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Crohn’s: Complications and Considerations

Presented by Jennifer Hasting, Dietetic Intern

with special help from MaraLee Beebe, RD

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Inflammatory Bowel Disease

Definition = an autoimmune, chronic inflammatory condition of the GI tract

Includes:

Ulcerative colitis
Crohn’s disease
Indeterminate colitis

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Inflammatory Bowel Disease

Incidence/Prevalence

Northern Hemisphere and Caucasian population

Europe

Incidence: 0.7 – 9.8 per 100 million

America

Prevalence: 388-444 per 100 million
Incidence: 5-15 per 100 million

Estimated $1.6 billion/year

The incidence of IBD has increased significantly around the world over the past 50 years, nearly doubling between 1955 and 1995.

It is most prevalent in the Northern Hemisphere (North America and Northern Europe) and among Caucasian and descendents of Ashkenazi Jews, (and less often in Southern Europe and Australia. There is very low prevalence in Asia and South American and in African-Americans.)

The incidence in European countries ranges from 0.7 to 9.8 new cases per 100 million. The US, in particular, currently has a prevalence of 388-444 per 100 million, with an incidence rate of 5-15 new cases per 100 million. Interestingly, as more countries become more industrialized, their rates of IBD are also increasing.

This disease costs us an estimated $1.6 billion/year in medical expenditures.

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Inflammatory Bowel Disease

Etiology

Genetics
Gut microbiome
Environment

Antibiotics
NSAIDS
Infectious agents
Stress
Diet
Oral contraceptive use
Smoking

Crohn’s disease has a multifactorial etiology, but the complete details of its cause are not fully understood.

It’s been theorized to develop in individuals with genetic susceptibility or with defects in their gut mucosal immune system who are then exposed to environmental triggers. The trigger causes a release of cytokines that cause an abnormal inflammatory autoimmune response in the GI tract, damaging the intestinal mucosa and resulting in one of the inflammatory bowel diseases.

There are currently investigations being done on the link between specific chromosomes and the inflammatory process seen in these patients. And in about 5-15% of patients with Crohn’s have a family history of the disease.

Some of the proposed environmental triggers include antibiotic use, NSAIDS, stress, diet and oral contraceptives.

Smoking actually doubles the risk for Crohn’s.

“The cause of the disease is unknown, but infection, genetics, and an altered immune system have been postulated to play a role.”-Caral-Ireton Jones

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Crohn’s Disease

Diagnostic Tests

Radiology (CT, XR, MRI)
Endoscopy—”Cobblestoning”
Biopsy—thickened wall
Serological markers

IL, TNF, CRP
ASCA & pANCA

Stool samples—lactoferrin, calprotectin, leukocytes

Diagnosing: JUST SKIM OVER THIS

There is not one specific test for diagnosing Crohn’s, but rather a combination of radiological, histological, endoscopic, and biochemical evaluations.

Barium X-rays → distribution of the disease along the GI tract, show ulcerations, and any narrowing or fistulae that may occur. CT scans → rule out or detect abscess and intestinal blockage.

The endoscopy will reveal “cobblestoning” of the intestinal mucosa.

Biopsies of the GI mucosa will appear different in UC vs Crohn’s. Whereas UC usually involves inflammation of the first two layers of the mucosa (in the olon and rectum), Crohn’s is characterized by damage to all 3 layers of the GI mucosa, causing thickening of the intestinal walls. (Mucosa, Submucosa, Muscularis externa).

Serological markers are used to distinguish between UC and Crohn’s and to distinguish IBD from other GI diseases.

Testing for markers of IBD include levels of cytokines (Interluekin and Tumor-necrosis factors) and anti-glycan antibodies (ANCA & ASCA) (ASCA is more specific to Crohn’s). And of course, CRP will be elevated.

Recently, levels of lactoferrin and calprotectin levels in stool have been found to be indicative of exacerbations of IBD.

Leukocytes in the stool confirm the inflammatory process.

In severe exacerbations, the patient will also have low albumin and may have elevated WBC. Fistulas and tracts between ulcerations can be observed in severe disease.

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Crohn’s Disease

Pathology

Entire GI tract
Skipping pattern of localized inflammation

Signs and Symptoms

Abdominal pain & cramping
Diarrhea
Weight loss
Fever
Malnutrition

CDAI (Crohn’s Disease Activity Index)

In Crohn’s, the inflammation is most often contained to the ileum and colon, but it can occur in any part of the GI tract, from mouth to anus, often in a skipping pattern.

Like UC, Patients with Crohn’s often complain of abdominal pain and cramping with chronic diarrhea, (but are less likely to have blood or mucus in the stool.)

Weight loss is very common due to increased needs and reduced oral intake. It is important in these patients to identify what is interfering with adequate intake. Some individuals electively restrict eating—avoid eating particular foods out of fear that they will lead to exacerbation or to avoid pain from mouth sores. Nausea, vomiting and diarrhea also can reduce their intake.

There are many factors besides poor intake that also lead to vitamin and mineral deficiencies and malnutrition. These patients should receive a MVI that meets the RDA for all nutrients.

Pts with Crohn’s experience alternating periods of exacerbation and remission of the disease. The Crohn’s Disease Activity Index is a score that describes the severity of their symptoms. 150 + is flare-up. 300+ have severe exaceration. Takes into account symptoms (diarrhea, abdominal pain, abdominal mass, decreased sense of well-being, extraintestinal manifestations, weight loss, lab features.

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Crohn’s Disease: Complications

Intestinal

Malabsorption
Fistulas and sinus tract formation
Abscesses
Obstruction
Bacterial overgrowth

Extraintestinal

Osteopenia/Osteoporosis
Skin and mouth ulcerations
Kidney stones and gallstones
Thromboembolism

Inflammation of the mucosa can decrease transit time and reduce the ability of the small intestine absorb nutrients. The inflammation results in decreased villous height, decreased enzyme production, and subsequent malabsorption of nutrients.

Because of the inflammation, patients are also at increased risk for the development of fistulas and abscesses, intestinal obstruction from strictures or dilation, and bacterial overgrowth (blind loop syndrome). Other complications include anal fissures, bowel perforation, and colon cancer. (and hyperoxaluria, steatorrhea, perianal disease, neoplasia)

Crohn’s disease can affect other parts of the body, with manifestations in the musculoskeletal system (osteopenia or osteoporosis and arthritis) and in the skin as painful ulcers (aphthous ulcerations, pyoderma gangrenosa), and can be associated with diseases of the eyes, kidneys (Kidney stones, UTI), and vascular system (thromboembolism)

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Our Patient

Miss B. J.

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Miss B. J.

Age: 22
Ethnicity/Sex: AAF
PMH: anemia, asthma, C. diff
Lives with parents in Charleston area
Family history: Crohn’s, IBD, Sarcoidosis

We finally get to our patient, Miss BJ:

BJ is a 22yo AAF with a PMH of anemia (diagnosed April 2014), asthma, and C. diff. She lives with her parents who are very supportive of her and have accompanied her throughout her hospital course.

Family History:

-Crohn’s: father

-IBD: mother

-Sarcoidosis: paternal aunt

Sarcoidosis= a heterogeneous, non-caseating, granulomatous disorder of unknown etiology that can involve any organ within the body. It is the growth of tiny collections of inflammatory cells in different parts of the body, believed to be the result of the bodys immune system responding to an unknwon substance. No cure.

Granulomas are masses of inflamed tissues that form in certain organs of the body.

(Anemia: poor intake Hb down to 6.8, heavy menstrual periods, probable chronic blood in stool). Started IV iron therapy.

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Assessment

May 2013:

Nausea
Vomiting
Diarrhea
Abdominal pain
Wt Loss

February 2014:

C. diff
Anemia
Elevated calprotectin
Elevated ANCA
Aphthae in cecum
Narrowing ileocecal valve
Biopsies

Past Medical History

BJ first began having GI complications in May of 2013, when she started having symptoms of N/V/abdominal pain/D and significant wt loss.

In February, she was diagnosed with C. diff and prescribed oral antibiotics (vancomycin). This resolved her diarrhea, but she continued to have intermittent bouts of N/V with epigastric abdominal pain, occurring about twice a week. She reported a wt loss of about 25# since her symptoms began.

In late February, she went to the ER after several days of persistent abdominal pain. There, she was found to have hypochromic microcytic anemia with thrombocytosis, likely Fe-def anemia. The doctor planned to evaluate the anemia with B12, folate, and iron studies.

Fecal samples were also taken, and returned with elevated calprotectin (1389--Normal range is <50 ug/g).

She also had very high ANC antibodies (ANC 25.06, normal is 2.2-7.6), confirming IBD.

A colonoscopy in Feb also found aphthae (ulcers) in the cecum, with significant narrowing of the ICV (ileocecal valve)? with ulceration and edema. Surgical biopsies were performed and showed no evidence of active colitis.

BJ continued to have recurrent episodes of epigastric abdominal pain with nausea and vomiting and made multiple visits to MUSC for evaluation.

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Assessment

March 2014:

IV iron infusions

May 2014:

CT →

Worsening of acute inflammation of the last 12 cm of ileum, cecum and appendix

August 2014:

Tachycardic—Fistula? Abscess?
MRE →

Acute on chronic
2 sinus tracts
2 phlegmonous collections
Marked wall thickening

Past Medical History

In March, She received 3 infusions of IV iron during her hospital stay. She first had anemia when she was 14 (1 year after starting her period). Her hgb has been between 9 and 10, but it was down to 6. She went in for additional IV iron in April and her CBC and ferritin were monitored for for IV iron response.

In May, she had a CT of the abdomen, which revealed significant worsening of the acute inflammation of the last 12 cm of the ileum, inflammation of the cecum and the appendix was involved.

In August, Miss BJ came to MUSC GI clinic with complaints of significant abdominal pain, describing a sharp gripping pain. Her mother said that she had not been acting her usual self for the past 3 weeks, with increased fatigue, and disinterest in normal activities. At this time, she had no signs of N/V/fever or blood in stool. She was, however, slightly tachycardic, which the physician attributed to a possible fistula or abscess formation. An MRE on 8/19 revealed inflammatory process in RLQ of TI (terminal ileum), cecum, appendix; acute on chronic. There were 2 sinus tracts arising from the TI and 2 phlegmonous collections of RLQ. No obstruction was noted at this time, though there was marked wall thickening.

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Right hemicolectomy with ileocolic anastomosis

Admitted 9/29 for surgical treatment of complications related to Crohn’s disease

The admission I will primarily be discussing began September 29, in which she came in for surgical evaluation for complications of Crohn’s disease.

70% of individuals with Crohn’s will require surgical intervention (compared to only 30% of UC pts). In UC, the most common procedure is a total colectomy, and in Crohn’s, the ileostomy is most common.

Of course, surgical removal of portions of the intestines will have a significant impact on nutrition.

Any change to the anatomy of the intestines will cause changes in motility, absorption, and in how waste products are handled. According to the Academy, any pt with bowel surgery should be considered at high nutritional risk until they are eating a full, regular meal plan without difficulties such as cramping, diarrhea, N/V. Acuity is higher if the underlying disease also caused primary malnutrition, which IBD certainly does!

Date of Surgery: 9/29 (POD #0)

Laparoscopic R hemicolectomy with ileocolonic anastomisis.

The terminal ileum was removed, so actually a ileocecectomy.

Loss of the ileocecal valve increases the risk for bacterial overgrowth. The valve normally helps prevent reflux of bacteria from colon into small intestines.

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Nutrient Absorption

Vitamin B12
Magnesium, Zinc, Copper
Iron
Water-soluble vitamins
Fluid and Electrolytes
Vitamin D
Calcium

The jejunum and ileum are the most important sites of absorption in the small intestine, but the jejunum is much more adaptive. The small intestines are actually quite adaptive in terms of absorptive capacity. About 50% of the small bowel has to be removed before you see a significant reduction in its ability to absorb.

If the entire ileum is removed, the pt would likely depend on long term parenteral nutrition.

-B12 deficiencies are common in pts with Crohn’s, especially after resection-- ileum contains the receptors for Vitamin B12.

-Bile is also absorbed in the ileum, so removal can cause fat malabsorption.

-Zinc, copper, and magnesium deficiencies can occur b/c of increased fecal output, ostomies, and fistulas. Magnesium also binds with fat in the lumen, so may be malabsorbed. 65% of pts with Crohn’s have zinc deficiency

-Patients may develop anemia due to poor iron absorption and loss of blood in the feces.

-Water-soluble vitamins are also lost with less water absorption in the terminal ileum and colon after resection.

The colon is less important for nutrient absorption, but is very important for fluid and electrolyte absorption and metabolism of soluble fiber to SCFA. (The colon can increase its absorption significantly (as much as 3 to 5 times more than normal).) If digestion and absorption have not occurred in the small intestine, nutrients from the small intestine are lost in the feces unless the substrate can be fermented to SCFA.

The removal of the ileocecal valve may an cause issues with transit time and ostomy output and fluid management. It can result in significant fluid, electrolyte, vitamin and mineral deficiencies.

About 13 % of adults with Crohn’s malabsorb calcium due to binding with undigested fats in the lumen and loss of portions of the ileum that cause vitamin D deficiency.

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Assessment

Medications

Home Medications	Purpose	Nutrition-Related Implications
Nexium	GERD	Decreases abs of Fe, Vit B1 & Ca. Take 30-60 minutes before meals.
Prednisone	Inflammation	Neg N balance, Ca wasting, diabetes, osteoporosis, decrease Vit C & A, increase TG
Calcium carbonate-Vit D	Supplement
Zofran	Nausea	Xerostomia, abd pain
Phenergan	Nausea	Xerostomia, N/V, constipation, elevated glucose
Zantac	GERD	Decreases abs of Fe, Vit B12
Tramadol	Pain	Avoid SJW, Xerostomia, N/V/D, abd pain. Habit forming

Hospital-ordered	Purpose	Nutrition-Related Implications
Cefazolin	Antibiotic	N/V/D. Decrease Vit K synthesis.
Remicade (infliximab)	Crohn’s treatment
Flagyl	C. Diff treatment	Na content, N/V/D, xerostomia, anorexia

Medications: Common medications, like steroids and antibiotics, can cause deficiencies in calcium, vitamin D and folate.

At this time, she was on several medications common for Crohn’s patients, including meds for acid reflux, steroids for inflammation, Tramadol for chronic pain, and nausea. The hospital administered antibiotics for a possible abscess. I only listed a few of the many side effects. Several of them alter the absorption of nutrients Fe, Vit B12, and calcium. BJ is on long-term use of prednisone, which has several serious nutrition-related implications. It can cause a negative N balance, Ca wasting which can lead to bone mineral disorders, increases glucose and can cause diabetes, and can also decrease blood levels of vitamin A, C and triglycerides. This is likely why she’s taking a Calcium/vit D supplement.

One medication I want to discuss in particular is Remicade. Remicade (infliximab) is an antibody against the tumor necrosis factor alpha receptor and the first drug like it to be approved for use in the treatment of Crohn’s in 1998. A Cochrane review in 2009 concluded that it is effective for maintenance of remission and fistula healing in patients who respond to induction therapy. Clinical trials have shown up to 80% improvement in symptoms in some patients. BJ is receiving it via IV in 500 mg infusions every 4 weeks.

-Nexium: Proton-pump inhibitor. Should be taken 30-60 minutes before meal. In one study, decreased Ca abs by 61%. Ca suppl may be advised.

-Prednisone: Diet should be low in Na, high in Ca, Vit D, and protein, and may need high K, and Vits A and C and P. Ca-vit D suppl recommended with LT USE. Caution w/grapefruit/related citrus. Increases appetitie, wt

-Zantac: Histamine H2 receptor antagonist. Must be taken 2 hr before or after Fe supplement b/c may decrease Fe and B12 absorption. Lowers gastric acid secretions. N/V/D constipation

-Tramadol: Opioid. Interaction with SJW. Xerostomia, N/V/D, abd pain, constipation. Habit forming.

-Cefazolin: cephalosporin. Can cause oral candidiasis and sore mouth and tongue with LT use. In less than 1%, can cause pseudomembranous colitis. N/V/D. LT use in malnourished can cause decrease in Vit K synthesis. Contains Na? May need to increase vit K to prevent bleeding. May cause anorexia.

-Flagyl: metronidazole. Used to treat C. diff. Contains Na. May cause anorexia, xerostomia, candidiasis, stomatitis, metallic taste, N/V/D/constipation, epigastric distress.

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Assessment

Biochemical Data

Hematology Test	9/30	10/1	Normal Range
Na	135	138.0	135-145
K	4.0	3.5	3.5-5.0
Cl	106.0	108.0	98.0-107.0
CO2	25	27	22-32
Glu	128	98	70-100
BUN	8.0	5.0	8.0-20.0
Cr	0.4	0.4	0.4-1.0
Ca	8.0	8.8	8.4-10.2
Phos	-----	2.4	2.4-4.7
Mg	-----	1.9	1.6-2.3

Hematology Test	8/8	Normal Range
25-Hydroxy D Total	20.0	25.0-80.0 ng/ml
Vit B12	988	211-911 pg/ml
Folate	33	>5.4 ng/ml

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Assessment

Ht: 172.7 cm (5’8”)
Wt: 56.9 kg (125#)
IBW: 63.6 kg (140#)
%IBW: 89%
BMI: 19 kg/m²

Anthropometrics

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Assessment

Increased needs post-surgery

Energy: 32-37 kcal/kg → 1800-2100 kcal/day
Protein: 1.5-1.7 g/kg → 85-95 g/day
Fluid: 25-30 ml/kg → 1420-1700 ml/day

Estimated Nutritional Needs: Anabolism

BEE (Mifflin-St. Jeor): 1377
Recommendations:
Energy

BEE x 1.3-1.5→ 1790-2066
25-35 kcal/kg→1423-1992

Protein

1.0-1.5 g/kg→ 85-95 g/day
1.5-1.7 g/kg→85-95 g/day

Textbook: In calculating energy needs, indirect calorimetry is best, but the harris benedict or MSJ with a stress factor of 1.3 or 1.5 may be used.

AND Nutrition care manual:

Pts with Crohn’s already have increased calorie, protein, and micronutrient needs, but BJ has additional needs to recover from surgery. In general, the Nutrition Care Manual estimated that needs for adults with IBD are met at 25 kcal/kg to 35 kcal/kg and 1.0 to 1.5 g/kg protein. Of course, needs should also be based lossess from inflammation in the GI tract, catabolism when infection is present, and healing for surgical wounds.

Protein: Based on lean body mass wasting and biochemical parameters. As high as 1.5-1.7 g/kg

Factors influencing nutritional requirements:

-Severity of disease

-Extent of stool output, malabsorption, etc

-Current medication regimen

-Previous medical and surgical history

-Quality and quantitiy of nutrient intake

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Assessment

Recent Dietary Intake

Ensure High-Protein
Crackers TID
Eggs
Broth
Milkshakes

Loss of appetite
Avoids “bulky” foods
Not taking MVI, but does take Vitamin D at home

RD Interview

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Diagnosis

(Problem) Inadequate energy intake (NI-1.4) related to
(Etiology) desire to avoid Crohn’s flare as evidenced by
(Sign/Symptoms) dietary recall of limited variety and amount of foods.

PES

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Intervention

Interventions

General/healthful diet (ND-1.1)
Commercial beverage (ND-3.1.1)

Plan

1. Recommend advancing diet to liquids as tolerated by pt
2. When diet is advanced, recommend Boost Plus TID
3. Encouraged pt to slowly re-introduce new foods into diet
4. RD to continue to monitor and f/u prn

Food intake may be problematic in the initial period following bowel surgery. Pts may experience discomfort, bloating, N/D and even fear of eating. When bowel functions returns (flatus and/or bowel movement), okay to start clear liquids.

According to research, advancing from a clear liquid to a full liquid diet may not be necessary, as full liquid diets are often very high in fat and may not be well tolerated post bowel surgery.

Gradual increase to a normal diet depending on pt’s course.

Research has shown that pts postop had no difference in tolerance to a clear liquid diet or regular diet, and more energy and protein were consumed on a regular diet compared with a clear liquid diet (74% vs 42% of energy and 58% vs 8% of protein). Careful evaluation of diet progression is needed in pts with significant bowel resection, strictures, fistulas, etc.

Other possible interventions:

-Multivitamin/Mineral

-Specific nutrient supplementation (n-3 fatty acids, glutamine, and prebiotics) may be considered

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Monitoring and Evaluation

Total energy intake (FH-1.1.1)
Weight (AD-1.1.2)
Electrolyte and renal profile WNL (BD-1.2)
Nutritional anemia profile WNL (BD-1.10)
Vitamin profile (BD-1.13)

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Clinical Course

Date	Event
10/1	Nutrition risk screen assessment. POD #2
10/3-10/4	Diet is advanced to full liquid, then regular
10/5	Septic CT abd pelvis → Fluid collection To OR for abdominal exploration, abscess drainage and loop ileostomy creation. NG tube placed, unclamped, on low suction
10/7	Post-op anemia 2/2 acute blood loss. XR abd → SBO 2/2 dilated loops and gas fluid levels
10/8	PICC placed. Start TPN. Nutrition f/u assessment.

A couple of days after we saw her, her diet was advance to full liquids. She tolerated those fine and was soon on a regular diet.

However, on the morning of Oct. 5, her abdominal pain increased, she became tachycardic with mild fever and newly increased leukocytosis—new onset of sepsis.

The CT showed fluid collection in subcutaneous tissue at her wound, as well as fluid collection in the RLQ. She went to the OR for pelvic abscess washout drainage and they created a diverting loop ileostomy about 15 cm proximal to the anastomosis to allow that part of the intestines to heal. An NG tube was placed for suction of gastric contents, and an ostomy bag is in place. There was no evidence of anastomic leak, but they did put her on more antibiotics (cefepime and cipro) for the abscess. and planned to taper stress dose steroids.

Because of blood loss from surgery, she was found to have postop anemia. Her potassium was also low, so they repleted her. Overnight, she started having significant abdominal pain and distention so they did yet another abdominal x-ray which revealed dilated loops of small bowel that were causing an obstruction!

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Diverting Loop Ileostomy

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Should we start nutrition support?

EN? or PN?

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Parenteral Nutrition Support

In MOST cases, PN with bowel rest is not necessary

Progress from clear to regular
Except….obstruction, fistula, anastomotic leaks, etc., may necessitate PN

ASPEN

Non-functional GI tract
EN not possible
Failed enteral nutrition with small bowel feeding

IS NUTRITION SUPPORT NEEDED? WHAT TYPE?

The type of nutrition care provided after bowel surgery depends entirely on the extent of bowel surgery and whether or not there were any postoperative complications.

In the best circumstance, the pt can progress directly from clear liquids to a regular diet as tolerated.

Most research indicates that PN with bowel rest is not necessary and not advantageous over EN. HOWEVER, for those patients with extreme malabsorption or complications (such as obstruction, fistula, leaks), PN may be necessary. The academy advises that the dietitian should consider the pt’s current nutritional status and the length the pt is likely to be NPO in determining the need to start PN.

According to ASPEN Guidelines, PN should be used when the GI tract is not functional or cannot be accessed and in patients who cannot be adequately nourished by an oral diet or EN. In addition, it should be initiated in pts with inadequate oral intake for 7-14 days.

Now that BJ has a SBO, she definitely meets the criteria for TPN. There is no specific compounding recommendations for IBD, but it is recommended that it be composed of 55-60% CHO, 25-30% lipids, and 10-15% amino acids. (Sculz—the German article)

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Nutrition Follow-up (10/8)

Reassessment

Noted significant output from NG tube (3700 ml)
Wt: 60.6 kg

Nutrition Intervention: Formula/solution (ND-2.2.1) goal

35 kcal/kg ENERGY: 2000 kcal
40% of total kcal for FAT: 65 g lipid
60% of total kcal for CHO: 286 gm CHO
1.7 g/kg PRO: 95 g protein

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Nutrition Follow-up (10/8)

Nutrition Plan

1. Will initiate TPN tonight at 80% of goal and increase to goal.
2. Check BMP, Mg, Phos daily. Check prealbumin, CRP, triglycerides, and hepatic panel weekly
3. D/C IV fluids when PN hangs at 10pm. Start SSI and q 4 hr FSBS.
4. Strict I&Os and daily wts.
5. RD will f/u daily for TPN order.

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Hematology Test	8	9	10	11	12	13	TPN	8	9	10
Na (135-145)	144	145	146	140	139	139	NaAcetate	200	125	--
K (3.5-5.0)	3.7	3.0	3.2	4.0	3.8	4.4	KCl + Bolus	20	40+60	50+60
Cl (98.0-107.0)	110	107	107	106	108	109	NaCl	100	100	100
CO2 (22-32)	26	32	34	29	26	27	Kacetate	50	40	40
Glu (70-100)	78	118	112	108	83	87	Dextrose	143	185	205
BUN (8.0-20.0)	10	11	8.0	8	9	13
Cr (0.4-1.0)	0.5	0.3	0.3	0.3	0.3	0.3
Ca (8.4-10.2)	8.7	8.4	8.8	8.9	8.7	9.2
Phos (2.4-4.7)	3.1	3.2	3.3	3.2	3.6	4.1
Mg (1.6-2.3)	2.1	2.0	2.0	2.0	2.0	2.0
Alb (3.5-4.8)	2.5				2.8
CRP	9.7

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Clinical Course

Date	Event
10/9	f/u KUB. NGT output lighter.
10/10	NGT clamped. Abdominal pain and distention improved. Tolerating clears.
10/11	Clear liquid diet. TPN still running
10/12	2 L ostomy output
10/13	TPN stopped.
10/14	Regular diet. Hospital Discharge. ☺

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Further Clinical Course

Date	Event
Week 1	Tolerating wider variety of foods
Week 2:	LLQ pain, cramps, decreased appetitie
10/29	Readmission due to increase pain in past 24 hrs Tachycardic CT scan → pelvic abscess IR drain placement
10/30	Screened at nutrition risk for reduced oral intake. PES: Inadequate energy intake RT pelvic abscess AEB pt reports of decreased appetite. RD intervention → Boost Plus TID + MVI, High protein foods, self-selection of bland, soft foods easily tolerated
10/31	Discharged home

About a week after being discharged, BJ appeared to be doing much better, eating wider variety of foods, though still experiencing some gas. About 2 weeks s/p d/c, however, mother called with concerns—BJ experiencing LLQ pain, crampy, decreased appetite due to pain, though eating or drinking wasn’t intensifying the pain. No N/V/fever.

Readmitted 10/29. Tachycardic and increased pain in past 24 hrs. Another CT showed new rim-enhancing fluid collection within pelvis, consistent with abscess. Plan to place drainage catheter.

Maralee saw her on 10/30 s/p IR drain placement for pelvic abscess.

Assessment: On regular diet—ate 100% of lunch despite decreased oral intake over the past few days. . Wt has been stable since presurgery.

Diagnosis: PES: Inadequate energy intake R/T pelvic abscess AEB prt reports of decreased appetite.

Monitoring: Total energy intake, Wt, Lytes and renal profile WNL. Nutrition anemia profile WNL. Vitamin profile

Intervention: Recommend adding Boost Plus TID and MVI, and encouraged high protein foods. She also recommended BJ self-select soft/bland foods she know she can tolerate.

D/C on 10/31.

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Further Clinical Course, cont.

Date	Event
11/10	Drain removal
11/19	Admitted again!! Recurrent vs persistent pelvic abscess LLQ pain, elevated WBC, fever CT → 2 intraperitoneal fluid collection IR drain placed again
11/26	Nutrition consult for TPN and low prealbumin? RD intervention → Check CRP, chewable MVI Taking Vit A supplements
11/28	Tolerating PO intake Discharged on home antibiotics, oxycodone, calcium carbonate with Vit D, 2500 U Vit A, and others

11/10—drain removed

11/19—admitted AGAIN! Recurrent vs persistent pelvic abscess. Presented with LLQ pain and Elevated WBC, fever. Output of ostomy controlled with Questran. Concerns for return of abscess due to similar pelvic pain. CT scan showed 2 intraperitoneal fluid collections. IR placed drain again. Put on broad-sprectrum IV antibiotics through PICC due to new infection. Continues to have consistently low Hgb (anemia, but not exhibiting symptoms) but does not want to be transfused.

11/26—Seen by Chris Bannister for nutrition consult for TPN and prealbumin of 5. BJ has little PO intake on regular diet, but is drinking Boost. She was c/o fluid retention. Yes, Prealbumin was low, but they did not draw a CRP. Wt: 59.3. Among other things, recommended chewable MVI. Pt taking Vitamin A at this time.

11/28—Tolerating PO intake and Discharged with home infusion antibiotics. Also d/c with oxycodone, Robaxin, Calcium Carbonate with Vitamin D, 2500 unit Vit A daily, Zantac, Colace, Nexium, Remeron, Zofran, Questran

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A little R&R

Low-fat, Low-fiber, high-protein, high-kcal
Small frequent meals
Supplements: Vit D, Zinc, Calcium, Mg, Folate, Vit B12, Iron
Restrict gas-producing foods
Avoid foods high in oxalate
Increase antioxidant intake
Consider probiotics/prebiotics

Recommendations for Remission

Crohn’s disease is a very complicated condition with serious nutritional consequences. Even during remission, patients are at risk for malnutrition due to poor intake, malabsorption, drug-nutrient interactions, and protein-losing enteropathies.

The AND Nutrition Care Manual advises that after nutrition support via TPN, patients with Crohn’s should follow an oral diet that progresses to low-fat, low-fiber, high-protein, high-kcal, and small frequent meals as tolerated. This should be supplemented with Vit D, Zinc, Calcium, Mg, Folate, Vit B12, and Iron. (or a MVI). Fiber should only be restricted during acute exacerbations or with strictures. The pt should add back to diet as soon as tolerated.

The pt may also want to restrict gas-producing foods, spicy or fried foods, caffeinated beverages, or any other food the individual patient identifies as problematic. Diet advancement should be highly individualized.

During remission, the goal is to optimize nutritional intake to maintain weight and replenish nutrient stores. It is encouraged to avoid foods high in oxalate (b/c they can increase their risk for kidney stones), increase antioxidant intake (research has shown pts with Crohn’s have lower serum levels of antioxidants Vit E, C, and beta carotene), supplement with n-3 fatty acids and glutamine, and consider the use of probiotics and prebiotics, which have shown to decrease symptoms for pts with IBD.

Foods high in oxalate:

-cocoa, tea, wheat germ, strawberries, nuts, spinach, beets, baked beans, peanut butter, tofu, high doses of Vitamin C >2g/day

-Can increase risk for urolithiasis (kidney stones)

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Prognosis

Lifelong disorder and rarely cured
80%--chronic malnutrition
70%--require surgery
90%--recurrence 1 year s/p surgery
50%--require 2^nd surgery
Treatment with Remicade:

Increased remission rates compared to placebo
Increased risk for sepsis, infection, TB, lymphoma

Fatal complications: intestinal rupture and toxic megacolon

Unfortunately, Crohn’s disease is a lifelong disorder and rarely cured.

About 80% of patients are chronically malnourished, and 70% will require some form of surgery (compared to 30% of UC patients).

Even with preoperative therapy and a well-performed operation, the recurrence rate of CD is still high: ~90% of pts will have endoscopic evidence of recurrence of disease 1 yr after surgery, and 50% will require an additional surgery.—Paulson, 2013.

Remicade has been shown to be effective in increasing remission rates compared with placebo at 4 weeks. Unfortunately, there is high risk for spontaneous infections, TB, and increased risk for sepsis, and some adolescents treated with Remicade have developed fatal lymphomas and other cancers.

Fatal but relatively uncommon complications of IBD include intestinal rupture and toxic megacolon.

Toxic megacolon = a very inflated colon with abdominal distention, and sometimes fever, adominal pain, or shock

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Cost Analysis

Lap hemicolectomy ~$75,000
Radiology exams ~ $920
Not Included:

PICC line placement
PICC tubing
Daily lab draws
NG tube placement
Ostomy bags
Pharmacy time

	TPN	EN
Cost of 1 bag	$450	$72
# Days	7	7
Total Bag Cost	$3,150	$504
RD time/day	30 min	15 min
Days per week	7	2
Cost per hr (assuming $50,000 salary)	$30/hr	$30/hr
Total RD cost	$105	$15
Total Nutrition Cost	$3255	$519

GI Surgeries:

-laparoscopic R hemicolectomy ~$75,000

-Diverting loop ileostomy

-Abscess drainage x 2

Radiology Exams: (only since 10/5)—Total $919.13

-CT abd drain placement—2 ($81.97) = 163.94

-CT abd & pelvis w contrast—3 ($154.10 each) = 462.3

-CT abd w/o contrast—1 ($81.97)

-XR abd 2 views—4 (18.35 each)

-XR abd AP—1

-XR chest AP—1 = 110.10

-CT chest pulm embolism w contrast—1 (100.82 each)

Not included:

-Previous endoscopy procedures

-NG tube for suction

-PICC tube

-Foley catheter

-Daily lab draws

-Ivs

-Ostomy bags

Assuming a salary of $50,000, an RD makes ~$30/hr. A pt on EN may need to be assessed ~2 x week about 15 minutes at a time assuming the TF needs to be adjusted and new orders written up. This would cost $15. An RD who assesses labs, writes TPN orders, and checks in on the pt daily, could easily spend 30 minutes per day. This pt was on TPN for 7 days. This would cost $105. That is an 86% difference in cost!

Total Cost of what I could Find:

$79,175

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References

Academy of Nutrition and dietetic. Nutrition Care Manual. Bowel Surgery. http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145209&ncm_toc_id=145223&ncm_heading=Nutrition%20Care. Accessed November, 2014.

Academy of Nutrition and Dietetics. Nutrition Care Manual. Inflammatory Bowel Disease. http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=19449. Accessed November, 2014.

Mills, S. C., von Roon, A. C., Tekkis, P. P., & Orchard, T. R. (2011). Crohn’s disease. Clinical Evidence, 2011, 0416.

Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition therapy & Pathophysiology (2nd ed). Belmont: Brooks/Cole Cengage Learning.

Paulson, E. C. (2013). Biologic Therapy and Surgery for Crohn Disease. Clinics in Colon and Rectal Surgery, 26(2), 128-133. Doi: 10.1055/s-0033-1348052

Pronsky, Z. & Crowe, J. (2010). Food-Medication Interactions (17th ed). Birchunville, PA: Food-Medication Interactions.

Schulz, R. J., Bischoff, S. C., & Koletzko, B., Working group for developing the guidelines for parenteral nutrition of The German Association for Nutritional Medicine. (2009). Gastroenterology – Guidelines on Parenteral Nutrition, Chapter 15. GMS German Medical Science, 7, Doc13. doi:10.3205/000072

Teitelbaum, J. E. Nutrient deficiencies in inflammatory bowel disease. In: UpToDate, Rutgeerts, PR, Lipman, TO, Motil, KJ, Hoppin, AG, Grover, S (Eds), UpToDate, Waltham, MA. (Accessed December 6, 2014.)

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Common Nutrition Problem	Etiology
Calories	Insufficient intake Anorexia Increased energy requirements Fear of abdominal pain and diarrhea after eating
Protein	Increased needs (losses from GI tract) Catabolism (steroid-induced, infection, or abscess) Healing from surgery
Fluid and Electrolytes	Short bowel syndrome High-volume diarrhea
Iron	Blood loss, inadequate diet Malabsorption
Magnesium, zinc, copper	Intestinal losses (SBS, fistulas, ostomies, diarrhea)
Calcium and vitamin D	Long-term steroid use Decreased intake of dairy (if restricting lactose)
Vitamin B12	Surgical resection
Folate	Medications used to treat IBD
Water-soluble vitamins	Surgical resections—loss of terminal ileum
Fat-soluble vitamins	Steatorrhea