INFLAMMATORY BOWEL

DISEASE

(IBD)

Kendra Manwill

What is it?

Lifelong

Chronic

50-80% require surgery (Crohn’s)

Alternating remission and acute flare-ups

Common Diseases:

Ulcerative Colitis

Crohn’s Disease

Microscopic Colitis

Crohn’s vs. UC

Crohn’s (left): Small and large intestine in segments

Ulcerative colitis (right): Starts in rectum, progresses

Normal Organ Function

Abnormal GI tract

Normal Intestine vs. IBD

Pathophysiology

Not completely understood

Interaction of GI immune system and genetic and environment

factors

Etiology

No one is positive, but it could be:

Altered immune system (genetic)

Inflammation triggered in bowel by bacterial antigens

Immune system doesn’t “down-regulate” after fighting

the antigens

A type of auto-immune process is no in effect

Signs and Symptoms

Complications are more common in Crohn’s disease

Abscesses

Anal fissues

Fistula

Malnutrition

Extraintestinal manifestations:

Osteoporosis

Kidney stones

S/S- Malnutrition

Main Mechanism Effect

Decreased food intake Anorexia

Abdominal pain, n/v

Restricted diets

Drugs

Nutrients malabsorption Reduced absorptive surface due to

inflammation, resection, bypass, fistula

Increased intestinal loss Exudative enteropathy (pro. Loss)

Occult/overt blood loss (Fe deficiency)

Steatorrhea

Hypermetabolic state Alterations of resting nrg expenditure

Drugs interaction Anorexia, nausea, test alteration,

proteolysis, interaction w/ nutrients

Nutritional status and nutritional therapy in IBD, World J Gastroenterol

Diagnosis

Initial diagnosis

Colonoscopy

Biopsy

Fecal calprotectin

Lab tests

CRP

White blood count

Stool assessment

Diagnosis- Truelove and Witt

Diagnosis- Crohn’s Disease Activity

Index

Medical Interventions

Aminosalicylates

Immunomodulators

Antibiotics

Biological modifiers

Corticosteroids

Surgical invervention

MNT

Nutrition assessment

Sample nutrition diagnosis

Typical MNT interventions (including principles of

the diet and general education needs)

Desired outcomes

Monitoring tools

Are there evidence based guidelines? If so,

how/where do we access them?

PES

Inadequate oral intake related to discomfort after eating as

evidenced by 1/3 normal intake for past 5 days

Inadequate mineral intake (iron) related to increased needs

resulting form blood loss with diarrhea as evidenced by

estimated intake of approximately 50% of requirements

Interventions

Meals and snacks

Vit/Min supplements

Initiate EN

Nutrition education

Nutrition counseling

Coordination of care

Exacerbation vs remission

Evidence Based Guidelines

IBD Introduction Crohn’s

Can affect any portion of GI tract from mouth to anus, but commonly ileum and colon

Often characterized by skipping areas

Can damage all layers of GI mucosa, and even damage beyond

Fistulas

Symptoms include o Abdominal pain o Diarrhea o Fever o Extraintestinal manifestations

UC

Generally affects lower bowel- colon and rectum

Continuous and circumferential w/ no areas of normal mucosa

Inflammation primarily confined to mucosal surface

Symptoms include o Abdominal pain/cramping o Bloody diarrhea o N/V o Fever

Diff than IBS:

IBS is a functional GI disorder, there is a disturbance in bowel function and is a syndrome (group of symptoms).

Chronic abdominal pain, discomfort, diarrhea, constipation.

Does not cause inflammation Normal organ function Pathophysiology

Not completely understood

Involves interaction of GI immunologic system and genetic and environmental factors

Diversity in genetic alteration = diff in disease development

Disease results from an inappropriate inflammatory response and an inability to suppress the inflammatory response (Krause)

In genetically susceptible individuals, environmental triggers cause an abnormal inflammatory autoimmune response within the GI tract. The excessive inflammation damages the mucosa of the GI tract, resulting in ulcerative colitis or Crohn’s disease (NCM)

Etiology

Identifiable factors include (NCM): o Genetics: seen often in Jewish populations, more than 30 genes are implicated in

various presentations of Crohn’s disease

o Environmental factors: antibiotics, NSAIDS, infectious agents, stress, diet, smoking o Possibly: oral contraceptive use, GI microbiome for presence of leukocytes

Best guess: Inherited altered immune system to begin with. Inflammation is the bowel is triggered by bacterial antigens, and the immune system is “up-regulated” to fight. The problem is that the immune system doesn’t “down-regulate”. A type of auto-immune process is initiated (Krause)

Emotional factors do not cause IBD, but they can aggravate symptoms.

Signs/Symptoms Extraintestinal manifestations

Musculoskeletal: osteopenia and osteoporosis, peripheral arthritis (joint problems) and ankylosing spondylitis

Dermatological

Ocular symptoms

Hepatobiliary complications

Kidney stones

Vascular: thromboembolic events Complications of Crohn’s:

Abscesses

Anal fissures

Bowel obstruction

Bowel perforation

Bowel resection (can result in SBS)

Colon cancer

Fistulas

Hyperoxaluria

Malnutrition

Steatorrhea

Strictures

Ulcers Other:

Intestinal rupture

Toxic megacolon Complications are more common to Crohn’s Diagnosis Criteria for measuring/assessing severity of disease

Truelove and Witt’s criteria for ulcerative colitis

Crohn’s disease activity index

American gastroenterological association practice guidelines diagnostic criteria for UC

Small bowel follow through Tests for initial diagnosis

Colonoscopy

Lower GI series with barium enema

Endoscopy

Antisacchromyces antibodies

Antineutrophil cytoplasmic antibodies

Biopsy

Fecal calprotectin- simple and noninvasive method for assessing excretion of macrophages into the gut lumen. Can be used to evaluate the response to treatment, to screen asymptomatic patients, and to predict IBD relapses

Lab tests for diagnosis, exacerbation, and response to therapy

CRP

Erythrocyte sedimentation rate

Lactoferrin

White blood count and differential

Stool assessment

X-rays: show narrowing of intestine or an intestinal blockage

CT scans: used to R/O or detect abcess fistulas and intestinal blockages

CT enterography

MR enterography

MRI of pelvis Medical Intervention Treatments include (NCM):

Aminosalicylates (reduce inflammation locally in GI)

Immunomodulators (suppress immune system to prevent inflammation)

Antibiotics (reduce intestinal bacteria and treat infections)

Biological modifiers (help reduce inflammation in colon through targeting specific TNF proteins involved in the inflammatory response)

Corticosteroids (rapidly produce immunosuppression)

Surgical intervention is required in both UC and Crohn’s disease in more than 60% of patients to resect segments of bowel that have significant inflammation

MNT Nutrition assessment

Food/nutrition-related history o Food avoidance/food aversions and misinformation/confusion about food o Inadequate nutritional intake due to symptoms o ID foods that might exacerbate/trigger events or symptoms o Meal-time behavior o Avoidance behavior o Food and nutrition knowledge skill o Appropriate intake of macro/micro nutrients

Antropometric measurements o Use actual height, current weight, determine weight change history, and BMI

Biochemical data, medical tests, and procedures

o Biochemical: albumin, prealbumin, hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, red cell distribution width, total iron-binding capacity, ferritin, transferring, vit B-12, folate

o Lab tests: CRP, erythrocyte sedimentation rate, lactoferrin (stool specimen), antisacchromyces antibodies, antineutrophil cytoplasmic antibodies

Nutrition-focused physical findings

Client history (including all previous surgeries and medications) Sample nutrition diagnosis

Inadequate oral intake related to discomfort after eating as evidenced by 1/3 normal intake for past 5 days

Inadequate mineral intake (iron) related to increased needs resulting from blood loss with diarrhea as evidenced by estimated intake approximately 50% of requirements

Other diagnoses may be: malnutrition, inadequate fluid intake, underweight, excessive bioactive substance intake- caffeine, disordered eating pattern, altered GI function, etc.

Typical MNT interventions (including principles of the diet and general education needs)

Meals and snacks o Composition of meals/snacks- fiber modified diet o Specific foods/beverages or groups

Vit/Min supplements o Mv/mineral o Mineral: calcium

Initiate EN o (article)- EN in adults is effective in inducing clinical remission of IBD, but corticosteroids

are more effective o Exclusive EN is an established primary therapy for pediatric CD

Nutrition education o Purpose of nutrition education o Priority modifications o Recommended modifications

Nutrition counseling o Motivational interviewing o Goal setting o Problem solving o Social support o Stress mgmt.

Coordination of care o Team meeting o Collaboration with other providers o Referral to community agency or program

Exacerbation: low fatk, low fiber, high protein, high kcal, small frequent meals, vit/min supplement

Remission: maximize energy and pro intake for maintenance of weight and replenishment of nutrient stores

Desired outcomes

Patient will identify symptoms that interfere with adequate oral intake

Patient will make the necessary intervention to correct or compensate for malabsorption secondary to loss of bowel function

Patient will have nutrition therapy that will meet increased nutritional requirements, correct nutritional deficiencies, and compensate for increased nutritional losses

Patient will understand and make appropriate interventions to address potential drug-nutrient interactions

Monitoring tools

Monitor intake of: food, fluid, bioactive substances, alcohol, caffeine, macronutrient, pro, fiber, micronutrient

Meal time behavior

Avoidance behavior

Restrictive eating and cause

Adherence

Weight and weight change

Lab tests Are there evidence based guidelines? If so, how/where do we access them?

NCM

MyPyramid

National Institute of Diabetes and Digestive and Kidney Disease

Crohn’s and Colitis Foundation of America

United Ostomy Association