Professional Documents
Culture Documents
KNH 411 - Case Study 11
KNH 411 - Case Study 11
KNH 411
Prof Matuszak
Case Study #11: Inflammatory Bowel Disease: Crohns Disease
1. What is inflammatory bowel disease? What does current
medical literature indicate regarding its etiology?
Inflammatory bowel disease (IBD) is am autoimmune, chronic
inflammatory condition of the gastrointestinal tract. The disease has
two diagnoses: ulcerative colitis and Crohns disease and while they
both fall until the IBD category, they both have very distinct
differences. Current medical literature indicates that the exact etiology
for IBD is still unknown however; the current hypothesis states that its
a combination of environmental and clinical factors that cause an
inappropriate immune response in genetically predisposed individuals.
Some of the environmental factors include smoking, infectious agents,
intestinal flora, diet, and physiological changes in the small intestine.
There is also a strong genetic association with IBD with a percent value
of 5-15% of patients, (Nelms, 418).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
2. Mr. Sims was initially diagnosed with ulcerative colitis and
then diagnosed with Crohns. How could this happen? What
are the similarities and differences between Crohns disease
and ulcerative colitis?
Ulcerative colitis (UC) and Crohns disease are both considered an IBD
so they have similarities between the two diseases but they also have
very distinct differences. Both sexes are affected equally in UC and
Crohns disease. Both diseases mainly develop in teenage years to
young adults, yet they can both occur at any point in a persons life.
The symptoms for both UC and Crohns are also very similar with the
symptoms including abdominal pain, tenesmus (urgency for
defecation), and diarrhea (although the diarrhea with UC is often
bloody). The treatment for Crohns and UC are very similar and include
antibiotics, immunosuppressive medications, immunomodulators, and
biologic therapies. In over 60% of patients with either UC or Crohns, a
surgical intervention is required. UC is chronic with repeated
exacerbations and remissions, while Crohns is rarely ever cured. With
these similarities, Mr. Sims was inappropriately diagnosed the first
time. With many aspects that are similar, the differences between the
two diagnoses are more important. UC is limited to the colon while
Crohns disease can occur anywhere between the mouth and anus. UC
is a constant inflammation of the colon; while in Crohns there can be
healthy parts of the intestine mixed in between inflamed areas, which
are commonly the ileum and colon. Serological markers that include
antibody testing have been used to distinguish between UC and
Crohns disease. Lastly, Crohns disease can occur in all layers of the
bowel walls while UC only affects the inner most lining of the colon,
(Nelms, 418-419).
Cited: Ulcerative Colitis vs Crohn's Disease |Center for Inflammatory
Bowel Diseases. (n.d.). Retrieved September 13, 2015, from
http://gastro.ucla.edu/body.cfm?id=169
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334). Boston, MA:
Cengage Learning.
3. A CT scan indicated bowel obstruction and the Crohns
disease was classified as severe-fulminant disease, CDAI score
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
5. Crohns patients often have extraintestinal symptoms of the
disease. What are some examples of these symptoms? Is there
evidence of these in his history and physical?
Crohns patients can often experience extraintestinal symptoms of the
disease or disease manifestations outside of the GI tract. These
symptoms include osteopenia and osteoporosis, dermatitis,
rheumatological conditions such as ankylosing spondylitis, ocular
symptoms, and hepatobiliary complications. Based on Mr. Sims history
and physical information, he does not show signs of any of these so he
is not experiencing any extraintestinal symptoms, (Nelms 420).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
6. Mr. Sims has been treated previously with corticosteroids
and mesalamine. His physician had planned to start Humira
prior to this admission. Explain the mechanism for each of
these medications in the treatment of Crohns.
Mesalamine is commonly used among Crohns patients and it works to
inhibit inflammatory cell proliferation by interrupting cellular RNA and
by inhibiting the overall immune response. Mesalamine is used with
Crohns disease when the ileal and colon are involved. Corticosteriods
are also anti-inflammatory medications that work to inhibit the overall
inflammatory response. Corticosteriods are often used to treat acute
exacerbations, especially in Mr. Sims case (severe-fulminant), however
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
11. For what classic symptoms of short bowel syndrome should
Mr. Sims health care team monitor?
A classic symptom of short bowel syndrome that Mr. Sims health care
team should monitor is diarrhea. The team needs to monitor his
vitamin and mineral losses since the intestine is unable to absorb
adequate amounts of vitamins A, D, E, and K. Other nutrients that can
become deficient as well are sodium, magnesium, iron, zinc, selenium,
and calcium because they are often lost in large amounts in the
diarrhea, (Nelms, 427).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
12. Mr. 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?
Over the years there has been much controversy on the safety and
efficacy of using high-dose immunosuppression and autologous
peripheral blood stem cell transplantation. Many patients with severe
Crohns disease remain refractory to conventional treatment and this
treatment may help induce remission in these patients. Upon doing
limited trials and research, it has been shown that autoPBSCT is safe
and appears to be effective among patients in order to induce
remission however; the treatment should be further evaluated in
following trials.
Cited:
Hasselblatt, P. (2012, September 2). Remission of refractory Crohn's
disease by high-dose cyclophosphamide and autologous peripheral
blood stem cell transplantation. Retrieved September 13, 2015, from
http://www.ncbi.nlm.nih.gov/pubmed/22937722
13. What are the potential nutritional consequences of Crohns
disease?
Crohns disease affects normal digestion and absorption; therefore
many nutritional consequences can come into play. Some nutrition
diagnoses related to Crohns include malnutrition, inadequate energy
intake, inadequate oral intake, increased nutrient needs, inadequate
vitamin/mineral intake, impaired nutrient utilization, food medication
interaction, and altered nutrition-related laboratory values. Malnutrition
can always be an issue, even when the patient has entered remission.
Protein-calorie malnutrition and other deficiencies can be caused by
decreased nutrient intake, malabsorption, drug-nutrient interactions,
anorexia, and protein-losing enteropathy. The severe abdominal pain
can cause patients to not want to eat and the excessive diarrhea can
cause patients to become calorie deficient and malnourished. When
there is inflammation or infection, protein needs are increased, in some
cases they go up to 150% of daily energy needs. Crohns patients are
also at risk for deficiency of micronutrients including calcium, vitamin
D, vitamin B12, iron, zinc, and magnesium. These micronutrients need
to be monitored due to malabsorption and losses in diarrhea. If the
Crohns patient decides to undergo new medication or surgery, these
nutritional risks compound those of the disease process. The use of
corticosteroids can result in hyperglycemia, nitrogen wasting, and
osteoporosis. The use of sulfasalazine can interfere with folate
metabolism and surgery will increase the protein and calorie needs
along with the need for additional nutrients, (Nelms, 421).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
14. Mr. Sims underwent resection of 200 cm of jejunum and
proximal ileum with placement of jejunostomy. The ileocecal
valve was preserved. Mr. Sims did not have an ileostomy, and
his entire colon remains intact. How long is the small intestine,
and how significant is this resection?
The small intestine is about 7 meters or 22 feet on average making it
the longest section of the digestive tube. The organ is made up of
three segments: the duodenum, the jejunum, and the ileum. The
duodenum is the shortest portion of the intestine (0.5m) and continues
the digestion process from your stomach. The jejunum (2-3m) rapidly
carries the food with wave-like contractions towards the ileum. The last
section of the intestine, the ileum, is the longest part (3-4m) and this is
where most nutrients from the food are absorbed. Fortunately for Mr.
Sims, no resection was done regarding his ileum and his ileocecal valve
was preserved and his colon remains intact. With his jejunum being
shorter, the surface area is reduced so the transit from the jejunum to
the ileum will be shorter than normal. However, with the ileum being
untouched, this is good news for Mr. Sims so that he can absorb the
nutrients needed. The preservation of his ileocecal valve is also
beneficial in order to absorb vitamin B12 and bile acid.
Cited: Organs: Small and Large Intestine. (n.d.). Retrieved September
13, 2015, from http://www.chp.edu/CHP/organs intestine
Reference
Range
6-8
3.5 - 5
16-35
< 1.0
>45 M
Neg
2/15 1952
14-17 M
40-54 M
215-365 M
20-300 M
30-80
30-100
12.9 (low)
38 (low)
180 (low)
16 (low)
85 (high)
22.7 (low)
5.5 (low)
3.2 (low)
11 (low)
2.8 (high)
38 (low)
+ (low)
(ng/mL)
Free retinol (vitamin A)
20-80
17.2 (low)
Ascorbic acid (mg/dL)
0.2 2.0
<0.1 (low)
Above are significant values regarding Mr. Sims laboratory results.
20. Select two nutritional problems and complete a PES
statement for each.
Inadequate protein intake (NI-5.7.1) related to decreased ability to
consume sufficient amounts due to Crohns diagnosis as evidenced by
a clients history of Crohns, a total protein level of 5.5 g/dL, an
albumin level of 3.2 g/dL, and a prealbumin level of 11 mg/dL.
Inadequate energy intake (NI-1.2) related to decreased ability to
consume foods due to Crohns disease as evidenced by weight loss of
16% in the past 6 months, history of Crohns, severe abdominal pain,
and diarrhea.
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?
The nutrition support team should evaluate his fluid and electrolyte
levels as well as his required nutrient intake. Since he will be in the first
phase of pre-op SBS, he will be experiencing large volumes of diarrhea
which will contribute to fluid and electrolyte losses. Mr. Sims will be
dependent on the parental nutrition in this phase. After several
months, Mr. Sims should slowly be moved to an enteral nutrition. There
will be a reduction in his diarrhea volume but fluids and electrolytes
should still be watched. Around this time there should be a gradual
transition to an oral diet as well. Since they did a resection of the
jejunum, his nutrients such as carbohydrates and protein, should be
watched to make sure they are getting absorbed at the proper
amounts. Since his lab values for protein have been low, these should
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).
Based on my first PES statement, I recommended that Mr. Sims start to
intake more protein through the PN diet and hopefully begin to take in
more protein orally within the next few months. He can do this by
either taking protein supplements or by increasing his consumption of
protein-based foods such as meat, chicken, and/or eggs. His daily
protein levels are below average and I would like his protein levels to
be around the recommended value of 95-110 g.
Based on my second PES statement, I would like Mr. Sims to start
increasing his energy intake. His recommended energy intake is
between 2,300 and 2,400 kcal/day. If he starts consuming more
calories with the PN support, this will help increase his intake, therefore
help him gain the weight that he lost back. I would like to see him gain
enough weight to be back to the recommended weight for a male his
height/age, 166 lbs. By increasing his caloric intake, monitoring his lab
values to make sure he is absorbing the right amount of nutrients and
watching his abdominal pain/diarrhea, he should be able to gain at
least 1 pound a week.
26. Indirect calorimetry revealed the following information:
Measure
Oxygen consumption (mL/min)
CO2 production (mL/min)
RQ
RMR
2022
What does this information tell you about Mr. Sims?
Indirect calorimetry is a technique that provides accurate estimates of
energy expenditure by using measurements of CO2 production and
oxygen consumption during rest and then again at steady-exercise.
Based on Mr. Sims results, his oxygen consumption is 295 mL/min,
which above the average of 250 mL/min. When that value is divided by
his CO2 production value of 261 mL/min (average 200 mL/min), his
respiratory quotient was calculated to be 0.88. Based on all of this
information, it shows that Mr. Sims is burning his protein stores during
metabolism. Lastly, it shows that his resting energy intake should be
2022 kcal/day, (Nelms, 105).
Cited: Robergs, R. (2010). Indirect Calorimetry. Retrieved September
13, 2015, from http://www.unm.edu/~rrobergs/426L11IndCalorim.pdf
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334). Boston, MA:
Cengage Learning.
27. Would you make any changes to his prescribed nutrition
support? What should be monitored to ensure adequacy of his
nutrition support? Explain.
I would make a few changes to Mr. Sims prescribed nutrition support.
As calculated in questions 17-18, his estimated energy requirements
and protein requirements are 2,358 kcal/day and 95-110 g/day
respectively. I would increase his amino acids that so that was
receiving at least 95 grams of protein a day. With his goal PN, he is
only receiving roughly 87 grams per day. This is needed to make sure
his level of protein doesnt fall below the recommended daily amount
and to help aid in the healing process from his resection. I would keep
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
29. Mr. Sims serum glucose increased to 145 mg/dL. Why do
you think this level is now abnormal? What should be done
about it?
Increased serum glucose can result from metabolic stress, dehydration,
or parenteral nutrition overfeeding. A complication from PN is
hyperglycemia and patients are usually at high risk. His daily dosage of
dextrose that he is receiving from PN should be reduced until the blood
sugars stabilize. He should be closely monitored until his lab results
can be evaluated and returned to normal.
Cited: Adult Enteral Feeding Policy. (2015, February 1). Retrieved
September 13, 2015, from
https://www.ashfordstpeters.info/images/policies/PAT108.pdf
30. Evaluate the following 24-hour urine data: 24-hour urinary
nitrogen for 12/20: 18.4 grams. By using the daily input/output
record for 12/20 that records the amount of PN received,
calculate Mr. Sims nitrogen balance on postoperative day 4.
How would you interpret this information? Should you be
concerned? Are there problems with the accuracy of nitrogen
balance studies? Explain.
N2 balance = (dietary protein intake/6.25) urine urea nitrogen 4
(Nelms, 58)
N2 balance = (86.7 g/6.25) 18.4g 4 = -8.5g
Mr. Sims nitrogen balance was calculated to be a -8.5g. This is
interpreted at Mr. Sims currently being in a negative nitrogen balance.
A negative nitrogen balance develops when nitrogen excretion is
order to monitor his daily intake and also to reevaluate his weight and
BMI to make sure he gets back to the normal range of 166-168 lbs. His
lab results will also need to be reevaluated to ensure that he is getting
adequate protein, albumin, and prealbumin intake (Nelms, 422-423).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular
System. In Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334).
Boston, MA: Cengage Learning.
References:
Adult Enteral Feeding Policy. (2015, February 1). Retrieved September 13, 2015, from
https://www.ashfordstpeters.info/images/policies/PAT108.pdf
Crohn's disease. (2012, December 12). Retrieved September 13, 2015, from
http://umm.edu/health/medical/reports/articles/crohns-disease
Hasselblatt, P. (2012, September 2). Remission of refractory Crohn's disease by high-dose
cyclophosphamide and autologous peripheral blood stem cell transplantation.
Retrieved September 13, 2015, from
http://www.ncbi.nlm.nih.gov/pubmed/22937722
Humira: Medication Guide. (n.d.). Retrieved September 13, 2015, from
http://www.fda.gov/downloads/Drugs/DrugSafety/ucm088611.pdf
Jeejeebhoy,K.(2002,May14).Shortbowelsyndrome:Anutritionalandmedical
approach.RetrievedSeptember14,2015,from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC111082/
Nelms, M., Sucher, K., & Lacey, K. (2016). Disease of the Cardiovascular System. In
Nutrition Therapy and Pathophysiology (Third ed., pp. 292-334). Boston, MA:
Cengage Learning.
Organs: Small and Large Intestine. (n.d.). Retrieved September 13, 2015, from
http://www.chp.edu/CHP/organs intestine
Phosphorus blood test: MedlinePlus Medical Encyclopedia. (2013, October 29).
Retrieved September 13, 2015, from
https://www.nlm.nih.gov/medlineplus/ency/article/003478.htm
Robergs, R. (2010). Indirect Calorimetry. Retrieved September 13, 2015, from
http://www.unm.edu/~rrobergs/426L11IndCalorim.pdf