal. Protein, albumin, prealbumin, bowel function, fluid and electrolyte levels, and input/output should also be monitored daily. Another concern is the preparation, placement, and feeding involved with the tube; an experience professional should do these tasks to avoid infection. (Nelms, Sucher, Lacey, Roth, 2011, p. 101)Mr. Sims’ serum glucose increased to 145 mg/dL. Why do you think this level is now abnormal? What should be done about it?The reason why glucose increased to 145 mg/dL is because of over feeding with parenteral feeding. The body was not familiar with using glucose for energy so when the glucose entered the body, it was pushed away and flooded the cells. The parenteral nutrition should be gradually delivered in order for the body to adjust back to using glucose as energy, instead of fat. 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. N2 balance=(dietary protein intake/6.25)-urine urea nitrogenN2 balance=(86.7g/6.25)-18.4g-4 = -8.5 gMr. Sims has a negative nitrogen balance, which means that more nitrogen is being excreted then being ingested. The reason why this number is of concern is because negative nitrogen is associated with malnutrition, inadequate protein consumption, and infection. It can be caused by traumatic injury, illness, or diarrhea. This may not be completely accurate because it is hard to record exact intake of nitrogen (Nelms, Sucher, Lacey, Roth, 2011, p. 54)On post-op day 10, Mr. Sims’ team notes he has had bowel sounds for the previous 48 hours and had his 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?When oral nutrition is introduced, a low residue, lactose free diet is suggested. Small, frequent meals has been seen to be best tolerated. If steatorrhea, fatty parts on feces, is present then fat should be reduced and MCT should be added to meet lipid needs. If there is a positive response to this diet, fiber and then lactose should be added as tolerated. Other foods may be added, restricting gas-producing foods, spicy or fried, caffeinated beverages, or other problem foods. (Nelms, Sucher, Lacey, Roth, 2011, p. 421)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. The primary nutrition concern for Mr. Sims is to increase energy intake in order to gain weight. To reach primary goal, maximizing energy and protein is important. His protein, albumin, and prealbumin levels are important in order to heal so increasing protein to about 100g/day is very important. Foods such as fruits, vegetable, vegetable oils, nuts, and fish, such as tuna and salmon, contain antioxidants. This is important to lower oxidative stress. Prebiotics could also be taken in order to enhance the gastrointestinal tracts natural flora and provide an anti-inflammatory marker. Physical rehabilitation would also be beneficial in order to gain muscle mass. When Mr. Sims returns, I can check his BMI and his protein, albumin, and prealbumin levels to monitor weight gain and protein intake. (Nelms, Sucher, Lacey, Roth, 2011, p. 422)ReferencesAbbvie. “How Humira works for moderate to severe Crohn’s disease.” (2013). Retrieved from of Nutrition and Dietetics. Nutrition Terminology Reference Manuel: Dietetics Language for Nutrition Care. 2014. Retrieved from website: , P., Shoeb, A. “Mesalamine for Inflammatory Bowel Disorder.” Harvard-MIT Division of Health Sciences and Technology. Retrieved from , Charles. “Corticosteroids.” (2014). The Chinese University of Hong Kong. Retrieved from corticosteroids.htmKaragozian, R., Burakoff, R. (2007). “The role of mesalamine in the treatment of ulcerative colitis.” Retrieved from /articles/PMC2376091/Medeiros, D. M., & Wildman, R. E. (2015). Advanced human nutrition (III ed.).Burlington, MA: Jones & Bartlett Learning.Micromedex. “Mesalamine (Oral Route).” (2014). Mayo Clinic. Retrieved from , Sucher, Lacey, Roth. (2012). Nutrition Therapy & Pathophysiology (II ed.) :Belmont, CA: Wadsworth. ................
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