Crohns Disease Case Study

F&N 434

Michael Sims was diagnosed with Crohns disease 18 months previously. He is now admitted with an acute
exacerbation of that disease.

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 1. What is inflammatory bowel disease? What is known about its etiology?

Inflammatory bowel disease is more of a term that is used to describe disorders that involves chronic
inflammation of the GI tract; Ulcerative Colitis and Crohns disease. The cause of inflammatory bowel disease
is not exactly known; however, it does involve genetic and environmental factors (dietary, stress, autoimmune
disorders).

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?

Crohns disease and ulcerative colitis are very similar, in that they share many of the same clinical
characteristics and are both treated the same way. For example, an individual may be experiencing symptoms of
diarrhea, fever, weight loss, anemia, food intolerances, malnutrition, growth failure, and extra intestinal
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manifestations in both Crohns and ulcerative colitis. Crohns can involve inflammation anywhere in the gut
(mouth to anus). Ulcerative colitis is where inflammation starts from the bottom, up. Ulcerative colitis usually
involves bleeding, whereas Crohns is characterized by abscesses, fistulas, fibrosis, submucosal thickening,
localized strictures, narrowed segments of the bowel, and complete or partial obstruction of the intestinal lumen.

3. What are the potential nutritional consequences of Crohns disease? Are there any specific concerns
when there is disease in the jejunum and ileum?

The potential nutritional consequences of Crohns disease include macronutrient and micro nutrient
deficiencies. In the jejunum, a person is at risk for lipid, monosaccharide, amino acid, and small peptide
absorption issues. Also, due to the upper half of the small intestine being inflamed, a person may experience
cramps after meals, diarrhea, or abdominal pain. In the ileum, a person may have a vitamin C, folate, vitamin
B12, D, K, or magnesium deficiency.

4. Calculate the patients IBW, %IBW, %UBW. Explain the nutritional risk associated with each value.

IBW: 9 x 6= 54+106= 160#

%IBW=140/160=0.875x100=87.5% mild deficit; this patient weighs less than his ideal body weight that can put
him at risk for longer hospital stay, excessive nutrient losses, increased muscle loss or impaired absorption.
%UBW=140/166-168=0.84-0.83x100=84-83%; this patient weighs less than his usual body weight and is a
more useful measure to look at when someone is ill, like in this case. He is losing weight unintentionally.

5. Using his admission chemistry and hematology values, anthropometric data, and other history and
presenting conditions, is the patient at nutritional risk?
List all of the laboratory values that support your assessment of nutritional risk and what nutrients (if
any) are of concern?)

This patient is at nutritional risk due to recent flare up that occurred from his Crohns disease. His albumin of
2.7 shows that he is experiencing inflammation in the body. Inflammation is present in the Ileum, which is
causing malabsorption of magnesium (1.4). The inflammation of the ileum is also causing the patient to
experience severe abdominal pain, that is resulting in him not consuming enough energy throughout the day.
Pre-albumin is low (16), indicating stress response. Patient is experiencing diarrhea, which may result in
electrolyte loss or dehydration. Labs do not show the patient is dehydrated, however, labs do reveal patient is
deficient in magnesium. WBC is high, indicating infection, inflammation, and high stress. Transferring is high
(422), indicating iron deficiency due to blood loss from fistulas and abscesses. This patient is at nutritional risk
and is malnourished considering laboratory values, anthropometric data, and presenting conditions.

6. Explain how each of the following abnormal labs is related to his diagnosis.

Albumin-In this case, albumin is below the normal range, indicating that inflammation is probably a key factor
to his flare up.
WBC-His WBC is above the normal range, indicating that an acute phase response is occurring.

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Mg and K-Mg is below the normal range, indicating that patient could have lost mineral through reported
diarrhea. He could also have an insufficient dietary intake or malabsorption is occurring in the in the ileum.
Corticosteroid use may cause magnesium to not be absorbed properly, be sure to monitor this. Potassium lab
value are normal, however borderline to below normal. Carefully watch K as inflammation is present in the
ileum, where K is absorbed and also patient experiencing diarrhea which can lead to mineral loss.
Cholesterol-Low cholesterol, indicating malnutrition in acute care setting malabsorption, skin breakdown or
malabsorption.
Hgb-Hemoglobin is within the normal range. Hgb is often tested in patients with IBD because anemia is often
correlated with IBD d/t impaired absorption and continuous blood loss leading to depletion of iron stores.

7. Dr. Tucker started Mr. Sims on methylprednisolone; metronidazole; ciprofloxacin. What are these
medications? What are the potential drug-nutrient interactions?
Resources: http://extension.colostate.edu/topic-areas/nutrition-food-safety-health/nutrient-drug-interactions-
and-food-9-361/
http://www.foodmedinteractions.com/

Methylprednisolone-decreases immune systems response to reduce swelling and pain. It is a coricosteriod

hormone. May cause sodium and water retention. May increase bodys loss of magnesium, vitamin K, C,
selenium and zin. May reduce absorption of calcium.
Metronidazole-used to treat infections caused by bacteria and fungi. May be taken with food to decrease
stomach upset, but food decreases bioavailability. Avoid alcohol.
Ciprofloxacin-antibiotic used to treat a variety of bacterial infections. Avoid drinking large amounts of caffeine
(cola), and chocolate. This drug may increase or prolong the effects of caffeine.

8. Dr. Tucker asked for a nutrition consult for enteral tube feeding. Do you agree that the patient would be
a candidate for enteral feeding? Why or why not?

I think that this patient could be a candidate for enteral feeding, however, I believe that this patient has been
able to control his flare ups very well according to his compliance in the past with following the low fiber diet. I
think that identifying what foods may trigger his flare ups is the best nutritional treatment at this time. Low
fiber/low residue foods should be slowly reintroduced back into his diet and MNT for Crohns should be
addressed by the RD. The RD should also counsel the patient regarding his cola intake, which may be the
source of the flare up. Cola has caffeine in it, which could interact with his medications. Caffeine can also cause
a lot of stimulation in the GI tract. The easiest protein for him to digest at this time would be shredded chicken
or eggs. Avoiding lactose at this time would also be a recommendation due to being hard to digest because they
are absorbed in the lining of the intestine. These low residue foods should also normalize the patients bowel
movements. Patient may also benefit from calcium and vitamin D supplementation due to corticosteroid usage.

9. Look at Mr. Simss labs on day 2 of his admission.

a. Why do you think his albumin has decreased to 2.7 mg/dL? What are the limitations of
evaluating albumin as a measure of short-term nutritional status?

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His albumin may have decreased due to the presence of inflammation, that could have occurred due to physical
stress on the body. Albumin is a negative acute phase protein and falls gradually in chronic inflammatory
diseases. This is why evaluating albumin cannot be used to measure protein status in patients especially who are
experiencing inflammation.

Admission 2
Michael Sims is readmitted 2.5 years after his initial diagnosis of Crohns disease. He undergoes a resection of
200 cm of jejunum and proximal ileum with placement of jejunostomy because of a small bowel obstruction.

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 10. Mr. Sims has had a 200-cm resection of this jejunum and proximal ileum. Is this a significant amount of
his intestine with regards to his nutritional status? Explain

In adults, the jejunum is typically 160-200cm in length. His jejunum is being completely removed and is
considered a significant amount of his intestine. The jejunum is important because this is where fat is absorbed,
however, when the jejunum is removed, the ileum will assume the role of fat absorption. Since proximal
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amounts of the ileum are being removed, steatorrhea may occur due to decreased absorption of fat by the
intestine. Nutritionally, it is important as the dietitian to monitor macronutrient absorption, micronutrient
absorption, hydration status, and to physically assess the patient to determine a nutrition plan or goal.

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

The jejunum and the ileum are the most important parts of the small intestine for absorption. The ileum can be
much more adaptive though and in this case the patient still has part of the ileum. Complete resection of the
jejunum may result in fat, amino acid and CHO malabsorption/digestive issues. Thiamin, riboflavin, niacin,
biotin, vitamin C, vitamin B6, fat soluble vitamins, phosphorus, iron, zinc, and magnesium are all absorbed in
the jejunum and the patient may experience nutrient deficiency in these.

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

Since phosphorus and magnesium are at the low end of the normal range, this could indicate that may be
experiencing diarrhea or fluid loss. This could also be because he is unable to tolerate or absorb sufficient
amounts of magnesium. Low phosphorus could also indicate hypothyroidism and low magnesium could
indicate hyperparathyroidism. This may lead to a loss in calcium and result in other issues. Phosphorous and
magnesium levels should be monitored and evaluated by the RD regularly. Low phosphorous and low
magnesium can also indicate refeeding syndrome along with other contributing factors.

13. What is refeeding syndrome? Explain the etiology. Is Mr. Sims at risk for this syndrome? How can it be
prevented? How do you correct it nutritionally?

Refeeding syndrome occurs when energy substrates, usually CHO, are introduced into the plasma of anabolic
patients. Rapid infusion of CHO stimulates insulin release, which reduces salt and water excretion and increases
the chance of fluid overload. If electrolytes such as, magnesium, phosphorus, and potassium are not supplied in
sufficient quantity to help with tissue growth, deficiencies may occur. To prevent refeeding, parental nutrition is
in place to start the amount of CHO distributed, slowly. It is important to monitor the levels of minerals and to
supplement if needed.

14. The surgeon notes that Mr. Sims probably will not resume eating by mouth for at least 7-10 days. What
influence would this have on deciding the route for nutrition support?

Post op complications such as, obstructions, fistulas, or leaks may occur. Parental nutrition support is best for
the patients current health situation. Advancement of his diet after 7-10 days will be evaluated by patient
tolerance. While patient is on parental support, it is important for the RD to monitor and maintain fluid balance,
electrolyte balance, and avoid episodes of diarrhea. The RD is to determine the amount of caloric intake to meet
his nutritional needs; CHO, fat, protein, and micronutrients.

15. Is Mr. Sims a likely candidate for short bowel syndrome diagnosis? Define short bowel syndrome.

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Short bowel syndrome can be defined as inadequate absorptive capacity resulting from reduced length or
decreased functional bowel after resection. People with short bowel syndrome cannot absorb protein, fat,
calories, minerals, water, vitamins, and other nutrients. The small intestine is approximately 600cm in length.
This patient had only 200cm removed of his small intestine. Since the ileum is very adaptive and over 2/3 of the
small intestine has to be removed in order for short bowel syndrome to occur, I do not believe that this patient is
a candidate. If this patient continues to experience obstructions, short bowel syndrome may be relevant then.

16. On postop day 10, Mr. Simss team notes that he has had bowel sounds for the previous 48 hours. The
nutrition support team recommends consideration of an oral diet. What foods should Mr. Sims be
allowed to try first? What would you monitor for tolerance?

Advancement of patients diet depends on his tolerance and extent of his surgery. About 75% of his nutrient
needs should be met orally before the parenteral nutrition is d/cd. I would transition the patient to clear liquids
and then once tolerated he should progress to low-fat, low-fiber, high-protein and high calorie foods at first for
the GI tract to regain function. Small frequent meals are encouraged vs. three large meals. I would monitor
food/fluid intake, meal behavior, weight, bowel movements, and electrolytes for tolerance.

17. What are the major MNT concepts important in this case? List 3 take away concepts.

1. To be able to determine the best route of nutritional support for this patient, whether it be parental
nutrition, enteral nutrition, or oral route.
2. To address and correct the symptoms that interfere with adequate oral intake to prevent malnutrition and
compensate for malabsorption.
3. To provide individual nutrition education for the patient to be able to maintain and prevent GI
problems/flare ups in the future.

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