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. 12th 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.
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