Hematology

Agranulocytosis – decrease in granulocytes, increased vulnerability to infection

Aleukemic Leukemia – decreased WBCs

Anisocytosis – RBC’s are unequal size (anemia, other blood conditions)

Anoxemia – subnormal oxygen of the arterial blood

Aplasia – failure of an organ or tissue

Basket Cell – GABAergic interneurons of the brain (in cerebellum, hippocampus)

Blood Dyscrasia – abnormal material in the blood (WBC count over 1,000,000)

Chemotaxis – movement of a motile cell or organism to increase/decrease concentration of a particular substance

Coagulation Time – time required by shed blood to clot

Cocatalyst – pair of cooperative catalysts

Complete Blood Count – RBCs and WBCs (overall health and can deices anemia, leukemia, and infection)

Dyscrasia – abnormal or disordered state of the body or of a bodily fluid

Erythremia – increase in blood volume and RBCs, bone marrow hyperplasia, enlarged spleen, redness of the skin

Erythrogenic – causing inflammation/redness of the skin (bacterial toxin)

Erythropenia – decreased erythrocytes in the blood

Extrinsic – not part of essential nature of someone or something (from outside)

Fragility Test – measures resistance of RBCs to hemolysis

Hematology – study of blood

Hematoma – solid swelling of clotted blood within the tissues

Hemoglobinuria – excretion of free hemoglobin in the urine

Hemolysis – rupture or destruction of RBCs

Hemoptysis – coughing up blood

Intravascular – in the vessels (blood vessels of vascular system)

Isotonic – taking place with normal contraction (same osmotic pressure)

Jaundice – obstruction of the bile duct, liver disease, excessive breakdown of RBCS

Karyolysis – dissolution of a cell nucleus, especially during mitosis

Macrocyte – “large cell” – type of anemia with large RBCs

Mean Corpuscular Hemoglobin (MCH) – mean hemoglobin / RBCs

Mean Corpuscular Volume (MCV) – volume of RBCs (Hct / RBC)

Megaloblast – Large RBC (anemia) associated with folic acid / B12 deficiency

Normoblast – immature RBC containing hemoglobin and a pyknotic nucleus in the bone marrow (anemia)

Pernicious Anemia – RBC deficiency related to B12

Poikilocytosis – presence of abnormally shaped RBCs called poikilocytes

Purpura – rash of purple spots (internal bleeding)

Sedimentation Rate – test used to detect and monitor inflammation in the body(RBC rate)

Sickle Cell Anemia – severe hereditary form of anemia – distorted RBCs in crescent shape at low oxygen levels

Target Cell – abnormal RBC that appears as a dark ring around a dark central spot (seen in some forms of anemia)

Xanthochromia – yellow discoloration indicating the presence of bilirubin in the CSF (cerebrospinal fluid)

Nutrigenomics

 

Allele – one of two forms of a gene (one mother and one father)

Angiogenesis – the development of new blood vessels

Apoptosis – programmed cell death (normal; without harmful substance release)

Bioactive Food Component – chemical that interacts with molecular components of an organism

Chromatin – a complex of proteins (primarily histones) and DNA that make up the chromosome; can alter between forms of euchromatin or heterochromatin

Codon – 3 nucleotides together that form a genetic code in DNA/RNA

Deoxyribonucleic Acid (DNA) – carries genetic information, main constituent of chromosomes, self-replicating

Down-Regulation – decrease in the quantity of a cellular component (RNA/protein) in response to external variable

Epigenesis – theory that embryo develops progressively from an undifferentiated egg

Gene – unit of heredity used to transfer from parent to offspring

Genome – the complete set of genes / genetic material in an organism

Genotype – an individual’s genetic identity based on the specific set of alleles (maternal and paternal) – not outwardly visible!

Haplotypes – “haploid” + “genotype” meaning linked polymorphism; ex. SNP’s, simple tandem repeats, insertions/deletions in the same region

Histones – group of basic proteins found in chromatin

Ligand – a molecule that binds to a specific site on a protein (usually a receptor) and is either an activator or inhibitor

Metabolome – the sum total of all metabolites in a cell/tissue/organ/organism

Methylation – methyl group is added to the cytosine or adenine DNA nucleotides

Methylcytosine – a methylated form of the DNA base cytosine

Methyltransferase – enzymes that catalyze the transfer of a metyl group to DNA

Microarray – a grid of DNA segments of known sequence that is used to test and map DNA fragments, antibodies, or proteins

Nanotechnology – design / manufacture of artificial nucleic acid structures

Nuclear Receptor – ligand-induced transcription factors (these ligands are found in various chemical classes such as steroid hormones, dietary lipids, etc.)

Nucleotide – form the basic structure of nucleic acids (i.e. DNA); nucleoside linked to a phosphate group

Nutritional preemption – DNA and amino acid to form food development, related to drug response and food response in foods to prevent disease

Phenotype – an observable characteristic or trait (ht, wt, hair/eye color, disease) that is directed by the genotype

Polymorphism – differences between otherwise identical macromolecules (via changes in DNA), similar to single nucleotide polymorphism

Proteome – the total collection of proteins in a cell or cellular substructure

Ribonucleic Acid (RNA) – a nucleic acid present in all living cells; messenger to carry instructions to DNA for controlling the synthesis of protein

Ribosome – a minute particle consisting of RNA and associated proteins, found in large numbers in the cytoplasm of living cells; they bind messenger RNA and transfer RNA to synthesize polypeptides and proteins

RNA Interference – process in which RNA molecules inhibit gene expression (by destroying mRNA molecules)

S-adenosylmethionine (SAM) – involved in methyl group transfers; naturally occurring in the body, but also a medication

Single Nucleotide Polymorphisms (SNPs) – common genetic variant consisting of a single nucleotide  pair difference  between the DNA of subject and a reference ind.

Transcription – 1^st step in gene expression DNA => RNA by RNA polymerase

Transcriptome – the sum total of all the messenger RNA molecules expressed from the genes of an organism

Transcriptomics – the study of transcriptomes and their functions

Translation – mRNA => a specific amino acid chain, or polypeptide; ribosomes create proteins

Up-regulation – increasing the response to a stimulus (cellular response to a molecular stimulus due to an increase in number of receptors on the cell surface)

Immunology

Adhesion – abnormal union of membranous surfaces due to inflammation or injury

Antiseptic – prevents the growth of disease causing microorganisms

Apoptosis – the death of cells that occurs as a normal and controlled part of an organism’s growth or development

Betadine – topical anti-infective to destroy microbes / less likely to sensitive or sting the affected area than iodine (soluble in water and does not stain clothes)

Clinical Manifestation – an indication of the existence, reality, or presence of something such as an illness (objective: by physician, subjective: by patient)

Contracture – a condition of shortening and hardening of muscles, tendons, or other tissues; resulting in deformity and rigid joints

Dehiscence – complication of surgical wound – breaking open of surgical incision when granulation tissue fails to form

Disinfectants – chemical liquid that destroys bacteria

Endotoxins – is present inside a bacterial cell and is released when cell disintegrates (in botulism, this causes the symptoms of the disease)

Epidemiology – the branch of medicine that deals with incidence, distribution, and possible causes of disease and other health factors

Etiology – branch of medicine that investigates the cause or set of causes of a disease or condition

Exotoxins – toxin released by a bacterial cell into its surroundings

Exudate – a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation

Hyperemia – an excess of blood in the vessels supplying an organ or other part of the body

Morbidity – incidence of disease

Mortality – death due to a disease (rate is divided by the total population)

Necrosis – death of most or all of the cells in an organ or tissue from disease/injury/blood supply

Outcome – the way things turn out / result

Pathogenesis – the manner of development of disease

Pathophysiology – the disordered physiological processes (function) associated with disease/injury

Prognosis – likely course of a disease or ailment

Signs – objective (ex. nose bleed – can be seen)

Sterilization – removal of all microorganisms/pathogens from an object or surface by treating it with chemicals or subjecting it to heat/radiation

Symptoms – subjective evidence of disease (back pain, anxiety, fatigue – patient)

Vasomotor – causing or relating to the constriction or dilation of blood vessels (or change in diameter), related to region in the medulla of the brain (vasomotor center) that regulates blood pressure

Water, Electrolytes, and Acid-Base Balance

Acid-base balance – The state of equilibrium between proton donors and proton acceptors in the buffering system of the blood (arterial blood: 7.4)

Acidemia – acidity of the blood

Acidosis – acidity of the body fluids or tissues

Alkalemia – a condition reducing hydrogen ion concentration of arterial blood plasma

Alkalosis – serum pH is higher than normal (7.45 of higher)

Anion Gap – the different between measured cations (Na+ and K+) and anions (Cl- and HClO3-)

Buffer – resists the change of pH (via an acid or alkali to neutralize a weak acid or salt)

Contraction Alkalosis – increase in blood pH that occurs as a result of fluid losses (esp. from vomiting)

Dehydration – the use or loss of more water than what is being taken in

Edema – excess fluid buildup in the cavities or tissues of the body

Electrolytes – an ionized or ionizable constituent of a living cell, blood, or other organic matter

Extracellular Fluid – (ECF or ECFV) is all body fluid outside of the cells

Extracellular Water – the sum of interstitial fluid and blood plasma

Insensible Water Loss – loss through evaporation from the skin and respiration

Intercellular (interstitial) Water – water found inside the cell

Intracellular Water (ICW)

Metabolic Acidosis – the body is producing too much acid OR the kidneys are not removing enough

Metabolic Alkalosis – pH tissue is above normal (7.35-7.45) signifying there is too much base or alkali in the body

Metabolic Water – the water created inside a living organism through their metabolism

Oncotic Pressure – (colloid osmotic pressure) pressure exerted by proteins (alb) in the blood vessel’s plasma that PULLS water into the circulatory system

Osmolality – concentration of a solution expressed as total number of solute particles per kg

Osmolarity – concentration of a solution – total number of solute per L

Osmotic Pressure – pressure needed against pure solvent to prevent it from passing into a solution through osmosis (expresses the concentration of the solution)

Respiratory Acidosis – carbon dioxide levels are too high and blood becomes acidic

Respiratory Alkalosis – carbon dioxide levels drop too low (blood pH rises and becomes alkaline)

Sensible Water Loss – sweating and vomiting

Third Space Fluid – where fluid usually does not collect in large amounts (i.e. peritoneal cavity and pleural cavity / loss is via tissue edema and evaporation

Water Intoxication – potentially fatal when brain functions result in normal balance of electrolytes in the body are beyond safe limits

Medical Nutrition Therapy Nutrient: Vitamin K

1. What is the nutrient?

Vitamin K is a fat-soluble vitamin that is required for blood coagulation and also has a crucial role in the calcium absorption into bones and tissues. There are three different types of Vitamin K. Vitamin K₁ is synthesized in plants and is considered the “plant” form of Vitamin K. Vitamin K₂ occurs when Vitamin K₁ is absorbed in animals and is considered the “animal” form of Vitamin K. There are also three synthetic forms of vitamin K not typically seen in human consumption but are used in others ways. For example, Vitamin K₃ is used in the production of pet food and Vitamin K₅ is used to inhibit fungal growth.

1. What is the RDA/DRI for the nutrient?

The RDA increases across the lifespan, and varies based on gender as well. Infants aged 0-6 months have an RDA of 2.0 μg/d and this increases to 2.5 μg/d between the ages of 7-12 months. Children 1-3 years of age have an RDA of 30 μg/d which increases to 55 μg/d from age 4-8. From there, RDA is gender based:

Males	RDA (μg/d)	Females	RDA (μg/d)
9−13 years	60	9−13 years	60
14−18 years	75	14−18 years	75
19+ years	120	19+ years	90

There is an exception to these RDAs in women pregnant or lactating. For women aged 18 and younger who are pregnant of lactating, the RDA is 75 μg/d. For women over the age of 19, the RDA is 90 μg/d.

1. How is the nutrient metabolized?

Vitamin K follows a well-established pathway along with most other dietary lipids and fat-soluble vitamins. This pathways consists of bile salts and pancreatic-dependent solubilization, the uptake of mixed micelles into the entereocytes, the packaging of dietary lipids, and their exocytosis into the lymphatic system. From here it is used to carry out the bodily processes mentioned earlier.

1. What are food sources of the nutrient?

Dietary sources of Vitamin K_1, or plant sources, include green vegetables (collards, spinach, salad greens, and broccoli), brussel sprouts, cabbage, and asparagus. Vitamin K₂ is found in fermented or aged cheese (gouda and brie), butter, egg yolks, and certain meats. Meat sources high in Vitamin K include goose liver, chicken liver and breast, and meat franks.

1. What disease states alter the nutrients metabolism?

Taking broad-spectrum antibiotics can reduce Vitamin K production in the gut and result in Vitamin K deficiency. The elderly also are at risk as the gut produces less Vitamin K with age. Those with chronic kidney disease or other kidney damage (alcoholics), cystic fibrosis, or inflammatory bowel disease are also at increased risk for deficiency. Secondary Vitamin K deficiency can occur in bulimics, those on stringent diets, and those taking anticoagulants.

1. What are the tests or procedures to assess the nutrient level in the body?

Vitamin K status is assessed by prothrombin time (PT) test which measures the time required for the blood to clot. Blood samples are mixed with citric acid and but in a firbometer – a delayed clot formation is the mark of a deficiency.

1.  What is the drug –nutrient interactions?

The most important thing to note when looking at Vitamin K is the ability of the blood to clot. Blood thinning drugs like Warfarin slow the blood clotting process while vitamin K can helps the blood thicken and speeds the clotting process. Changes in Vitamin K intake can impact those who are on blood thinners, and decrease the overall effect.

1.  How is the nutrient measured?

Vitamin K is measured in mcg.

1. What is the Upper Tolerable Limits?

There is no known toxicity level, and no tolerable upper intake level has been set. The only exception is to those taking Warfarin as there is an increased risk of the drug not working when vitamin K consumption is inconsistent. In order for physicians to prescribe the accurate amount of blood thinner, Vitamin K consumption must remain consistent.

10. What are the physical signs of deficiency?

Average diets are not usually lacking in Vitamin K and is rare in adults. Newborn infants are at risk and in most countries, Vitamin K shots are given at birth to prevent this. Deficiency usually results I coagulopathy, a bleeding disorder. Symptoms include anemia, bruising, bleeding of the gums or nose, and heavy menstrual bleeding in women.

11. What are physical signs of toxicity?

Toxicity has not been noticed in vitamin K, although allergic reaction to supplementation is possible.

Sample Menu Items

Breakfast

• Decaffeinated coffee with cream and sugar
• Cup of juice, such as no-pulp orange juice, apple juice, or cranberry juice
• Cream of wheat
• Scrambled eggs
• Waffles, French toast, or pancakes
• White-bread toast with margarine and grape jelly (no seeds)
• Milk (if tolerable)

Lunch

• Baked chicken, white rice, canned carrots, or green beans
• Salad with baked chicken, American cheese, smooth salad dressing, white dinner roll
• Baked potato (no skin) with sour cream and butter or margarine
• Hamburger with white seedless bun, ketchup, and mayonnaise — lettuce if it doesn’t worsen your symptoms
• Cheeses (if tolerable)

Dinner

• Tender roast beef, white rice, cooked carrots or spinach, white dinner roll with margarine or butter
• Pasta with butter or olive oil, French bread, fruit cocktail
• Baked chicken, white rice or baked potato without skin, and cooked green beans
• Broiled fish, white rice, and canned green beans
• Cheese (if tolerable)

Food Guidelines

Remember: Eat small meals or snack every 3 to 4 hours. Stay hydrated. Drink small amounts of water throughout the day.

Foods to Avoid

• Seeds, nuts, or coconut, including those found in bread, cereal, desserts, and candy
• Whole-grain products, including whole-grain breads, cereals, crackers, pasta, rice, and kasha
• Raw or dried fruits, such as prunes, berries, raisins, figs, and pineapple
• Most raw vegetables
• Certain cooked vegetables, including peas, broccoli, winter squash, Brussels sprouts, cabbage, corn (and corn bread), onions, cauliflower, potatoes with skin, and baked beans
• Beans, lentils, or tofu
• Tough meats with gristle and smoked or cured deli meats
• Cheese with seeds, nuts, or fruit
• Crunchy peanut butter, jam, marmalade, or preserves
• Pickles, olives, relish, sauerkraut, and horseradish
• Popcorn
• Fruit juices with pulp or seeds, prune juice, or pear nectar

Medical Nutrition Therapy: Low Residue Diet

Purpose

1. Nutrition Indicators: Ulcerative Colitis (UC) and Crohn’s Disease (CD).
2. Criteria to Assign the Diet: Diets are altered from the norm and assigned based on each patient’s individual sensitivities, as some are more sensitive than others to different foods with high and medium residuals. The most effective way to decide what foods are “trigger foods” in this disease are for patients to keep a food journal to monitor intake and symptoms during and after meals. This can determine the amount of residue, fiber, and diary allowed in the diet.
3. Rationale for Diet: Some evidence suggests that a long-term low-residue diet can decrease the number of inflammatory outbreaks of those with Ulcerative Colitis or Crohn’s Disease, and perhaps even slow the effect and progression of the disease (Nelms). During outbreaks, it has been known to decrease symptoms while after outbreaks it possibly prolongs future outbreaks. The decrease in roughage moving throughout the intestine allows the gut heal.

Population

2. Overview: Ulcerative colitis and Crohn’s disease are inflammatory bowel diseases that are characterized by chronic inflammation of the digestive tract. The epidemiology as well as signs and symptoms have some overlap and therefore mistaking the diagnosis is plausible. Both diseases occur equally in both sexes and both have a high level of occurrence in North America, Northern Europe, and the UK. The peak onset of both diseases are also similar as UC typically begins between the ages of 20 and 30 years while Crohn’s disease most often begins in the teens and twenties (Nelms).
3. Disease Process: Ulcerative colitis is specifically inflammation of the colon, while Crohn’s disease encompasses the inflammation of any part and every part of the digestive tract but most commonly the ileum and colon. Ulcerative colitis is very specific in that it includes a constant inflammation of only the inner most lining of only the colon. Crohn’s disease is broader as it includes inflamed sections of the intestines at any layer of the bowel walls, and perfectly healthy parts can be present in between the inflamed areas (Nelms). Signs and symptoms of both UC and Crohn’s include diarrhea, abdominal pain, weight loss, fever, and blood or mucus in the stool. The way in which these diseases are diagnosed are very similar as well – including abdominal ultrasound, MRI, CT, antiglycan antibodies (ASCA) levels, and ferritin/transferrin levels (Best).
4. Biochemical and Nutrient Needs: Those with UC or Crohn’s disease are at an increased risk for malabsorption depending on how much of the bowel has been affected. The specific nutrients that need to be taken into account are also based upon which section(s) of the bowel has been altered. For example, damage to the jejunum may results in a decreased ability to absorb carbohydrates, protein, sodium, vitamin A, vitamin D, water soluble vitamins, and water while damage to the ileum may impact the body’s ability to reabsorb bile salts that must be recycled in order to aid in the breakdown of food (Nelms). Based on the area effected, anthropometrics, and chemical labs, one can assess the specific nutrient deficiencies and suggest supplements as necessary.

General Guidelines

3. Nutrition Rx: Medications often include corticosteroids which keep the immune system from fighting infection, as the symptoms of UC and Crohn’s Disease are caused by the immune system’s attack on the intestinal tract. This allows the inflammation to go down and normal function to continue. Mesalamine is also commonly prescribed as it relieves symptoms and inflammation, and has also been proven to be 45-55% effective in the sending UC and CD into remission. In severe cases, the gut is too damaged to continue use and it is therefore appropriate to remove and resect portions of the gut. This has been proven as an effective treatment (Mahan). One consequence of this, however, is the chance of developing Short Bowel Syndrome (SBS) in which the portion of gut removed is too large and malnutrition related to malabsorption occurs (Nelms).
4. Adequacy of Nutrition Rx: In mild to moderate cases, a low-fiber diet may be initiated in order to reduce the risk of further damage to the intestinal tract. In more severe cases, bowel resection and a modified consistency diet or even temporary TPN may be administered (Nelms). Corticosteroid use can also effect specific nutrient intake: calcium, vitamin D, magnesium, and Vitamin K. If used to long term, even more deficiencies become possible such as vitamin C, vitamin B12, folic acid, zinc, and selenium (Vavricka).
5. Goals: Both UC and Crohn’s disease are rarely cured, can sometimes require surgery, and include lifelong intermittent and repeated exacerbations (Nelms). Therefore, the goal is to decrease the strain on the gut via a low fiber, low residue, and/or low dairy diet especially during periods of exacerbations. Modifications in the diet can also prolong exacerbations if trigger foods are identified.
6. Does it Meet DRI: Low residue, low fiber, and/or low dairy diets have the ability to meet the DRIs in all categories with proper nutrition education. Based on weight fluctuations and lab values, supplements may be needed if the gut is not absorbing enough nutrients.

Education Material

4. Nutrition Therapy: “Low-residue” is actually starting to become outdated and is the term “Low-fiber” is not the preferred term of the Academy of Nutrition and Dietetics. The only reputable difference between the two terms is the elimination of milk in a low-residue diet, however milk has been found to be a medium residue food, and therefore it is simpler to identify patients as being on a low-fiber regimen and then specify whether the diet is lactose-free or if lactose is tolerated as in some cases, lactose-intolerances or lactose sensitivities coexists with Ulcerative Colitis and Crohn’s Disease (Cunningham).
5. Ideas for Compliance: Keeping a food journal is highly encouraged to help patients monitor foods that are causing symptoms. Nutrition education should be implemented on reading labels, altering menus, and tracking symptoms. Also, education on increasing caloric intake to match needs and increasing specific micronutrient needs that are lacking in that individual may be necessary.

Sample Menu

5. Foods Recommended: Low fiber grains, skinless poultry and tender meats (not fried), canned or soft fruits without seeds, well-cooked vegetables (excluding beans and legumes), and dairy products as tolerated.
6. Foods to Avoid: Nuts, seeds, whole-grain products, raw or dried fruits, raw vegetables, certain cooked vegetables (peas, broccoli, squash, cabbage, corn, onions, cauliflower, the skins of potatoes), beans, lentils, tofu, tough meats, crunchy peanut butter, jam or marmalade with seeds, pickles, sauerkraut, popcorn, fruit juices with pulp.
7. Example of a meal plan

Breakfast

• Decaffeinated coffee with cream and sugar
• Cup of juice, such as no-pulp orange juice, apple juice, or cranberry juice
• Cream of wheat
• Scrambled eggs
• Waffles, French toast, or pancakes
• White-bread toast with margarine and grape jelly (no seeds)
• Milk (if tolerable)

Lunch                           

• Baked chicken, white rice, canned carrots, or green beans
• Salad with baked chicken, American cheese, smooth salad dressing, white dinner roll
• Baked potato (no skin) with sour cream and butter or margarine
• Hamburger with white seedless bun, ketchup, and mayonnaise — lettuce if it doesn’t worsen your symptoms
• Cheeses (if tolerable)

Dinner

• Tender roast beef, white rice, cooked carrots or spinach, white dinner roll with margarine or butter
• Pasta with butter or olive oil, French bread, fruit cocktail
• Baked chicken, white rice or baked potato without skin, and cooked green beans
• Broiled fish, white rice, and canned green beans
• Cheese (if tolerable)

Websites

6. Organizations with Websites

• Crohn’s and Colitis Foundation of America: http://www.ccfa.org/

1. Government Websites

7. References
8. Journal articles references

Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn’s disease activity

Index (1976). National Cooperative Crohn’s Disease Study. Gastroenterology 1976;

70: 439–44.

Cunningham, E. (2012) Are low-residue diets still applicable? Journal of the Academy of

Nutrition and Dietetics, 112(6), 960.  doi: 10.1016

Mahan, L. K., Stump, E., & Raymond, J.L. (2012). Krause’s Food and the Nutrition Care Process. 12^th edition. Elsevier/Saunders, St. Louis, MO; 2012

Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

Vavricka, S., Schoepfer, A., Scharl, M., & Rogler, G. (2014). Steroid Use in Crohn’s Disease.

Drugs, 74(3), 313-324.

Diet Instruction: Self-Made Case Study

Description of Patient and Diagnosis

Patient Summary: Jessica Crowns was diagnosed with mild Crohn’s disease 1 week ago.

History:
Onset of disease: Dx. Crohn’s disease 1 week ago
Medical history: Diagnostics revealed that damage was present in the latter half of the ileum and a small portion of the colon. Jessica has been taking corticosteroids. Most recent Dx. Suggests immunosuppressing medications have allowed Jessica’s gut to heal.
Family history: What? Inflammatory bowel disease. Who? Maternal Aunt.

About:
Age: 16
5’ 2” 102 pounds (UBW 107 pounds)

Bio: Jessica is a sophomore in high school and is very active – she participates in cross country and track, and works at the local Boys and Girls club. Jessica states that in the last few weeks she has had very little energy and little appetite due to stomach pains. Jessica had lost 5 pounds in the 3 weeks prior to diagnosis, and missed school several times this past week from excessive bowel movements and diarrhea.

Complaints of stomach pain, tiredness, frequent bowel movements, diarrhea.

Dx: Barium X-rays reveals that Jessica had some abnormalities in her lower small intestine. An endoscopy revealed that Jessica has mild Crohn’s disease in the ileum and beginning portion of the colon.

Necessary Lab Values: CDAI of 190

Tx: Corticosteroid 1/day until symptoms subside.

Medical Nutrition Therapy Goal: Diet should be altered as necessary to provide patient with comfort as the gut heals, as well as decrease likelihood of worsening symptoms. Proper weight gain should be a priority.

Etiology

Inflammatory bowel disease is defined as chronic inflammation of all or parts of the gastrointestinal tract. The pain caused by this disease, as well as other signs and symptoms, can have a huge impact on a person’s life. The two most commonly found diseases under this category are ulcerative colitis (UC) and Crohn’s Disease. Jessica is a 16-year old who was just diagnosed with Crohn’s Disease. Crohn’s disease is the inflammation of sections of the intestine – usually the latter half of the ileum and the beginning of the colon. It can also effect the thickness of the entirety of the GI tract. This damage leads to malabsorption, malnutrition, abdominal fistulas and abscesses, intestinal obstruction, bacterial overgrowth, gallstones, kidney stones, urinary tract infections, thromboembolic complications, perianal disease, and neoplasia (Nelms).

The etiology of this disease is unknown but the following factors are linked to CD: smoking, infectious agents, intestinal flora, genetics, and an abnormal inflammatory response in the small intestine. The peak onset of Crohn’s disease is in the teens and twenties. Signs and symptoms include diarrhea, abdominal pain, weight loss, fever, urgent need to move bowels, constipation, and blood or mucus in the stool (Nelms).

Diagnostic Measures

Diagnostic techniques include abdominal ultrasound, MRI, CT, antiglycan antibodies (ASCA) levels, and ferritin/transferrin levels. Colonoscopies and endoscopies are also used to look at the gut in order to determine the current severity of the disease (Crohn’s and Colitis Foundation). Crohn’s Disease Activity Index (CDAI) is used to give a numerical value to the severity of a patient’s current disease state. The scale is broken up into different stages of mild to moderate disease (CDAI 150 – 220), moderate to severe disease (CDAI 220-450), severe-fulminant disease (CDAI >450). Remission is also a stage in which the individual is asymptomatic due to medical intervention or surgical resection. Those with mild to moderate disease are at low risk of dehydration, toxicity, high fevers, abdominal tenderness, painful mass, obstruction, or more than a 10% weight loss (Best). Jessica falls into the category of mild to moderate with a CDAI of 190.

Treatment

Medical/Surgical/Psychological: Jessica has been prescribed to take Corticosteroids. These keep the immune system from fighting infection. Crohn’s disease is a disease in which the immune system attacks the intestinal tract, therefore the use of corticosteroids decreases the severity of symptoms by suppressing the body’s immune system which is attacking the GI lining. This results in the inflammation going down and normal function continues. Corticosteroids are not to be used long term or there is a possibility that the body will become dependent, so use is to be stopped or decreased once the body has gone into remission (Vavricka). Based on this severity, treatment options can range from simply diet alterations to medicinal interventions such as corticosteroids to the surgical removal of portions of the GI tract. In mild to moderate cases, a low-fiber diet may be initiated in order to reduce the risk of further damage to the intestinal tract. In more severe cases, bowel resection and a modified consistency diet or even temporary TPN may be administered (Nelms).

Medical Nutrition Therapy: Both UC and Crohn’s disease are rarely cured, can sometimes require surgery, and include lifelong intermittent and repeated exacerbations (Nelms). According to Nelms, there is research that suggests that a long-term low-residue diet can decrease the number of inflammatory outbreaks, or even slow the effect of the disease. However, this information is outdated and is no longer supported by the Nutrition Care Process created by the Academy of Nutrition and Dietetics (Cunningham). It is now referred to as simply a low-fiber diet. This is due to the inconsistency of the term “low-residue” as the only reputable difference between low-residue and low-fiber is the elimination of milk. However, milk is actually a medium residue food. Overall, the Academy of Nutrition and Dietetics’ Nutrition Care Manual does not support the “low-residue” diet, but supports low-fiber diets for those with bowel resection, ileostomy, Crohn’s disease, and ulcerative colitis (Cunningham).

Research has been unsuccessful at determining what specific foods are the culprit for everyone with this condition. Bottom line: there’s no one diet to alleviate Crohn’s disease. Yet, important steps in treatment for Crohn’s include keeping a detailed food diary, avoiding foods that cause symptoms and consulting with a registered dietitian experienced in digestive health.

Nutrient Needs

Nutrient deficiency is a common concern as the inflammation and damage to the internal wall of this condition interferes with nutrient absorption. As a result, people with Crohn’s disease need a nutrient-rich diet with adequate calories, protein and healthy fats. For Jessica, the primary goal is for her to return to her usual body weight by finding foods that are irritating her gut lining, and eliminating those foods short term. When symptoms subside, these foods can then be consumed in moderation with an awareness of symptoms worsening. Multivitamins may also be needed. Corticosteroid use can also effect specific nutrient intake: calcium, vitamin D, magnesium, and Vitamin K. If used to long term, even more deficiencies become possible such as vitamin C, vitamin B12, folic acid, zinc, and selenium (Vavricka).
Jessica is going to be put on a diet of 1,900-2,200 kcal diet until her weight returns to normal. The focus will be on taking in nutrient dense foods as absorption may also be currently compromised. When symptoms subside, Jessica may return to a predominantly normal diet that eliminates or reduces the frequency of foods that were determined as irritants for her specifically. This will be done through her keeping a journal. Lactose-intolerance will be tested, and lactaid tablets may be administered if needed.

Prognosis

There is no cure. Treatment with anti-inflammatory steroids and proper diet can suppress symptoms and prolong the time between episodes. Some may experience inflammation and irritation often while some can go decades with suppressed symptoms. The severity range varies widely. Some experience one episode while others experience frequent spurts with minimal suppression in between. In severe cases, surgery can be done to remove the most damaged areas of the bowel (Mahan). Death is very rarely a result of Crohn’s disease with technology, so there is a normal life expectancy.

References

Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn’s disease activity

Index (1976). National Cooperative Crohn’s Disease Study. Gastroenterology 1976; 70:

439–44.

Christian, G.M., Alford, B., Shanklin, C.W., & DiMarco, N. (2013) Milk and milk products in

low-residue diets: Current hospital practices do not match dietitians’ beliefs. J Am Diet

Assoc. 91:341-342

Crohn’s and Colitis Foundation of America (2015). What is Crohn’s Disease? Retrieved

February 16, 2015 from http://www.ccfa.org/what-are-crohns-and-colitis/what-is-crohns-

disease/

Cunningham, E. (2012) Are low-residue diets still applicable? Journal of the Academy of

Nutrition and Dietetics, 112(6), 960.  doi: 10.1016

Mahan, L. K., Stump, E., & Raymond, J.L. (2012). Krause’s Food and the Nutrition Care

Process. 12^th edition. Elsevier/Saunders, St. Louis, MO; 2012

Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology.

Vavricka, S., Schoepfer, A., Scharl, M., & Rogler, G. (2014). Steroid Use in Crohn’s Disease.

Drugs, 74(3), 313-324.

Metabolic Stress Case Study

1. What is the Glasgow Coma Scale (GCS)?

The Glascow Coma Scale is a scoring system used to assign a level of consciousness of a person after brain injury, and is used to assess severity on a scale of 3 to 15. GCS is the most commonly used scale and involves measure of eye opening, verbal response, and motor response. The overall score is the sum of the three categories but all can be evaluated individually as well.

Source(s): http://www.unc.edu/~rowlett/units/scales/glasgow.htm

2. What was Chelsea’s initial GCS score? Is anything in the initial physical assessment consistent with this score? Explain.

Chelsea’s initial score was 10 E4V2M4 broken down into an eye opening response score of 4, a verbal response score of 2, and a motor response score of 4. Initially when admitted, it was stated that she had no verbal response but withdrew and moaned when touched. This means that she is somewhat responsive in her comatose state. A score of 3 is very unconscious while a score of 15 is extreme awareness of surroundings while still in a coma. This score of 10 seems consistent with what the actions described.

3. Define the following terms found in the admitting history and physical:
   1. Intensivist: A physician who specializes in the care of critically ill patients (usually in the Intensive Care Unit)
   2. L-sided hemiparesis: general weakness on the left side of the body

Source(s): http://www.medterms.com

4. Read the CT scan and MRI report. The CT scan report was very general, noting density in the frontal lobe. The MRI indicated more localized areas of edema and blood in the frontal lobe. It also discusses a shearing injury.
   1. What causes edema and bleeding in a traumatic brain injury?

Brain injury occurs as a result of a blow or jolt of the head in which the brain is smashed into the skull wall. The edema is a build-up of water in the spaces around the brain or blood-brain barrier and occurs as the brain tissue swells. This is a natural response to trauma but excess edema can prevent fluids from leaving the brain.

1. What general functions occur in the frontal lobe? How might Chelsea’s injury affect her in the long term?

The frontal lobe is responsible for motor functions, memory, problem solving and judgment, planning, reasoning, impulse, and social behavior. Depending on how the severity of the injury Chelsea may suffer from memory loss, impaired motor functions, and personality / emotional alterations.

Source(s): http://www.neuroskills.com/brain-injury/frontal-lobes.php

5. What factors place the patient with traumatic brain injury at nutritional risk?

Chelsea is at increased nutritional risk as traumatic brain injuries can cause physical, cognitive, and sensory issues that can result in difficulty swallowing (dysphagia) and cognitive impairment that affects ability to concentrate on food consumption. She is currently unable to feed herself but also she is at nutritional risk because of possible impaired organ function, alterations in vitamin and mineral absorption, possible drug/nutrient interactions, and fluid and electrolyte imbalances.

6. Chelsea’s height is 132 cm, and her weight on admission is 27.7 kg. At 9 years of age, what is the most appropriate method to evaluate her height and weight? Assess her height and weight.

The most appropriate method to evaluate her height and weight are to use the CDC growth charts that look at stature-for-age and weight-for-age charts for children age 2 to 20. As a 9 year old, Chelsea falls in the 35^th percentile for weight and the 49^th percentile for height.

7. What method should you use to determine Chelsea’s energy and protein requirements? After specifying your method determine her energy and protein needs.

REE (for females age 3-9) = 22.5 x W(kg) + 499

= 22.5 (27.7kg) + 499

= 1122kcal x (stress factor) 1.7

= 1,900 – 2,000 kcal/day

Protein = 2,000kcal/day x .3 (30%) = 600kcal / 4 g/kcal = 150g PRO

 

8. Chelsea was to receive a goal rate of Nutren Jr with fiber @ 85 cc/hour. How much energy and protein would this provide? Show your calculations. Does it meet her needs?

Nutren Jr = 1.0kcal/mL

85 mL x 24 hours = 2040kcal/day

Protein = 12% of kcal from Nutren Jr

= .12 x 2040 = 245kcal / 4 = 61 grams PRO

Although calorie needs are being met, protein needs are not being met.

9. Using the patient care summary sheet, answer the following:
   1. What was the total volume of feeding she received on June 5?

Chelsea received 1495 TF Formula/Flush.

1. What was the nutritional value of her feeding for that day?

62 cc/hour for 24 hours:

Energy: (62mL)(24hrs)(44g)/100mL

= 2,226 kcal

Protein: (62 mL)(24hrs)(12g) / 100mL

= 179g PRO

1. What percentage of her needs was met?

2,226 actual intake / 1,950 needed intake x 100 = 114%

1. There is a note on the evening shift that the feeding was held for high residual. What does that mean?

This means that there was still a high volume of food or liquid left in Chelsea’s stomach from previous feeding, and therefore Chelsea was not given this particular feeding for fear of pulmonary aspiration. This should be taken into consideration because this is a decrease in caloric and protein intake. It also is essential to find out what is causing the residue to hopefully stop its recurrence.

1. What is aspiration? What are the potential consequences?

Aspiration is when food or fluid is inhaled into the bronchi and lungs. This can result in choking, food going down the airway, or pneumonia. If choking occurs without notice, a patient in Chelsea’s condition could die.

1. What is the usual procedure for handing a high gastric residual? How do you think Chelsea’s situation was handled?

Gastric residual is checked every 4/6 hours and the RV is adjusted as necessary to prevent aspiration from occurring. In those with high gastric residual, the head is to be propped up and tube placement checks should occur before each bolus or every 8 hours if continuous. Enteral feeding is reduced or stopped if necessary and other measures (perhaps TPN) may be necessary for short term. I think there should have been better communication about Chelsea. It should not just have been a chart note as that can impact her nutrient intake and also it should be closely monitored after the first occurrence.

1. What other information would you assess on the daily flow sheet to determine her tolerance of enteral feeding?

Other areas to check would be her lab values, blood pressure, blood glucose, bowel movements and urine/nitrogen output.

1. Look at the additional information on the patient care summary sheet. Are there any new factors of concern?

There is a lack of urine output and only one soft BM which means that her body is not responding well to the feedings. Possible dehydration and subsequent constipation are of concern. Also, her weight has dropped since entering and this may mean that she is in need of greater protein/kcals to reduce muscle wasting.

10. Evaluate Chelsea’s laboratory data. Note any changes from admission day labs to June 3. Are there any changes of nutritional concern?

Since admission, Chelsea’s glucose and calcium levels have leveled out to normal. However, since she has arrived her Chloride level remains elevated and her creatinine and BUN remain low. Her Albumin levels are especially important to not as they have dropped below normal which means she is not getting the amount of protein her body needs to heal during this crucial time. Kidney function may also be of concern based on these numbers, and it is essential to continue to track any changes in BUN, creatinine, and albumin as she progresses.

11. On June 6, a 24-hr urine sample was collected for nitrogen balance. On this day, she received 1650 cc of Nutren Jr. Her total nitrogen output was 14 grams.
    1. Calculate her nitrogen balance from this information. Show all your calculations.

Nitrogen balance = nitrogen intake – nitrogen losses

= 1650mL/24hrs x 12g/100mL

= -5.75

1. How would you assess this information? Explain your response in the context of hyper metabolism.

This number is negative meaning Chelsea’s output is greater than her input, which is indicative of her protein intake. Because protein is the macronutrient that contains nitrogen, this means that her protein levels are too low. Her nitrogen balance should be no less than zero.

1. Are there any factors that may affect the accuracy of this test?

Nitrogen can be excreted through the skin and also through respiration which may account for some of the nitrogen loss. Her body is also taking in a lot of the protein and using it for healing so her body will naturally be holding onto more nitrogen than it normally would.

1. The intern taking care of Chelsea pages you when he reads your note regarding her negative nitrogen balance. He asks whether he should change the enteral formula to one higher in nitrogen. Explain the results in the context of the metabolic stress response.

Chelsea’s number of -5.75 just means she is having a metabolic response and this categorizes her as being in a mild hypermatabolic state, or level 1 stress category. The formula should not need changing for the sake of nitrogen but rather protein. Right now, this just need to be closely monitored but if her hypermetabolic state continues to increase and her nitrogen balance decreases further, a higher protein formula should be administered.

12. Chelsea has worked with occupational therapy, speech therapy, and physical therapy. Summarize the training that each of these professionals receives and what their role might be for Chelsea’s rehabilitation.

All members of this team are essential in Chelsea’s recovery. Occupational therapists treat patients with injuries, illnesses, or disabilities by helping patients develop or recover skills needed for daily life. In Chelsea’s case, the occupational therapist will focus on regaining the intellectual ability that existed before the accident – feeding herself, writing, drawing. Speech therapists focus on language, speech, and all aspects of voice. For Chelsea this would include perhaps swallowing, chewing, mouthing words, and regaining speech. Physical therapists focus on building muscular strength to perform daily activities. Right now for Chelsea the goal is to prevent muscle wasting and depending on her progress, the physical therapist will eventually help Chelsea regain the ability to walk, play, and even run.

13. The speech pathologist saw Chelsea for a swallowing evaluation on hospital day 10.
    1. What is video fluoroscopy?

Video fluoroscopy is an x-ray evaluation of swallowing function. X-rays are taken of the mouth/throat/esophagus while foods and liquids of different consistencies and textures are swallowed – these foods/liquids are mixed with barium to allow the x-ray image to be taken.

1. What factors were noted that support the need for enteral feeding at this time?

It was noted that Chelsea had choked several times on ice chips, and showed signs of fatigue / decreased cooperation after a few swallows. As a result, her PO feeding was inhibited and her energy intake decreased.

14. As Chelsea’s recovery proceeds, she begins a PO mechanical soft diet.
    1. Calculate her intake and average for these two days of calorie counts.

Chelsea took in about 700 kcals on the first day and about 1000 kcals on the second day. This is extremely low for someone in Chelsea’s condition with her energy needs. This is less than 50% of her EER even with a reduced activity/healing factor.

1. What recommendations would you make regarding her enteral feeding?

I would recommend that Chelsea consume at least double the number of calories she is currently consuming, and increase protein intake. Her enteral feeding should contain at least 1,000kcals and to ensure adequate protein (as much of the foods she is consuming is not high in protein, her enteral supplement should be a high protein one.

Source(s): fitday.com for calories