CASE STUDY:

AN EVALUATION OF THE
NUTRITIONAL CARE OF A SURGICAL
PATIENT WITH CROHNS DISEASE

Taylor Palm
URI NFS 561
Topics To Be Covered
Overview of Crohns Disease
Subjective/Objective Data of the Patient
Nutrition Care Process
Dietary Rationale for Crohns patients:
flares v. remission and post-op
Effectiveness of Nutritional Care
Crohns Disease
Inflammatory bowel disease
Segmented inflammation can occur along any
part of the gastrointestinal tract 1,2
Periods of active inflammation and remissions3
Symptoms: diarrhea, constipation, vomiting,
abdominal pain, malabsorption, anorexia and
weight loss1,2
Complications: Fistulae, fissuring ulceration,
abscesses, hemorrhage, scarring, bowel
perforation, narrowing or obstruction1,3
Nutritional complications can include:
malnutrition, anorexia, unintentional weight loss, Inflammation of Crohn's.
and deficiencies1 http://www.onhealth.com/content/1/croh
ns_disease. Accessed December 5,
2016.
Subjective/Objective Data
Patient: 42 y/o female
Ht/Wt: 177.8cm (510) and 65.9kg (145#)
Weight History: 17# (10.5%) weight loss in the past 5 months
Social hx: Unemployed; lives with husband who does the cooking and
food shopping
PMHx: Crohns disease and anemia, no surgical hx
Food/Nutrient interactions or allergies: None
Medications prior to admission: Anti-anxiety medications and
Mesalamine
Diet hx: Patient eating <75% of meals, following a low fiber diet
Subjective/Objective Data
Admission diagnosis: Uncontrolled Crohns disease with an enterocolic
fistula
Lab values: low potassium, magnesium, phosphorous, H/H and MCH,
other labs WNL
Surgical Intervention: Exploratory laparotomy, lysis of adhesions,
abdominoperineal proctocolectomy with end ileostomy, and
enterocolic fistula take down
Medication post-operation: Pain medications, Zofran, Compazine,
antibiotics, potassium chloride, Mag-ox, phosphate and intravenous
fluids
Total Proctocolectomy with End
Ileostomy

Total Proctocolectomy. Johns Hopkins Medicine

https://gi.jhsps.org/GDL_Disease.aspx?
CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F-
E79D2B9FC358&GDL_Disease_ID=5F8BA0A9-ACCC-43B8-9815-
7976ABA08EE2. Accessed December 5, 2016.
Subjective/Objective Data
Diet: NPO perioperatively, advanced to a clear liquid diet
when ostomy output was noted, advanced to a low-fiber
diet after 24 hours
2-day calorie count:
Day 1 on clears: 2 Ensure clears, low sodium chicken broth, and a
diet iced tea (450 kcal and 15 g/protein)
Day 2 on low-fiber diet: white bagel, 2 Ensure Enlives, and
American cheese omelet (1,000 kcal and 55 g/protein)
Malnutrition Assessment: Moderate malnutrition as
evidenced by >10% weight loss in 6 months and pt reported
eating less than 75% of meals for >1 month. No muscle
wasting, fat wasting or fluid retention. A hand dynamotor
assessment was not performed.
Patient Needs
Energy needs (25-30kcal/kg) : 1647-1977 kcal/day
Protein needs(1.2-1.5g/kg) : 80-99g/day
IBW: 150#
%IBW: 96.7%
ADIME
Assessment: complete
Diagnosis:
PES statement: Inadequate oral intake related to poor appetite as evidenced by 2 day
calorie count, >10% weight loss in 6 months, and intake less than 75% of meals for >
1 month
Intervention:
inpatient diet education on clear liquids and low fiber
verbal and written education on ileostomy diet for discharge
Ensure Enlive TID
Recommendation to primary team to replete phosphorous, magnesium and potassium
Monitor/Evaluate:
Weight change
Labs- specifically potassium, magnesium, phosphorous
Acceptance of nutrition supplements
Oral intake
MNT Goals
Short term dietary goals: Meet energy and protein needs on
a low fiber diet by increasing oral intake to at least 75% of meals and
supplementing Ensure Enlive three times daily, maintain adequate
hydration, and patient verbalized understanding of ileostomy diet
education.
Long term dietary goals: Adequate oral intake, weight
restoration and maintenance, compliance with ileostomy diet, as well
as preventing nutrient deficiencies.
Dietary Rationale- Flares/Remission

Flare Up:
Low Fiber diet with special attention to possible nutrient
deficiencies1,4
Remission:
Limited studies/mixed results on fiber during remission 5,6
Individualization
Elimination diet7
Surgery Overview
Up to 70% of patients with Crohns disease will
require surgery at some point in their disease
course3
Surgeries can include resections, abscess
drainage, or strictureplasty8
May be required for hemorrhages, perforations or
obstruction8
A total proctocolectomy which removes the colon
and rectum is associated with a lower rate of
recurrence8
Dietary Rationale- Post-op Clears/Low Fiber

Clear liquid diet8,9 Low Fiber diet

Transparent fluids Studies in favor of
Easily tolerated solid foods over clear
Difficult to meet liquid diet post-
energy/protein operation10,11,12
needs
Dietary Rationale- Ileostomy Diet
Allows the bowel to heal and avoid obstructions in the
ileostomy13
Roughly 6 weeks
Small frequent meals and low fiber foods as tolerated
Avoid gastric irritants like greasy, spicy, acidic foods and
high sugar foods
Specific foods to control the ostomy stool output with
special attention to adequate hydration
Effectiveness of Nutritional Care
Magnesium, potassium and phosphorous were
repleted and found to be within normal limits,
prealbumin low
Energy/protein needs not met from oral intake
during stay
Clear liquids v. Low fiber post-surgery?10,11,12
Better encouragement for oral intake and
supplements
Normal ostomy output w/o nausea or vomiting
Patient receptive to dietary education
Effectiveness of Nutritional Care
Follow-up appointment
Crohns in remission
5# weight gain
improved appetite
Labs within normal limits.
Referral to outpatient
dietitian
Elimination diet
Conclusion
Recommendations for direction of future
research
Successful hospital course for Crohns
patient
Lifelong medical, dietary and possible
further surgical management of the disease
will continue
References:

1. Basson a. Nutrition management in the adult patient with Crohns disease. South African J Clin Nutr. 2012;25(4):164-172.
2. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier
Saunders; 2012.
3. Wilhelm SM. Impact of Inflammatory Bowel Disease. Am J Manag Care. 2016;22:S32-S38.
4. Santucci NR, Alkhouri RH, Baker RD, Baker SS. Vitamin and Zinc Status Pretreatment and Posttreatment in Patients with
Inflammatory Bowel Disease. J Pediatr Gastroenterol Nut.r 2014; 59:455457.
5. Academy of Nutrition and Dietetics. DF: gastrointestinal disease (2008). Evidence Analysis Library.
https://www.andeal.org/topic.cfm?menu=1586&cat=3471. Published 2008. Accessed November 20, 2016.
6. Brotherton CS, Taylor AG, Bourguignon C, Anderson JG. A high-fiber diet may improve bowel function and health-related quality of
life in patients with Crohn disease. Gastroenterol Nurs Off J Soc Gastroenterol Nurses Assoc. 2014;37(3):206-216.
doi:10.1097/SGA.0000000000000047.
7. Nguyen DL, Limketkai B, Medici V, Mendoza MS, Palmer L, Bechtold M.Nutritional Strategies in the Management of Adult Patients
with Inflammatory Bowel Disease: Dietary Considerations from Active Disease to Disease Remission. Curr Gastroenterol Rep. 2016;18:
55. doi:10.1007/s11894-016-0527-8.
8. Lichtenstein GR, Hanauer SB, Sandborn WJ. Management of Crohns disease in adults. Am J Gastroenterol. 2009;104(2):465-83, 484.
doi:10.1038/ajg.2008.168.
9. Warren J, Bhalla V, Cresci G. Postoperative diet advancement: surgical dogma vs evidence-based medicine. Nutr Clin Pr.
2011;26(2):115- 125. doi:10.1177/0884533611400231.
10. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the
Adult Critically Ill Patient. Vol 44.; 2016. doi:10.1097/CCM.0000000000001525.
11.Lau C, Phillips E, Bresee C, Fleshner P. Early use of low residue diet is superior to clear liquid diet after elective colorectal surgery: A
randomized controlled trial. Ann Surg. 2014; 260(4): 641-7; discussion 647-9. doi: 10.1097/SLA.0000000000000929.
12.Sharma M, Wahed S, ODair G, Gemmell L, Hainsworth P, Horgan AF. A randomized controlled trial comparing a standard
postoperative diet with low-volume high-calorie oral supplements following colorectal surgery. Color Dis. 2013;15(7):885-891.
doi:10.1111/codi.12168.
13. Academy of Nutrition and Dietetics. Ileostomy Nutrition Therapy. Nutrition Care Manual.
https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=344. Accessed November 20, 2016.