Ana Maria Pelcastre

Case 11 Questions

I. Understanding the Disease and Pathophysiology

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

Inflammatory bowel disease involves chronic inflammation of the GI tract. It includes Crohns disease and ulcerative colitis. Both of them share some clinical characteristics including diarrhea, fever, weight loss, anemia, food intolerances, malnutrition, growth failure and extra-intestinal manifestations (arthritic, dermatologic and hepatic).Current medical literature says that the causes are not completely understood, but it involves the interaction of the GI immunologic system and genetic and environmental factors. Regarding the genetic factor, a number of possible gene mutations that affect risk and characteristic of the disease. The diversity in the genetic alterations among individuals may help explain differences in the onset, aggressiveness, complications, location and responsiveness to different therapies as seen in the clinical setting.

2. Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with Crohns.How could this happen? What are the similarities and differences between Crohns diseaseand ulcerative colitis?If Mr. Sims was initially diagnosed with UC and later diagnosed with Crohns is probably because both of the diseases are very similar. For example, as I previously mentioned, both Crohns disease and ulcerative colitis share clinical characteristics such as diarrhea, fever, weight loss, anemia, food intolerances, malnutrition, growth failure and extra intestinal manifestations (arthritic, dermatologic and hepatic). In Mr. Sims case he was mainly complaining of more frequent diarrhea, unbearable abdominal pain and high temperature. He also lost weight. Some of the differences between the two diseases are: Crohns disease: it involves any part of the GIT (mainly ileum and colon). Also there are segments of inflamed bowel and healthy segments. All layers of the mucosal are affected. Ulcerative Colitis: it happens mainly in the large intestine and rectum. The disease is continuous without healthy segments. This disease only affects the mucosa layer and also bloody diarrhea is more common with UC.

4. What did you find in Mr. Sims history and physical that is consistent with his diagnosis of Crohns ? Explain.First, he has lost weight since his last visit. This is probably due to the frequent bowel movements and poor nutrition absorption. He also has high fever, unbearable abdominal pain and frequent diarrhea for the last couple of months. These symptoms can be due to the inflammation due by possible ulcerations, fistulas, fibrosis, submucosal thickening, localized strictures, narrowed segments of bowel and partial or complete obstruction of the intestinal lumen (Krauses p.628) which are Crohns characteristics. Regarding his abdomen, his chart says he has distension, extreme tenderness with rebound and guarding and minimal bowel sounds. All these symptoms are also related to Crohns symptoms.

5. Crohns patients often have extraintestinal symptoms of the disease. What are someexamples of these symptoms? Is there evidence of these in his history and physical?Some of the extra-intestinal symptoms include arthritic, dermatologic, and hepatic.

Extra-intestinal symptoms include other organ systems affected in IBD. Some examples are bones and joints, skin, eyes, hepatobiliary system, lungs and kidneys. (http://www.ncbi.nlm.nih.gov).Perhaps some evidence of extra-intestinal symptoms in his chart is dry skin.

6. Mr. Sims has been treated previously with corticosteroids and mesalamine. His physicianhad planned to start Humira prior to this admission. Explain the mechanism for each ofthese medications in the treatment of Crohns.

corticosteroids, mesalamine and humira are anti-inflammatory agents, they inactivate one of the primary inflammatory cytokines. They also decrease the activity of the immune system thus reducing inflammation. One of the drawbacks is that the patient becomes susceptive to other infections.

7. Which laboratory values are consistent with an exacerbation of his Crohns disease?Identify and explain these values.Albumin: it is low which was caused by malnutrition, inflammation, and poor absorption of proteins.Total protein: is low due to poor absorptionPrealbumin: is low due to poor absorption of nutrients therefore the patient is malnourished. Transferrin: is low due to iron deficiency and poor protein digestion. Therefore the total iron binding capacity increases and the transferring saturation decreases. CRP is increased due to the inflammation condition.Osmolarity lab is low because of his dehydration due to frequent diarrhea.Hemogloblin and Ferritin are low due to iron deficiency.

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

He may be at risk for vitamin and mineral deficiencies because they cant be fully absorbed due to the crohns disease and inflammation.

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: it is defined as inadequate absorptive capacity resulting from reduced length or decreased functional bowel after resection. A loss of 70% to 75% of small bowel results in SBS, defined as 100 to 120 cm of small bowel without a colon or 50 cm of small bowel with the colon reminding. Another practical definition of SBS is the inability to maintain nutrition and hydration needs with normal fluid and food intake, regardless of bowel length (Krause p.637).Mr. Sim can be a candidate for SBS if his diet is not closely watched which may worsen his condition because if removed part of his small bowel (ileum) his absorption of vit B12 will decrease as well as other nutrients absorption and metabolism of fats. II. Understanding the Nutrition Therapy13. What are the potential nutritional consequences of Crohns disease?

Some of the potential nutritional consequences of Crohns disease include protein, and vitamins such as folate, B6, B12 and trace minerals such as magnesium and zinc mal absorption; Also fat vitamins due to lack of fat metabolism. If the patient doesnt receive supplements and the appropriate diet he may experience weight loss, muscle wasting, and dehydration and he may probably need enteral or parental nutrition feeding.

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 length of the small intestine in an adult is approximately 400cm long. As long as the terminal ileum remains intact, resection of large sections of jejunum is tolerated well. If more than 100cm of the terminal ileum is resected that major mal-absorption problems, severe diarrhea, and malnutrition occur.

15. What nutrients are normally digested and absorbed in the portion of the small intestineThat has been resected?The nutrients include calcium, folate, fat soluble vitamins, free fatty acids, vitamin B12, sodium and water.

III. Nutrition Assessment16. Evaluate Mr. Sims % UBW and BMI.

%UBW: 140#/168# x 100= 83% = mild degree of malnutrition.BMI: 64Kg/(1.75m)2= 21 kg/m2 Normal weight

According to his UBW he is currently at 83% which means he has a mild degree of malnutrition. His BMI says he is within normal range however, since he has lost weight the last couple of weeks this BMI is not accurate and if he continues in this condition he will advance to severe malnutrition.

17. Calculate Mr. Sims energy requirements.Using the Harris Benedict Formula his nutrient needs (REE) are as follow:Male: 66 + (13.7 x 64kg) + (5 x 175cm) (6.8 x 35)= 1514kcals Disease state: REE x Activity Factor x Injury Factor: 1514 x 1.3 x 1.5= 2952kcals Total Energy needs: 2952 or 2955kcals/day.

18. What would you estimate Mr. Sims protein requirements to be?Because of his current condition and surgery he will need more protein for healing and to restore his protein needs. If his protein intake is 2g per Kg he will need: 128 grams of proteins per day.

19. Identify any significant and/or abnormal laboratory measurements from both hishematology and his chemistry labs.Albumin is low because of the nutrient malabsorption including protein and also due to the inflammation.Total protein is low due to malabsorptionPrealbumin is low due to malnutritionTransferrin is low due to iron deficiency (this is also due to poor absorption)Total Iron binding capacity will be high because there is low iron concentration in the body.Transferring saturation is low for the same reason CRP is high because of the inflammation conditionThe osmolarity lab is low because of the dehydration (due to diarrhea).Hemoglobin and ferritin are low because of poor absorption.

IV. Nutrition Diagnosis20. Select two nutrition problems and complete the PES statement for each.First nutrition problem: poor protein levelsInvoluntary protein deficiency related to Crohns disease due to protein malabsorption as evidence by clinical lab values of Albumin, total protein, transferrin, hemoglobin, ferritin outside of normal ranges. Second nutrition problem: DehydrationInvoluntary dehydration related to Crohns disease due to inadequate fluid and nutrient absorption as evidence by low osmolarity lab values.

V. Nutrition Intervention21. The surgeon notes Mr. Sims probably will not resume eating by mouth for at least710 days. What information would the nutrition support team evaluate in deciding theroute for nutrition support?

The nutrition support will depend on how much intestinal resection took place, if his GI is functioning (motility, ileum resection) nutrient needs, if he is able to eat by mouth, if there is presence of fistula, obstruction and if he is currently having diarrhea or vomiting. They will also take into account fluid needs to prevent dehydration.

22. The members of the nutrition support team note his serum phosphorus and serummagnesium are at the low end of the normal range. Why might that be of concern?

If phosphorous and magnesium are low it confirms the patient has electrolyte imbalance due to malabsorption, dehydration due to diarrhea and inflammation. If these minerals are low then calcium and potassium may also be affected and become imbalanced as well. In the long run, a deficiency in these minerals will affect enzyme function including DNA synthesis. Energy metabolism, nerve conduction, nutrients transportation such as iron and calcium will be affected.Chronic deficiency of magnesium and phosphorus can also lead to magnesemia and phosphataemia. Therefore it will alter bone metabolism, cardio-respiratory, hematological and nervous systems.

23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it beprevented?Refeeding syndrome: a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or are severely malnourished. This condition may occur if the patient is aggressively fed npo or by nutrition support such as parental nutrition. This condition will cause electrolyte imbalance (loss of electrolytes), fluid retention and therefore it can be a life threatening condition. This patient can be at high risk of refeeding syndrome because he has two of the main risk factors which includes: malnutrition and weight loss. The condition can be prevented by beginning slowly parental nutrition and monitoring electrolyte levels, including serum glucose (particularly because of the dextrose content in the given formula).

24. Mr. Sims was placed on parenteral nutrition support immediately postoperatively, anda nutrition support consult was ordered. Initially, he was prescribed to receive 200 gdextrose/L, 42.5 g amino acids/L, and 30 g lipid/L. His parenteral nutrition was initiatedat 50 cc/hr with a goal rate of 85 cc/hr. Do you agree with the teams decision to initiateparenteral nutrition? Will this meet his estimated nutritional needs? Explain. Calculate:pro (g); CHO (g); lipid (g); and total kcal from his PN.Yes Mr. Sims needs PN because he underwent intestinal resection and he is already malnourished. Also his gut needs time to heal before the re-introduction of food into the digestive system. However, the prescription seems to be a little low for his kcals needs because he is only receiving one liter per day and the total kcals are 1150 (CHO: 680, PRO:170 and FAT 300) when in reality he needs 2955 Kcals. Actual Energy requirements: 2955 Kcals Protein Requirements: 2grams x 64kg: 128g/day Gms of dextrose, kcals provided and mg/kg/min1000mL= 200gms dextrose200gms Dex x 3.4kcals/g= 680kcals 200mgs dex / 35 yr old/ 1.44= 3.96gms/kg/min Gms of protein, kcals and gm/kg1000mL= 42.5gms AAs 42.5gms x 4=170kcals pro42.5gms/ 35kg= 1.2 gm pro/kg Lipids 30gms of fat x 10= 300kcals Pro: 170 kcals / 1150 kcals= 15% Cho: 680 kcals / 1150 kcals= 59% Fats: 300 Kcals / 1150 kcals= 26%Totals kcals: 1150 of TPNVI. Nutrition Monitoring and Evaluation

26. Indirect calorimetry revealed the following information:Measure Mr. Sims dataOxygen consumption (mL/min) 295CO2 production (mL/min) 261RQ 0.88RMR 2022What does this information tell you about Mr. Sims?Mr. Sim has a high consumption of oxygen because the normal amount is 250mL/min. This is due to his high metabolic induced by Crohns Disease. The CO2 production is also high due to his high metabolic condition (Normal CO2 production is 200m/L. Also his respiratory Quotient falls within normal range which is 0.7-1. Finally his RMR says its 2022 which is higher compared to his recommendations. 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 thisinformation? Should you be concerned? Are there problems with the accuracy of nitrogenbalance studies? Explain.

42.5 pro/6.25 18.4 UUN + 3 Factor= -8.6His nitrogen balance is negative which means he is not getting enough protein intake in his diet. The Nitrogen balance should be a positive number and therefore he needs to increase his protein intake in order to repair and heal his bowel resection. Yes there are problems because his Nitrogen balances are negative which can lead to further complications of his conditions (bowel resection) by not healing properly and wasting muscle and other tissue proteins.

31. On post-op day 10, Mr. Sims team notes he has had bowel sounds for the previous48 hours and had his first bowel movement. The nutrition support team recommendsconsideration of an oral diet. What should Mr. Sims be allowed to try first? What wouldyou monitor for tolerance? If successful, when can the parenteral nutrition be weaned?

The first oral diet that Mr. Sims should be allowed to try is clear liquids. The diet would be small frequent meals to see the stomachs level of tolerance. The nutrition department would look for symptoms such as nausea, vomiting, diarrhea etc. If successful in his oral intake, the parental nutrition can be wean after 2 or more weeks.

32. What would be the primary nutrition concerns as Mr. Sims prepares for rehabilitationafter his discharge? Be sure to address his need for supplementation of any vitamins andminerals. Identify two nutritional outcomes with specific measures for evaluation.One of the primary nutrition concerns includes hyper-metabolism, poor protein intake (negative nitrogen levels) hyperglycemia and insulin resistance. Regarding vitamins and other nutrient needs, he most likely will need vitamin B12, fat soluble vitamins and electrolytes. Two nutritional outcomes with specific measures for evaluation is protein status (healing) and dehydration which can be determined by weight loss or gain.