Crohn’s Disease Ashley Spence, Dietetic Intern University of Maryland, College Park
Objectives • Understand the pathology of the disease • Case Study
• Medical Nutrition Therapy • Outcomes and Summary
Crohn’s Disease
What is Crohn’s Disease • chronic inflammatory disease of the intestines
• causes ulcerations of the small and large intestines • can affect the entire digestive system from the mouth to the anus • Also known as: colitis, regional enteritis, ileitis, or terminal ileitis Krause, 2012
Who’s at Risk? • Men and women
• Genetic • 20% of cases have blood relative with IBD
• Between ages of 15-30 • Smokers CDC
Complications of CD • Inflamed intestinal tissue • Thickened intestinal wall leading to narrowing • Blockages of the intestines as a result of narrowing • Ulcerations (may lead to tunneling) • Fistulas resulting from tunneling (surrounding areas and skin) • Nutritional deficiencies : • inadequate dietary intake • malabsorption Ferguson et al. 1998,
Normal
Crohn’s
Inside Crohn’s: A Closer Look
https://gi.jhsps.org/GDL_Disease
Symptoms of CD • Major Symptoms: • Abdominal pain- right lower quadrant • Diarrhea • Decreased appetite/intake • Weight loss • Rectal bleeding
• Additional Symptoms: • Arthritis • Skin problems
• Fever
Krause, 2012
The Crohn’s Cycle: Chronic Relapse • Mild- antibiotics Inflammation
• Moderate- Corticosteroids Remission
• Severe- surgery, bowel rest, EN/TPN
Symptoms
Treatment
Nutrition and CD • Nutrition is the primary therapy in CD • Oral nutritional supplements- 600 kcal/day are beneficial • Nocturnal tube feeding can promote weight gain and growth
• TPN is only indicated with the presence of intestinal failure, multiple bowel resections, or high output fistulas Donnellan et al., 2013
Use of Enteral Nutrition in CD • Enteral nutrition can induce and maintain remission • Used as a first line defense
• Associated with growth, weight gain, and minimal side effects as compared to steroids • Associated with mucosal healing and reduced inflammation • Use of elemental feeds is preferred Donnellan et al., 2013
Nutrition and CD • Elimination –reintroduction diets • Patients who can still meet needs orally
• Elimination-Remission induced by elemental feeds • Reintroduction -Transition to Low Fiber/Low residue diet- 2 year remission rate of 59% • Compliance issues in adult populations- reduce remission rates
Case Study
Patient Background • Report Upon Admission: • 66 year old female • Admitting Dx: chronic GI bleed • Intraabdominal abscess at the site of previous fistula
• Past Medical History: • Crohn’s • MI • HTN
• Bowel obstruction • Acute renal failure • CKD stage 3 • Smoker
Patient Anthropometrics • Height: 170.2 cm • Weight: 49.6 kg (109#) • BMI: 17.2 • BMI Consistent with: Underweight • IBW: 60.77 kg • %IBW: 81.62%
Patient Anthropometrics • Height: 170.2 cm
Weight History
• Weight: 49.6 kg (109#)
7/15/14
57 kg
126#
• BMI: 17.2
10/24/14
53 kg
117#
11/28/14
50 kg
111#
• BMI : Underweight • IBW: 60.77 kg
• %IBW: 81.62% • 13% weight change
Nutrition History • Patient reported TPN at home with liquid PO diet • Cyclic TPN, 12 hours on/off • No appetite PTA • Diet included occasional whey protein shakes • No trouble chewing or swallowing • Lactose intolerance reported at follow-up
Current Intake and Physical Findings • NPO
• Appeared undernourished
• TPN compounded as • 230g dextrose • 50g amino acid
• Thin
• 125mL fat emulsion • Kcal per day-1236 • Grams PRO- 50g • PRO/kg-1.01
• Weak
• Irritable and Angry • Reported diarrhea and nausea
Labs, Meds, Test, and Procedures • 12/10- MR Enterography• Abnormal matted small bowel loops in the left abdominal section • Bowel dilation, wall thickening • Fluid collection consistent with fistula • Right lower bowel- wall thickening, distention
Medication
Function
Nutritional Implications
Colestid
Helps lower cholesterol (bile acid binding resin)
May interfere with fat soluble vitamin absorption causing deficiency; increased chance of bleeding due to possible vitamin K deficiency
Heparin
anticoagulant
N/A
Humalog (SSI) Sliding scale insulin
May cause hypokalemia, avoid use in patients using potassiumlowering medications
Pentasa
Loss of appetite, nausea, vomiting
treats/prevents flare-ups of Crohn’s
(less common)
Prednisone
Protonix
Corticosteroid, treats inflammation
Can cause hyperglycemia, limit sodium intake, steroids increase bone loss-increase calcium and vitamin D intake. Proton Pump inhibitor; treats May inhibit folic acid, B-12, iron reflux symptoms; inhibits and beta-carotene absorption, gastric acid secretion avoid alcohol with use
Carafate
Treats and prevents ulcers
Avoid antacid use 30 minutes before and after use which may less the effect of Carafate,
Entocort
steroid/anti-inflammatory/ treats Crohn’s symptoms
Can cause hyperglycemia, steroids increase bone lossincrease calcium and vitamin D intake.
Questran light/
Helps lower cholesterol (bile acid binding resin)
May interfere with fat soluble vitamin absorption causing deficiency; increased chance of bleeding due to possible vitamin K deficiency
Zoysn
Antibiotic
Can cause diarrhea
Vancocin
antibiotic
Can cause diarrhea
prevalite
Labs During Admission • Trending high throughout admission: • Sodium • Creatinine • Glucose • BUN • WBC • Hct • Hgb
Inadequate oral intake related to Crohn’s Disease exacerbations and
Chronic GI bleed discomfort as evidenced by prolonged poor po
intake PTA and 13% weight change in 5 month period.
PES Statement Problem, Etiology, Signs and Symptoms
Estimated Energy Needs • Estimated needs using kcal/kg • Kcal/kg min: 30 Promote weight gain and prevent further weight loss • Kcal/kg max: 35 • Kcal/day min: 1488 • Kcal/day max: 1736
• Protein • 1-1.1 g/day (GFR 45) • 49.6-54.6 g/day • Fluid- 1240mL
Intervention • Goal- Nutrition support meets >75% of estimated needs and PO intake >25% of needs • Low residue diet initiated 12/10
• TPN- TPN to provide 1488 kcal, 50 g PRO, 265g dextrose, 19.5 mL of lipid • Ensure Clear BID (400 kcal, 14g PRO)
At Follow Up
Current Intake and Physical Findings • Current Intake: • Patient NPO for guided aspiration 12/12 • TPN- compounded as 250g dextrose, 50g PRO, and 200mL fat emulsion • Kcal/day: 1453 • ~1g PRO/kg • Patient reported tolerating TPN well
• Noted muscle loss-temples, clavicles, arms, shoulders consistent with malnutrition
• Weak • Improved mood
• Reported diarrhea and nausea
Labs, Meds, Test, and Procedures • 12/11-Pt checked for C.Diff (neg) • 12/11- CT Guided Aspiration (drainage of fistula)
Malnutrition related to Altered GI function, active Crohn’s Complications and matted bowel loops as evidenced by prolonged poor po intake, muscle loss (temples, clavicles, shoulders, arms) and documented severe 13% weight change in 5 month period.
Updated PES Statement Problem, Etiology, Signs and Symptoms
F/U: Estimated Energy Needs • Estimated needs using kcal/kg • Kcal/kg min: 30 Promote weight gain and prevent further weight loss, • Kcal/kg max: 35 malnutrition • Kcal/day min: 1488 • Kcal/day max: 1736
• Protein • 0.8-1.1 g/day (weight gain, GFR 38, Mg, Phos, K+ stable) • 39.6-54.6 g/day • Fluid- 1240mL
Intervention • Goal- Nutrition support meets >75% of estimated needs • Advance diet when medically able • TPN- TPN to provide 1488 kcal, 50 g PRO, 265g dextrose, 19.5 mL of lipid • Supplements- re-consult when diet is initiated
At Discharge • Patient ordered TPN for home use • Prescription for Prednisone • Diet at discharge: • Cardiac (low saturated fat, low salt, low cholesterol) • Low residue, small frequent meals
Outcomes and Summary • Enteral feeding can induce remission in as much as 70% of cases • Enteral feeding is as effective as steroids and should be used as primary therapy • Nutrition therapy is effective in improving overall nutrition status, promoting weight gain, and increasing BMI • 10% of patients maintain long term remission • Remission rates are not effected by bowel resection, extensive resection is unnecessary
Verma et al., 2000
• CDC • Donnellan, Clare F., Lee H. Yann, and Simon Lal. Nutritional Management of Crohn's Disease. Therapeutic Advances in Gastroenterology. (2013): 6(3): 231-42. • Fazio, Victor W., Floriano Marchetti, James M. Church, John R. Goldblum, Ian C. Lavery, Tracy L. Hull, Jeffery W. Milsom, Scott A. Strong, John R. Oakley, and Michelle Secic. Effect of Resection Margins on the Recurrence F Cohn's Disease in the Small Bowel. Annals of Surgery. 1996: 224(4): 563-73. • Ferguson, Anne, Michael Glen, and Subrata Ghosh. Crohn's Disease: Nutrition and Nutritional Therapy. Baillière's Clinical Gastroenterology. 1998: 12(1): 93-114. • Knight, C., Wael El-Matary, Christine Spray, and Bhupinder K. Sandhu. Long-term Outcome of Nutritional Therapy in Pediatric Crohn's Disease. Clinical Nutrition. 2005: 24(5): 775-79.
References
• Morain, C.O., A.W. Segal, A.J. Levi. Elemental Diet as Primary Treatment of Acute Crohn's Disease: a Controlled Trial. British Medical Journal Clinical Research. 1984: 288: 1859-1862. • Triggs, Christopher M., Karen Munday, Rong Hu, Alan G. Fraser, Richard B. Gearry, Murray L. Barclay, and Lynnette R. Ferguson. Dietary Factors in Chronic Inflammation: Food Tolerances and Intolerances of a New Zealand Caucasian Crohn's Disease Population. Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis. 2010: 690(1-2): 123-38. • Veloso, F. T., Ferreira, J. T., Barros, L. and Almeida, S. Clinical Outcome of Crohn's Disease: Analysis According to the Vienna Classification and Clinical Activity. Inflammatory Bowel Diseases. 2001:7(4): 306–313. • Verma, S., B. Kirkwood, S. Brown, and M.h. Giaffer. Oral Nutritional Supplementation Is Effective in the Maintenance of Remission in Crohn's Disease. Digestive and Liver Disease. 2000: 32(9):769-74.
References