MED/SURG CASE STUDY

Crohn’s Disease
The client is a 34 year old woman with a ten year history of Crohn’s ileocolitis. She
presents with diarrhea, abdominal pain, and weight loss for the past three weeks, which
has not responded to treatment with mesalamine and budesonide. She also has a past
medical history of nephrolithiasis. She is a single mother who works full time as an
operating room assistant and has three school age children.

1. Anthropometric Measurements
Ht: 5’4”
Wt: 140 lbs.
Usual wt: 150 lbs.
Wt change: 10 lbs. loss in the past 3 weeks

2. Biochemical Data & Test Results

a. Labs

Parameter Value

Sodium 145 mEq/L

Potassium 3.6 mEq/L

Chloride 110 mEq/L

Carbon Dioxide 22 mEq/L

BUN 32 mg/dL

Creatinine 1.3 mg/dL

Glucose 140 mg/dL

Albumin 3.0 g/dL

C-reactive
protein 6 mg/dL

Folate 174 mg/dL

Vitamin B12 162 ng/dL

Iron 20 mcg/dL

Ferritin 6 ng/mL

b. Pertinent test results:

A CT scan of the abdomen and pelvis revealed thickening of terminal ileum and cecum and
inflammatory changes in the mesenteric fat along the right colon. Nephrolithiasis
noted in kidney. No obstruction of the small bowel was noted.
 3. Nutrition-Focused Physical Findings
Abdominal exam revealed mild right lower quadrant (RLQ) tenderness with no guarding or
rebound. Temperature was 100.8 F. Pulse 112 bpm. Blood pressure 95/65 mm Hg.
Respirations 20 breaths per minutes.

4. Client History
Social History: She smokes ½ pack per day. Drinks alcohol socially.

5. Food/Nutrition-Related history
Usual diet prior to present illness: The patient generally skips breakfast. She eats lunch in the
cafeteria at work where she often chooses salad bar with iceberg lettuce, chicken salad,
macaroni salad, cheese, croutons, and creamy dressing. She drinks a large serving of
fruit drink. When she gets home from work, she gets busy with her children’s activities
and homework, and often relies on fast food. Sometimes she heats up frozen chicken
nuggets and French fries or macaroni and cheese for dinner, along with some canned
fruit in syrup. She drinks chocolate milk with dinner. At night she has a bowl of ice cream
with her kids before going to bed.
Over the past three weeks, she has been taking mostly liquids due to her pain and diarrhea. She
primarily drinks fruit punch and tea.

Medications
Mesalamine 4.8 g/day
Budesonide 9 mg daily
Started on IV methylprednisone 20 mg every 12 hours

QUESTIONS

1. Draw a picture of the GI tract and specify where specific macro- and micro-nutrients are
digested and absorbed.
2. What factors led to inadequate intake in this patient? ​Pain and diahrrea
What percentage of her UBW has she lost? ​Lost 6.6% of UBW in 1 week, severe
weight loss
What are some other factors that might lead to poor intake in individuals with Crohn’s?
Poor absorption and having to go to the bathroom all the time, medications with
side effects, stressful life.

3. What specific nutrients might she have difficulty absorbing due to her ileal disease? ​Bile
salts, vitamin C, B12, vitamin D, vitamin K, Mg
Which nutrients might be at risk due to drug-nutrient interactions?
Drug interactions
- Mesenalanine causes constipation, diarrhea, abdominal cramps, and
decreased renal function.
- Budesonide causes glossitis, tongue edema, dyspepsia, nausea, enteritis
- Methylprednisone causes increased appetite, weight gain, bloating, and
dyspepsia.

4. What nutrients is she likely to be losing in the diarrhea? ​electrolytes and water

5. What is C-reactive protein and how might it be used in this type of patient? ​CRP is
produced by the liver when inflammation is present. This will show that she is in
an inflammatory state.
Which of her biochemical lab values indicates that she is anemic and why? ​Ferritin can
be falsely high during an inflammatory state. However, in this case it is low,
indicating the patient has low iron stores and is anemic.

6. Is her nephrolithiasis history related to her Crohn’s, and if so, why? ​CD causes fat
malabsorption because bile salts cannot be as readily absorbed. The fat then binds
to calcium leaving the oxalates (salt), which is deposited in the kidney where it can
form stones. Recommend foods with low oxalates for people with CD.
Are there nutritional measures that could help to decrease her risk for further problems
with kidney stones? ​Increase fluid intake and increase to 5 servings of fruits and
vegetables to prevent stone formation.

7. What type of oral diet would you recommend for her in the short term? ​Low residue,
encourage fluids, and high protein.

8. Under what circumstances would you consider enteral or parenteral nutrition for an
individual with Crohn’s? ​If they continue to have severe weight loss and protein
intake is less and 25% of estimated needs. Or if the patient has surgery to remove
part of the GI and is in recovery, but still need nutrition for healing.

9. Identify an appropriate nutrition diagnosis and write a PES statement based on the
available nutrition assessment data. ​Malnutrition related to reduced PO as evidenced
by 6.6% weight loss in 3 weeks.

10. What are your goals for this patient, and how would you monitor the effectiveness of
treatment?
1. consume small frequent meals with increased protein.
2. drink calories (include a supplement) if chewing food is too difficult.
3. increase fluids..
4. keep a food diary to monitor what “trigger” foods are.

Monitor weight gain and patient verbalizes understanding about diet prescription.