Kristi Spencer 4-15-15 FCS 448- Clinical Dietetics II Cast study 11- Crohn’s Disease p 115 1. 1pt 1pt pag page e 415 415-4 -416 16 Ina!!atory "o#el Disease $I"D% is an autoi!!une& chronic ina!!atory condition o' the gastrointestinal tract. I"D can (e either ulcerati)e colitis or Crohn’s Disease. I"D generally is characteri*ed (y diarrhea $#hich !ay or !ay not contain (lood%& a(do!inal pain& 'e)er& #eight loss& ane!ia& !alnutrition& arthritis& arthritis& s+in changes& and li)er in)ol)e!ent. ,he etiology 'or I"D is un+no#n (ut en)iron!ental en)iron!ental and genetic 'actors ha)e (een associated #ith I"D. ,he en)iron!ental en)iron!ental 'actors can include in'ectious agents& intestinal intestinal ora& a(nor!al ina!!ation o' the s!all intestine& and s!o+ing. S!o+ing is one o' the (iggest ris+ 'actors that can (e controlled. enetics is a 'actor (ecause a positi)e 'a!ily history puts a person !ore at ris+ 'or I"D& also pre)alence is higher in Caucasian and sh+ena*i /e#ish ancestry. 0. pt pt pag page e 415 415-4 -412 12 ,his !ay ha)e happened happened (ecause (ecause ulcerati)e colitis colitis and Crohn’s Crohn’s Disease Disease are (oth considered to (e ina!!atory (o#el diseases that trigger an a(nor!al i!!une response in the gastrointestinal !ucosa. ,hey also can (oth ha)e ti!es o' re!ission and ha)e !any o' the sa!e sy!pto!s that !ay result in con'usion. lso the tests that are done to help #ith diagnosing are si!ilar. ,he test done 'or 'or ulcerati)e colitis colitis include3 include3 a(do!inal ultrasound& ultrasound& I& I& C,& SC7C& Calprotectin& lacto'errin& pol!orphonuclear neutrophil elastase& colonoscopy& and (ariu! ene!a. ,he tests done 'or Crohn’s Disease include3 a(do!inal ultrasound& I& C,& SC7C& Calprotectin& Calprotectin& lacto'errin& pol!orphonuclear pol!orphonuclear neutrophil elastase& D& and upper I series. di9erence (et#een these test is that SC is !ore speci:c 'or Crohn’s disease& #hereas 7C is !ore speci:c 'or ulcerati)e colitis. di9erence (et#een the! is that ulcerati)e colitis typically #ill a9ect one area o' the I tract& the colon. Crohn’s Disease s+ips around a9ecting !any di9erent portions o' the I tract& and a9ecting all layers o' the !ucosa. ;ne di9erence di9erence in sy!pto!s that people generally e
ccording to the 7C=& ulcerati)e colitis and Crohn’s Disease can (e distinguished 'ro! each other (e loo+ing at the sy!pto!s& gastrointestinal in)ol)e!ent& (iopsy& and anti(ody testing. . pt pt pa page 41 412 2 CDI score o' 4>> usually indicates that the patient is in a !oderate to se)ere disease stage. ,his suggests that the patient has not responded to the treat!ents so 'ar or ha)e sy!pto!s that include 'e)er& signi:cant #eight loss& a(do!inal pain or tenderness& inter!ittent nausea )o!iting #ithout o(structi)e :ndings& and signi:cant ane!ia. classi:cation o' ser)e-'ul!inant disease is usually co!(ined #ith a CDI score o' !ore than 45>. It also suggests that the patient has ongoing sy!pto!s e)en #hile ta+ing !edication such as steroids or (iologic agents. Sy!pto!s include a high 'e)er& persistent )o!iting& intestinal o(struction& re(ound tenderness& tenderness& cache
C-reacti)e protein protein is an indicator that he is getting #orse. ,his is (ecause Ceacti)e =rotein is ele)ated during ina!!ation and disease and in Crohn’s disease the (o#el is ina!ed. s this nu!(er increases& increases& the !ore ina!ed the (ody is indicating indicating that the e
r. Si!s is on se)eral )ita!in and !ineral supple!ents (ecause people #ith Crohn’s Disease are at ris+ 'or !any de:ciencies. Ae is at ris+ 'or de:ciencies (ecause #ith such e> o' 05> c! o' his @e@unu!. Ae also has Crohn’s disease #hich is a disease that is associated #ith a loss o' a(sorption. Ae is una(le to !aintain protein& energy& uid& electrolyte or !icronutrient (alances so 'ar on his !edication and on the diet that he #as told to 'ollo#. I' his Crohn’s disease continues to get #orse he !ay lose sections o' his s!all intestine (ecause o' trau!a to the!. 1>.1 ? page 405 'ter resection the s!all intestine adapts and goes through a three phase process. process. ,he :rst phase a'ter the resection resection usually lasts (et#een B-1> days and patients loss uid and electrolytes and need to (e on parenteral nutrition. ,he second phase can last se)eral !onths and diarrhea reduces as the adaptation #ith the re!aining (o#el (egins. ,his is a good point to start to transition to enteral nutrition and then e)entually to oral nutrition as #ell. ,he third phase is #here #here !ost o' o' the adaption o' the s!all intestine intestine ta+es ta+es place& this stage can ta+e (et#een 1- 0 years. "lood o#& secretions& and !ucosal cell gro#th increases. ,he inner lu!en increases in length and
height and also )illous height increases #hich increases the sur'ace area o' the s!all intestine that is le't in order to increase a(sorption. 11.1 ? page 405 ,he !ost co!!on sy!pto!s o' short short (o#el syndro!e syndro!e include include #eight loss& loss& diarrhea& decreased transit ti!e& !ala(sorption& dehydration& loss o' electrolytes& electrolytes& and hypo+ale!ia. hypo+ale!ia. ,he health tea! should !onitor his #eight& uid status& and !a+e sure that his electrolytes are (alanced. ,hey also need to !onitor 'or ane!ias& especially "10 (ecause i' the ileu! is lost it pre)ents "10 a(sorption and (ile salts #hich can lead to 'at !ala(sorption !ala(sorption and 'at !ala(sorption can then lead to de:ciencies o' the 'at solu(le )ita!ins K& & D& . Sodiu!& !agnesiu!& iron& seleniu!& and calciu! should (e !onitored (ecause o' loss due due to diarrhea. diarrhea. ,he !otility o' the I tract should should also (e loo+ed at (ecause there are !edications that can (e gi)en to help slo# it do#n or to thic+en up the stool to help decrease diarrhea. 10.S+ip 1.0 ? 7C= ,he potential nutritional conseEuences conseEuences o' Crohn’s Crohn’s Disease include include anore-05 c! in length& the the @e@unu! is a(out 05> c! in in length& and the ileu! is a(out >> c! in length. ,otaling a(out 5B> c! or 1812 'eet& (ut depends on gro#th as a child& gender& and si*e. "eing that the resection too+ 0>> c! o' the 05> c! o' the @e@unu!& the resection is Euite signi:cant. ,he @e@unu! a(sor(s lipids& !onosaccharides& !onosaccharides& a!ino acids& s!all peptides& and !ost )ita!ins and !inerals. Since 8>G o' the @e@unu! is no# gone& !otility #ill (e !uch 'aster and the sur'ace area has decreased decreased causing !ala(sorption. ,o a)oid !ala(sorption& a @e@unosto!y #as placed to ad!inister nutrition. 15.0
,he nutrients that are digested digested and a(sor(ed in the @e@unu! include3 include3 lipids& lipids& !onosaccharides& !onosaccharides& a!ino acids& s!all peptides& thia!in& ri(oa)in& niacin& pantothenate& (iotin& 'olate& ita!in ita!in "6& C& & D& & K& calciu!& phosphorus& phosphorus& !agnesiu!& iron& *inc& chro!iu!& !anganese& and !oly(denu!. 16.1 G" H 8G "I o' 14> l(s H 0>.B H Aealthy A ealthy #eight "I o' 168 l(s H 04.8 H high end o' Aealthy #eight )en though he is #ithin a healthy #eight& he has lost 1BG o' his (ody #eight unintentionally in the last 6 !onths #hich is considered to (e se)ere !alnutrition related to chronic illness. 1B.1 ? page 40> $1>6.5% J $6.05 1B5.%- $5 5% J 5 H 156> 1.5 H 041 ange o' 0>>-04>> calories I used a stress 'actor o' 1.5 (ecause he has lost 1BG o' his (ody #eight and (ecause he is in the se)ere-'ul!inant stage o' his Crohn’s disease and his sy!pto!s ha)e gotten #orse. lso #ith ha)ing a resection done he #ill need !ore calories to reco)er 'ro! the surgery. 18.1 ? page 401 6.5 +g 1.B5 H 111 g Ais protein reEuire!ents are 1>6-111 g. I choose a 'actor o' 1.B5 (ecause people #ith Crohn’s Disease Disease usually need a(out 1.5-1.B5 g per +g and (ecause r. Si!s has lost 1BG o' his (ody #eight& he needs !ore protein to regain his lean (ody !ass. 12.0 ,he la(s )alues that are a(nor!al a(nor!al include include al(u!in and and preal(u!in preal(u!in that are are declining& this is due to the 'act that he has ina!!ation. ,his also can (e caused (y diarrhea& !alnutrition& and lo# protein& and since he has not (een eating lately this #ill (eco!e #orse. lso C-reacti)e protein is an indicator that he is getting #orse (ecause it is ele)ated during ina!!ation and disease. SC is used to diagnosis Crohn’s Disease 'ro! ulcerati)e colitis& and is also used to !onitor the progression o' the disease. Ae!oglo(in& he!atocrit& trans'errin& and 'erritin are all lo# and typically as Crohn’s Disease progresses these )alues sho# non-nutritional ane!ia& #hich are 'ro! (leeding& (ecause he has (loody stools& #hen co!(ined #ith a lo# C and CAC it #ould indicate iron de:ciency. Since he has had a @e@unosto!y resection he has lost a good portion o' his @e@unu! #here !any )ita!ins and !inerals are a(sor(ed. Ais =, #as also a(nor!al and #as on the high side. ,his !ay (e due due to the 'act that that the patient does does not eat !any )egeta(les )egeta(les or other sources o' )ita!in K and !ay (e de)eloping a ita!in K de:ciency. == is an indicator o' iron de:ciency and indicates !alnutrition. hen == is high that !eans that it is not co!(ining #ith iron to !a+e he!e and that iron is lo# in the (ody. ita!in D 05 hydro
cid are also lo# and this is due to !ala(sorption and through not ha)ing suLcient dietary sources. 0>. InadeEuate protein and calorie inta+e related to increased need& !ala(sorption& !ala(sorption& and poor inta+e as e)idenced (y 1BG loss o' (ody #eight& lac+ o' appetite 'ro! diarrhea and a(do!inal pain& and an oral protein inta+e o' 50 g #ith a reco!!endation o' 1>6-111 g o' protein and an oral calorie inta+e o' 1226 #ith a reco!!endation reco!!endation o' 0>>-04>> calories. InadeEuate parenteral nutrition in'usion related to altered I 'unction 'ro! e6-111 g.
01.0 ,he !ost i!portant i!portant thing to consider consider in deciding deciding #hat #hat route to ta+e ta+e 'or nutrition support& support& #ould (e to loo+ at the condition o' the patient’s s!all intestine. ,his patient @ust had a resection o' the @e@unu! and pro days a'ter surgery the patient should (e on parenteral parenteral nutrition. ,hen the patient should (e assessed to see i' any o' their la(s ha)e i!pro)ed that are associated #ith de:ciencies due to !ala(sorption. !ala(sorption. ,he patient’s uid and electrolytes should also (e care'ully care'ully !onitored. )entually in the ne
phosphate& and !agnesiu! to lo#er in the (lood& #hich !ay cause cardiac arrest and uid retention $so!eti!es the uid retention !ay (e in the lungs%. ,o ,o co!(at it& car(s car(s should (e gi)en slo#ly slo#ly and potassiu!& potassiu!& phosphorus& phosphorus& and !agnesiu! should (e supple!ented i' )alues are lo#ering. Feedings change in order to pre)ent re'eeding syndro!e (y decreasing the a!ount o' car(s (y hal'& supple!enting and ha)e 'eedings (e 1>-15 +cals+g and increase to the goal o' calories o)er -5 days. onitoring o' potassiu!& phosphorus& phosphorus& and !agnesiu! should (e loo+ed at e)ery 10 hours. r. Si!s is at ris+ 'or re'eeding syndro!e (ecause he has had a prolonged period o' !alnutrition and he is a(out to start to go on parenteral nutrition and he already has lo# )alues o' phosphorus and !agnesiu!. ,his can (e pre)ented (y starting out his parenteral nutrition slo#ly& decreasing the a!ount o' car(s that he needs (y hal' and slo#ly increasing his parenteral nutrition o)er the ne cchr #ill not !eet his nutritional needs 'or the day. 5> cchr H 10>> !l H 1.0 P 0>>1.0 H 240 g .4 H 816 kcals 40.5 1.0 H 51 g 4 H 204 kcals > 1.0 H 36 g 2 H 324 kcals Total = 1344 kcals kca ls 85 cchr H 0>4> !l H 0.>4 P 0>> 0.>4 H 408 g .4 H 1387.2 kcals 40.5 0.>4 H 86.7 g 4 H 346.8 kcals > 0.>4 H 61.2 g 2 H 550.8 kcals Total = 2284.8 kcals ,he protein protein needs 'all short on (oth o' these parenteral parenteral nutrition nutrition supports& supports& they should (e at 1>6-111 g. ,he calorie reEuire!ents 'or the day need to (e 0>>-04>> +cals& the 5> cchr does not !eet this need (ut the 85 cchr co!es close to the range and is only 15 calories short. ,he calories 'or 85 cchr are not too 'ar o9 (ut the protein is still too lo#& so the 'or!ula needs to (e changed to account 'or !ore protein. 05.4 InadeEuate protein and calorie inta+e related to increased need& !ala(sorption& !ala(sorption& and poor inta+e as e)idenced (y 1BG loss o' (ody #eight& lac+ o' appetite 'ro! diarrhea and a(do!inal pain& and an oral protein inta+e o' 50 g #ith a reco!!endation o' 1>6-111 g o' protein and an oral calorie inta+e o' 1226 #ith a reco!!endation reco!!endation o' 0>>-04>> calories. ain 4-8 l(s #ithin the ne6-111 g Increase calories to 0>>-04>>
eals and Snac+s - Co!position o' !eals and snac+s ? energy !odi:ed diet and protein !odi:ed diet $7D- 1.0 $0%$%% InadeEuate parenteral nutrition in'usion related to altered I 'unction 'ro! e6-111 g. Increase protein co!position o' parenteral nutrition to 1>6-111 g (y increasing increasing a!ino acids to 50 gP to (e in nitrogen (alance. =arenteral 7utrition I uids ? Co!position ? increase protein $7D0.0.1% 06.0B 0 pt Co!(ine your ans#er& so that the ans#er to 0B is (ased on 06. 0B.Co!(ine- page 04-044 http3###.andeal.orgte!plate.c'!O+eyH1>>6 ,his in'or!ation in'or!ation tells us that r. r. Si!s in a resting resting state is (urning (urning 0>00 +cals per day. Ais respiratory Euotient is at .88 #hich ta+es the C;0 production o' 061 and di)ides that (y the o e)en #hen they are healthy. I #ould not !a+e changes to !y prescri(ed nutrition support o' 0>>-04>> +cals and 1>6-111 g o' protein (ut I #ould de:nitely !a+e changes to the tea!’s parenteral nutrition support 'or!ula. I #ould not !a+e changes to !y nutrition support (ecause (ecause e)en though the states 0>00 +cal& this does not ta+e into account his acti)ity and disease state. I' you ta+e the 0>00 +cal and !ultiply that (y an acti)ity 'actor o' 1.1& he #ill need 0004 +cals& #hich puts hi! to a close range. ,o ensure that his nutrition support is adeEuate& his hydration status& status& I; chart& electrolyte electrolyte le)els $phosphorus& $phosphorus& potassiu!& sodiu!& and !agnesiu!%& (lood glucose& al(u!in& preal(u!in& and protein totals& along #ith #eight $ loo+ing 'or possi(le uid retention%& and signs o' nutrient de:ciencies should all (e !onitored. 08. ccording to the 7utrition Care anual the nutrition support tea! should !onitor the I; chart& inta+e& hydration status& electrolyte electrolyte le)els& (lood glucose& protein inta+e& calorie inta+e& and uid retention#eight change each day. ach #ee+ nitrogen (alance& !eal ti!e and a)oidance (eha)ior should (e loo+ed at to assess #hy $ this #ould (e !onitored once he has started eating orally%& current #eight#eight change& "I& )ita!in and !ineral la( tests to chec+ 'or de:ciencies& trans'errin& trans'errin& 'erritin& he!oglo(in& he!atocrit& al(u!in& preal(u!in& preal(u!in& and C-reacti)e protein $to assess i' ina!!ation is going do#n%. 02.1
Ais glucose le)els !ay no# (e increased increased (ecause he !ay (e e> g o' de.0 ? page 54 $86.B g 6.05% 6.05% ? 18.4 g H -4.508 g ,his in'or!ation in'or!ation indicates indicates that he is in in negati)e nitrogen nitrogen (alance& (alance& #hich !eans that nitrogen eG or !ore o' his inta+e 'ro! oral inta+e. hen (eing ta+en o9 o' parenteral nutrition it should (e done gradually o)er a 'e# hours so that the (ody can get used to not ha)ing glucose in'used directly directly into the (lood strea!. 0. ,he pri!ary nutrition nutrition concerns concerns #ould #ould (e to !a+e !a+e sure that that he is getting adeEuate protein& calories& and )ita!ins and !inerals and that his electrolytes are are (alanced. lso to gain (ac+ so!e o' the #eight that he has lost o)er the past 6 !onths. I thin+ that he should ta+e supple!ents supple!ents 'or !agnesiu!& ita!in & ita!in C& ita!in D& Calciu!& and "10 so he should ta+e a daily !ulti-)ita!in that !eets the D I 'or all nutrient needs. ating 'ruits and )egeta(les that are high in antio
ina!!ation. Ae should also include pro(iotics and pre(iotics in his diet to help to enhance the nor!al ora o' the I tract. ain 4-8 l(s #ithin the ne6-111 to o(tain a nitrogen (alance o' close to >.
