Case Study: Lower GI Tract (Crohn’s Disease)

1. What is inflammatory bowel disease? What does current medical literature indicate regarding 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. The complete etiology for these diseases are unknown but there are several factors that have seen consistency which include the following: environmental (i.e. smoking, infectious agents, and intestinal flora), genetics, and an abnormal inflammatory response in the small intestine that damages the gastrointestinal mucosa.

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

 

 

2. 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?

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. 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.

The differences are found when assessing the area affected, and degree and manner of impact. 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. There is also another subcategory of inflammatory bowel disease called indeterminate colitis in which the features of both ulcerative colitis and Crohn’s disease are present.

Also, there are extreme differences in the resulting complications of Crohn’s and UC as well as prognosis. Ulcerative colitis can lead to toxic colitis, toxic megacolon, strictures, perforation, and intolerance to immunosuppression, colonic strictures, dysplasia, and carcinoma. Crohn’s disease leads to malabsorption, malnutrition, abdominal fistulas and abscesses, intestinal obstruction, bacterial overgrowth, gallstones, kidney stones, urinary tract infections, thromboembolic complications, perianal disease, and neoplasia. Both UC and Crohn’s disease are rarely cured, can sometimes require surgery, and include lifelong intermittent and repeated exacerbations.

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

 

3. A CT scan indicated bowel obstruction and the 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 indicate?

The Crohn’s Disease Activity Index (CDAI) is a scale used to assess the severity of disease. The variables used to produce this scale are collected over the course of seven days and include the following: number of liquid or soft stools, abdominal pain, general well-being, presence of abdominal mass, lab features, deviating from standard weight, and complications. Complications include joint pains, inflammation of the iris or uveitis, presence of ulcers, fistulae or abscesses, and fever. All variables have a different weight factor that is used to calculate an overall CDAI score. Treatment plans are altered based on where they lie on the index throughout the course of the disease.

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. Those with moderate to severe disease are failing to respond to treatment or possess major symptoms such as fevers, significant weight loss, pain, nausea or vomiting (without obstructive findings), and significant anemia. Those with sever-fulminant disease are resistant to outpatient treatment and have persistent high fever, vomiting, intestinal obstruction, cachexia, and/or evidence of an abscess.

Mr. Sims had a CDAI score of 400 which categorizes his disease state as moderate to severe. However, because his CT scan noted a that there was either partial or total blockage of the bowel (or a bowel obstruction), this places him at a sever-fulminant disease state in which very little to nothing is able to pass through his gastrointestinal tract.

Source(s): Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology 1976; 70: 439–44.

4. What did you find in Mr. Sims’ history and physical that is consistent with his diagnosis of Crohn’s? Explain.

Mr. Sims’ history or diarrhea, fever, and abdominal pain are all consistent with the diagnosis of Crohn’s disease. Weight loss and fever are also consistent, however all of these signs and symptoms are consistent with other gastrointestinal diseases, as well as microbial infections. Vitamin and mineral levels such as vitamin D, free retinol, and ascorbic acid are also off balance which also correlates to Crohn’s disease.

Some values that point to Crohn’s disease include a low total protein level of 5.5 g/dL, low albumin and prealbumin levels of 3.2 g/dL and 11 mg/dL respectively. However, perhaps the most prevalent laboratory result that is used to diagnose Crohn’s disease is the presence ACSA or Anti-Saccharomyces Cerevisiae antibody. ACSA is used as a sort of biomarker – those with ulcerative colitis are more likely to have the antibody pANCA present while those with Crohn’s disease are more likely to have ACSA present.

However, the best way to tell the difference between ulcerative colitis and Crohn’s disease are to use other methods of testing. Barium X-rays can be used to see ulcers or narrowed parts of the intestine. Also, fistulaes and abnormal connections can be seen. CT scans can be used to find abscesses, or small pockets of infection. Perhaps the most accurate assessment however is a colonoscopy or sigmoidoscopy in which a tube is inserted through the anus and a small camera projects the image onto a screen. The presence of ulcers, and the degree of bleeding and inflammation can be evaluated using this method.

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

5. 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?

There are several extra intestinal symptoms that can occur in patients with Crohn’s disease. Inflammation can occur in the eyes (uveitis and sclera) and can lead to vision loss. Nodules sometimes occur on the skin of Crohn’s patients. There is an associating rheumatologic disease that can cause arthritis in the joints. This can cause warmth, swelling, pain, stiffness, and movement difficulty in small joints (in the hands and feet) as well as larger joints (knees, hips, shoulders, wrist, and elbows). Gall stones can also result if the disease is present in the ileum as it can increase the cholesterol to bile ratio.

Because Crohn’s disease can affect the body’s ability to absorb, there are many extra intestinal symptoms directly associated with malnutrition. Calcium deficiencies can lead to oral health problems as well as osteoporosis, which increases the risk of bone fractures. If the ileum is affected or removed, deficiencies of vitamin B12 are common while problems with the duodenum and jejunum lead to folate deficiencies. Neurological problems are also possible such as seizures, stroke, myopathy, headaches, and depression.

In Mr. Sims case, there is a presence of iron deficiency. He is pale and easily fatigued but there are also lab values that support this theory. Mr. Sims’ prothrombin time is elevated and his hemoglobin and hematocrit levels are at a low of 12.9 Hgb and 38 Hct respectively. There are also decreased levels of transferrin, 180 mg/dL, and ferritin, 16 mg/mL.

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

 

6. Sims has been treated previously with corticosteroids and mesalamine. His physician had planned to start Humira prior to his admission. Explain the mechanism for each of these medications in the treatment of Crohn’s.
7. Corticosteroids – Corticosteroids keep the immune system from fighting infection. Because Crohn’s disease is a disease in which the immune system attacks the intestinal tract, the use of corticosteroids stops or at least decreases the severity of symptoms as the attack on the lining lessens. This allows the inflammation to go down and normal function to continue. 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. When taking corticosteroids, vaccinations are not to be taken and there should be limited contact with ill others. This is most likely why Mr. Sims got sick every time he went back to school – his immune system was inefficient and the students were most likely making him ill.
8. Mesalamine – Mesalamine is used for mild Crohn’s disease – it is an oral aminosalicylate. It relieves symptoms and inflammation. It’s proven to be 45-55% effective in sending those with CD into remission.
9. Humira – Crohn’s disease causes an excess production of the protein TNF, and this leads to inflammation. Humira works as a TNF blocker as it binds to the protein and keeps it from inducing the inflammation. Humira also lowers the immune response.

Source(s): Vavricka, S., Schoepfer, A., Scharl, M., & Rogler, G. (2014). Steroid Use in Chron’s Disease. Drugs, 74(3), 313-324.

7. Which laboratory values are consistent with an exacerbated of his Crohn’s disease? Identify and explain these values.

Possible exacerbations include obstruction of the gastrointestinal tract, abscesses (pockets of puss), and hemorrhaging or bleeding. Megacolon can also occur which is a massive distension or dilation of the colon. Perforation is the most immediately life threatening exacerbation in which there is a tear in the gastrointestinal tract. This is considered a surgical emergency. Usually it can be treated with antibiotics, the insertion of a nasogastric tube, and bowel rest in which no foods or liquids are consumed. If severe, removal of spilled fecal matter from the abdominal cavity might be necessary to prevent massive or even fetal infection. Luckily, perforations only occur in 1-3% of those with inflammatory bowel disease. This most often occurs in those with ulcerative colitis during the first flare up of symptoms. To prevent such exacerbations, regular exams and testing should occur.

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

 

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

Mr. Sims is at risk for vitamin and mineral deficiencies because nutrients are absorbed through the intestines and the abilities of his intestinal tract is currently compromised as evidence by his weight loss. Mr. Sims is at risk for the following vitamin and mineral deficiencies:

1. Vitamin B12. If the lower intestine is damaged or removed, 1 B12 vitamin should be taken daily.
2. Folic Acid. Medications such as sulfasalazine and methotrexate taken for CD can interfere with folate absorption, therefore 1 mg should be taken daily.
3. Fat soluble vitamins (especially A, E, and K). One with CD has difficulty absorbing fats, especially after surgery.
4. Iron is a common deficiency in those with CD, therefore iron tablets or injections are highly recommended.
5. Potassium, magnesium, and zinc. All have low absorption in those with Crohn’s disease. A multivitamin is recommended.
6. Calcium (ascorbic acid). Nearly half of all people living with Crohn’s disease have osteopenia. 1,500 mg are recommended daily.
7. Vitamin D. 800 IU is recommended daily.

The deficiencies noted in Mr. Sims are Vitamin A, Vitamin D, iron, and calcium. The deficiencies in calcium and vitamin D are possibly due to the medications he is on as corticosteroids can affect absorption.

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

 

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 is malabsorption that results from the removal of a large portion of the small intestine. It can also be a caused by dysfunction of a large portion of the bowel. However the small intestine is very efficient and adapts well, therefore over 2/3 of the small intestine has to be removed or effected in order to short bowel syndrome to occur. I don’t believe Mr. Sims is a likely candidate for short bowel syndrome based on the amount of small intestine that has been removed. However, SBS may be a future concern if more of his intestinal tract becomes inefficient or if more of his small intestine later needs to be removed.

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

 

10. What type of adaptation can the small intestine make after resection?

The small intestine is 19.7 feet / 6 meters in length. Typically, short bowel syndrome doesn’t occur unless the small intestine because less than 6.6 feet / 2 meters. This is due to intestinal adaptation – the ability to make physiological changes to increase absorption capacity. This includes enlarging and lengthening the villi that make up the brush border, increasing the overall diameter of the small intestine, and slowing down peristalsis (the movement of food). Typically if there is at least 6.6 feet / 2 meters of healthy small intestine left intact, the small intestine can reach the same efficiency.

Source(s): Musch, M. W., Bookstein, C., Rocha, F., Lucioni, A., Ren, H., Daniel, J., & Chang, E. B. (2002). Region-specific adaptation of apical Na/H exchangers after extensive proximal small bowel resection. American Journal Of Physiology: Gastrointestinal & Liver Physiology.

11. For what classic symptoms of short bowel syndrome should Mr. Sims’ health care team monitor?

The signs and symptoms of short bowel syndrome include increased abdominal pain, diarrhea, fluid depletion, weight loss, malnutrition, and fatigue. Many of these signs and symptoms are similar to what is already being seen in Mr. Sims but the worsening of any of these would be something to investigate. Also, in the case of SBS, Mr. Sims’ diarrhea would become steatorrhea which is more oily or sticky and possibly more foul smelling.

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

 

12. Sims is being evaluated for participation in a clinical trial using high-dose immunosuppression and autologous peripheral blood stem cell transplantation (autoPBSCT). How might this treatment help Mr. Sims?

AutoPBSCT is a treatment commonly used in those with cancer, including leukemia, sarcoma tumors, and lymphoma. It consists of a high dose of immunosuppression and an autologous peripheral blood stem cell transplantation. Most people with Crohn’s disease are sent into remission by the use of corticosteroids and Humira, but there is still 10% who are seemingly unresponsive. This may help Mr. Sims as there has been some success using this treatment on that 10% of the CD population.

Source(s): Hasselblatt, P., Drognitz, K., Potthoff, K., Bertz, H., Kruis, W., Schmidt, C., & Kreisel, W. (2012). Remission of refractory Crohn’s disease by high-dose cyclophosphamide and autologous peripheral blood stem cell transplantation. Alimentary Pharmacology & Therapeutics, 36(8), 725-735.

 

13. What are the potential nutritional consequences of Crohn’s disease?

There are numerous potential nutritional consequences of Crohn’s disease. A few that I have already touched on are vitamin deficiency and anemia (iron deficiency). Others include cachexia, total parenteral nutrition, malabsorption of fats, and physical retardation. Cachexia is when the body is undernourished and is searching for some sort of energy source, and therefore starts to catabolize fat and muscle resulting in severe weight loss. Total parenteral nutrition occurs when so much of the digestive tract has been damaged that the body can no longer get the necessary nutrients through diet, and nutrients must be obtained through a tube that goes directly into the stomach. The malabsorption of fats is caused by an inability to reabsorb bile salts. Without these salts, fat just passes through the body and is excreted via feces/diarrhea. Physical retardation occurs in children with Crohn’s disease because of hormonal imbalances that are a result of malnutrition and immunosuppressive treatments. This can mean a retardation of growth and sexual maturity.

Source(s): Massironi, S., Rossi, R., Cavalcoli, F., Della Valle, S., Fraquelli, M., & Conte, D. (2013). Nutritional deficiencies in inflammatory bowel disease: Therapeutic approaches. Clinical Nutrition, 32(6), 904-910.

 

14. Sims underwent resection of 200cm 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 the resection?

The small intestine, as I mentioned earlier is 6 meters or 600 cm in length. This means that 400 cm still remains in Mr. Sims. Usually serious problems occur if there is less than 200 cm of healthy small intestine present, so Mr. Sims’ intestine should be able to adapt and return to normal function. However, these adaptations will take time and should be monitored closely until signs and symptoms subside.

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

 

15. What nutrients are normally digested and absorbed in the portion of the small intestine that has been resected?

Food is absorbed by villi and microvilli that make up what is called the “brush border” or the intestinal tract. The jejunum specifically does a lot – carbohydrates, protein, sodium, vitamin A, vitamin D, water soluble vitamins, and it is responsible for the absorbing 85% of water. The ileum collects the remaining nutrients from protein breakdown, some water, and is primarily responsible for the collection of bile salts to be recycled.

Source(s): Ross, Insel Turner (2009). Discovering Nutrition.

 

16. Evaluate Mr. Sims’ % UBW and BMI.

                  Weight = 140 lbs / 2.2 = 63.64 kg

Height = 5’9” = 69 in X 2.54 = 175 cm or 1.75 m

% UBW = (100 X Actual Body Weight) / Usual Body Weight

= (100 X 140) / 167

= 84%

BMI = wt. (kg) / ht (meters) squared

= 63.64 / (1.75)²

= 20.8

This BMI falls into the classification of normal (but on the lower end of normal).

Source(s): Reference Sheet

17. Calculate Mr. Sims’ energy requirements.

Mifflin-St. Jeor

Men     10 X wt (kg) + 6.25 X ht (cm) – 5 X age (yrs) + 5

(10 X 63.64) + (6.25 X 175) – (5 X 35) + 5

636 + 1,094 – 175 +5

= 1,560

1,560 X (PAL) 1.2 X Stress Factor 1.5

= 2,808 cal / day

Source(s): Reference Sheet

18. What would you estimate Mr. Sims’ protein requirements to be?

Protein Needs

Weight (kg) X 0.8-1.8 gm/kg

63.64 X 1.4

= 117.4 gm protein/day

This number should also be adjusted due to possible the lack of absorption.

Source(s): Ross, Insel Turner (2009). Discovering Nutrition.

 

19. Identify any significant and/or abnormal laboratory measurements from both his hematology and his chemistry labs.

First, Mr. Sims’ hematology labs show signs of having iron-deficient anemia. He has low hemoglobin and hematocrit measures as well as transferrin and ferritin. His sodium and potassium levels were also on the lower end of normal – this is probably due to the diarrhea. His total protein, albumin, and prealbum levels were all too low as well which can occur for several different reasons. Mr. Sims most likely shows these signs because of his nitrogen protein balance, which is common in infections and disorders of antibody cells. His increased ZPP level can also be explained by his inflammatory conditions.

20. Select two nutrition problems and complete the PES statement for each.
21. Malnutrition related to involuntary weight loss as evidence by 26% weight loss in 6 months and 84% IBW.
22. Inadequate Iron intake related to impaired GI absorption as evidence by low hematology values of Hemoglobin (12.9 g/dL), hematocrit (38%), transferrin (180 mg/dL), and ferritin (16 mg/mL)

 

21. The 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?

Parenteral nutrition support is ideal for Mr. Sims current state. The goals of his nutrition therapy plan is to decrease the risk of obstruction, maintain fluid and electrolyte balance, reduce excessive fecal output, and minimize gas/flatulence. It is important to monitor is caloric intake and make sure they are meeting his nutritional needs. The ratios of carbohydrates, fats, and proteins that make up his diet must be closely monitored as well as the amount of vitamins, minerals, and electrolytes. Fiber in the solution is also important – if water fecal continues, soluble fiber should be increased and insoluble fiber should be decreased. Constant monitoring of all aspects should occur and be adjusted as seen necessary.

Source(s): Yamamoto, T., Nakahigashi, M., Umegae, S., Kitagawa, T., & Matsumoto, K. (2007). Impact of long-term enteral nutrition on clinical and endoscopic recurrence after resection for Crohn’s disease: A prospective, non-randomized, parallel, controlled study. Alimentary Pharmacology & Therapeutics, 25(1), 67-72.

 

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

There are several reason that each of these readings could drop individually. Serum phosphorus can be low in the case of general malnutrition, hypokalcemia, osteomalacia (Vitamin D deficiency), and hypothyroidism. Serum magnesium can be low in the case of gastrointestinal disorders, prolonged diarrhea and post-surgery, but it can also occur in hypoparathyroidism. Because these is an overlap in hypothyroidism and hypoparathyroidism, this may be a point of concern. Both are a result of too little thyroid hormone being released by the thyroid and parathyroid glands. This can cause a loss of calcium in the rest of the body, and hurt with bone calcium absorption – leading to other related problems. Therefore, this need to be closely monitored.

Source(s): Ross, Insel Turner (2009). Discovering Nutrition.

 

23. What is refeeding syndrome? Is Mr. Sims at risk for this syndrome? How can it be prevented?

Refeeding syndrome is a metabolic disturbance when nutrients are reintroduced to starved or severely malnourished patients. If a person has been starved for more than a few days, the liver slows. Ketosis then occurs and the body uses stored free fatty acids as energy, resulting in a decrease of the basal metabolic rate. The body does this to try and find an alternate energy source while holding on to any nutrients possible.

The problem occurs when these carbohydrate are reintroduced, and the body shifts its function back to carbohydrates as a primary energy source. This shift requires a lot of magnesium, potassium, and thiamin and therefore deficiencies can occur at a harmful level. Too little phosphorus can cause hemolysis, impaired cardiac function, impaired respiratory function, or even death. Low magnesium levels can results in tremors, muscles twitching, cardiac arrhythmia, or paralysis. Low potassium can result in cardiac abnormalities, and low thiamin levels can result in Wernicke’s encephalopathy.

This is why the implementation of parenteral nutrition must be started slowly and the amount of carbohydrates should also be kept low in the beginning to make sure refeeding syndrome doesn’t occur. If orally fed, these feedings should also occur slowly via small meals. Mineral levels should be constantly monitored and supplementation should be added as needed.

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

 

24. Sims was placed on parenteral nutrition support immediately postoperatively, and a nutrition support consul was ordered. Initially, he was prescribed to receive 200g 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? Explian. Calculate: pro (g); CHO (g); lipid (g); and total kcal from his PN.

I agree with the team’s decision to initiate parenteral nutrition. This will decrease the chance of damage done on the intestinal tract, allowing time for recovery while still acquiring proper nutrition.

1. Protein – 0.8 g/kg are recommended for regular adults. However, Mr. Sims is healing from surgery and also needs to gain back weight therefore his protein needs are higher (1.5-2g/kg/day).

63.64 kg X 1.7 = 108.2 g protein/day

2. Lipid – should be 1.2g/kg/day.

63.64 kg X 1.2 = 76.4 g lipid/day

3. Carbohydrate should make up the remaining calories needed.

(108.2 g protein/day X 4 kcal/g) + (76.4 g lipid/day X 11 kcal/g)

= 432.8 kcal + 840.4 kcal

= 1,273.2 kcal

Daily caloric need of 2,808kcal – 1,273 kcal = 1,535 kcal

Kcal / 3.4 = 451.5 g carbohydrate

Source(s): Nelms, K. Sucher, K. Lacey, S. Roth (2011). Nutrition Therapy and Pathophysiology. (p.93-101)

25. For each of the PES statements you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology).
26. Malnutrition

• Goal: Maintain current weight during recovery then once surgery has healed, slowly gain weight until reaching a normal weight.
• Intervention: Use PN to maintain, and then use nutrition counseling to educate Mr. Sims on how to gain weight without foods that will trigger his inflammation. This should be done at a rate of 1 pound per week by an increase in caloric intake of 500 kcal daily.

2. Inadequate Iron Intake

• Goal: Increase iron levels.
• Intervention: Absorption should naturally increase as the intestinal tract heals, but an iron supplement should also be taken.

 

26. Indirect calorimetry revealed the following information:

Measure	Mr. Sims’ data
Oxygen consumption (mL/min)	295
CO₂ production (mL/min)	261
RQ	0.88
RMR	2022

What does this information tell you about Mr. Sims?

RMR is the resting metabolic rate – the necessary number of calories Mr. Sims currently needs to maintain his weight. RQ (respiratory quotient) is an analysis of the oxygen consumption and carbon dioxide production. Because fat consumes more oxygen in a ratio to carbon dioxide this ratio can indicate which fuel source (fat or carbohydrate) is being metabolized. An RQ of 1 is pure carb while an RQ of 0.7 is pure fat.

Source(s): Nelms, S. Roth (2009). Medical Nutrition Therapy: A Case Study Approach.

 

27. Would you make any changes to his prescribed nutrition support? What should be monitored to ensure adequacy of his nutrition support? Explain.

Mr. Sims is currently utilizing more carbohydrates than fat as his primary energy source and because of the chances of refeeding syndrome, I would aim to lower is RQ by increasing the level of fats in his diet and decreasing the level of carbohydrates. This should be slowly altered and closely monitored. Also, the exact caloric intake should be closely monitored daily to assure that as Mr. Sims weight and RMR increases, so do the number of calories consumed.

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

28. What should the nutrition support team monitor daily? What should be monitored weekly? Explain your answers.

I believe certain aspects of Mr. Sims progress should be monitored daily including several chemistry levels that may result in harm if they drop too low, such as sodium and potassium levels, magnesium and calcium. Also, protein and albumin levels should be increasing daily as well as hemoglobin, transferrin, and ferritin. PT should also decrease and if it doesn’t, blood thinners may be necessary to prevent blood clotting. Urine tests should also be performed daily to test for glucose and ketone presence.

Things that can be monitored weekly are things that are less detrimental to immediate health status such as weight, HDL levels (though they should increase over time), and vitamin A, vitamin D, and ascorbic acid (though they should also slowly see an increase). Some things that will not change much are the presence of ASCA and a high ZPP which are constant throughout the duration of Crohn’s disease.

 

29. Sims’ serum glucose increased to 145 mg/dL. Why do you think this level is now abnormal? What should be done about it?

A rise in glucose levels may be a result of the corticosteroids as these are known to cause Cushing’s syndrome, which is a sudden increase in glucose levels. This is easily treated if caught early. It also may a result of refeeding syndrome as carbohydrates are reintroduced into Mr. Sims’ diet. In this case, lowering the carbohydrate intake. Lowering the corticosteroid dosage may help reduce Cushing’s syndrome.

Source(s): Giordano, R., Guaraldi, F., Berardelli, R., Karamouzis, I., D’Angelo, V., Marinazzo, E., & Arvat, E. (n.d). Glucose metabolism in patients with subclinical Cushing’s syndrome. Endocrine, 41(3), 415-423.

 

30. Evaluate the following 24-hour urine data: 24-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.

Nitrogen intake should be equivalent to nitrogen excretion. This is a representation of overall protein status. It should be noted, however, that it is not possible to measure nitrogen loss through diarrhea which may cause a lack of accuracy in this account. Because Mr. Sims has had such bad diarrhea, I don’t believe this is an accurate assessment of protein intake. I believe protein lab values are a more accurate assessment.

 

31. On post-op day 10, Mr. Sims’ team notes he has had bowel sounds for the previous 48 hours and had his first bowel movement. The nutritional support team recommends considering 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?

To start, Mr. Sims’ should be on a low-reside and lactose free diet consisting of small and frequent meals. There should be an avoidance of high fiber foods, spicy food, fried foods, caffeine, and other trigger foods. Small amounts of fiber can slowly be introduced as well as lactose if tolerable. If steatorrhea occurs, the amount of fat in the diet should be reduced. If no problems occur, PN can slowly be decreased as oral caloric intake increases. The speed of occurrence is dependent upon Mr. Sims’ reactions to oral intake. Throughout this process and even after being released, a multivitamin and mineral supplement should be taken – specifically with vitamin B12, iron, zinc, calcium, magnesium, and copper.

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

32. 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 measure for evaluation.
33. Weight gain should occur with foods that won’t cause harm to the gastrointestinal tract. This should include low fiber fruits, vegetables, proteins, and grains. Some dairy can be implemented as tolerable. Avoid skins and seeds of fruits, raw fruits and vegetables, whole grains, nuts and seeds. Other trigger foods may include soda, fried foods, and alcohol.
34. A daily multivitamin should be taken, especially for iron deficiency and a deficiency of vitamin D, vitamin A, and ascorbic acid as these all had low values in Mr. Sims’ laboratory results.

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

 

 

 

 

References:

Giordano, R., Guaraldi, F., Berardelli, R., Karamouzis, I., D’Angelo, V., Marinazzo, E., & Arvat, E. (n.d). Glucose metabolism in patients with subclinical Cushing’s syndrome. Endocrine, 41(3), 415-423.

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