Ana Maria Pelcastre

Case 11 Questions
I. Understanding the Disease and Pathophysiology
1. What is inflammatory bowel disease? What does current medical
literature indicate
regarding its etiology?
Inflammatory bowel disease involves chronic inflammation of the GI tract. It
includes Crohns disease and ulcerative colitis. Both of them share some
clinical characteristics including diarrhea, fever, weight loss, anemia, food
intolerances, malnutrition, growth failure and extra-intestinal manifestations
(arthritic, dermatologic and hepatic).
Current medical literature says that the causes are not completely
understood, but it involves the interaction of the GI immunologic system and
genetic and environmental factors. Regarding the genetic factor, a number
of possible gene mutations that affect risk and characteristic of the disease.
The diversity in the genetic alterations among individuals may help explain
differences in the onset, aggressiveness, complications, location and
responsiveness to different therapies as seen in the clinical setting.
2. Mr. Sims was initially diagnosed with ulcerative colitis and then
diagnosed with Crohns.
How could this happen? What are the similarities and differences
between Crohns disease
and ulcerative colitis?
If Mr. Sims was initially diagnosed with UC and later diagnosed with Crohns
is probably because both of the diseases are very similar. For example, as I
previously mentioned, both Crohns disease and ulcerative colitis share
clinical characteristics such as diarrhea, fever, weight loss, anemia, food
intolerances, malnutrition, growth failure and extra intestinal manifestations
(arthritic, dermatologic and hepatic). In Mr. Sims case he was mainly
complaining of more frequent diarrhea, unbearable abdominal pain and
high temperature. He also lost weight.
Some of the differences between the two diseases are:
Crohns disease: it involves any part of the GIT (mainly ileum and colon).
Also there are segments of inflamed bowel and healthy segments. All layers
of the mucosal are affected.

Ulcerative Colitis: it happens mainly in the large intestine and rectum. The
disease is continuous without healthy segments. This disease only affects the
mucosa layer and also bloody diarrhea is more common with UC.

4. What did you find in Mr. Sims history and physical that is
consistent with his diagnosis of Crohns ? Explain.
First, he has lost weight since his last visit. This is probably due to the
frequent bowel movements and poor nutrition absorption. He also has high
fever, unbearable abdominal pain and frequent diarrhea for the last couple of
months. These symptoms can be due to the inflammation due by possible
ulcerations, fistulas, fibrosis, submucosal thickening, localized strictures,
narrowed segments of bowel and partial or complete obstruction of the
intestinal lumen (Krauses p.628) which are Crohns characteristics.
Regarding his abdomen, his chart says he has distension, extreme
tenderness with rebound and guarding and minimal bowel sounds. All these
symptoms are also related to Crohns symptoms.
5. Crohns patients often have extraintestinal symptoms of the
disease. What are some
examples of these symptoms? Is there evidence of these in his
history and physical?
Some of the extra-intestinal symptoms include arthritic,
dermatologic, and hepatic.
Extra-intestinal symptoms include other organ systems affected in IBD. Some
examples are bones and joints, skin, eyes, hepatobiliary system, lungs and
kidneys. (http://www.ncbi.nlm.nih.gov).
Perhaps some evidence of extra-intestinal symptoms in his chart is dry skin.
6. Mr. Sims has been treated previously with corticosteroids and
mesalamine. His physician
had planned to start Humira prior to this admission. Explain the
mechanism for each of
these medications in the treatment of Crohns.
corticosteroids, mesalamine and humira are anti-inflammatory agents, they
inactivate one of the primary inflammatory cytokines. They also decrease the
activity of the immune system thus reducing inflammation. One of the
drawbacks is that the patient becomes susceptive to other infections.

7. Which laboratory values are consistent with an exacerbation of

his Crohns disease?
Identify and explain these values.
Albumin: it is low which was caused by malnutrition, inflammation, and poor
absorption of proteins.
Total protein: is low due to poor absorption
Prealbumin: is low due to poor absorption of nutrients therefore the patient
is malnourished.
Transferrin: is low due to iron deficiency and poor protein digestion.
Therefore the total iron binding capacity increases and the transferring
saturation decreases.
CRP is increased due to the inflammation condition.
Osmolarity lab is low because of his dehydration due to frequent diarrhea.
Hemogloblin and Ferritin are low due to iron deficiency.
8. Mr. Sims is currently on several vitamin and mineral supplements.
Explain why he may be at risk for vitamin and mineral deficiencies.
He may be at risk for vitamin and mineral deficiencies because they cant be
fully absorbed due to the crohns disease and inflammation.
9. Is Mr. Sims a likely candidate for short bowel syndrome? Define
short bowel syndrome,
and provide a rationale for your answer.
Short bowel syndrome: it is defined as inadequate absorptive capacity
resulting from reduced length or decreased functional bowel after resection.
A loss of 70% to 75% of small bowel results in SBS, defined as 100 to 120 cm
of small bowel without a colon or 50 cm of small bowel with the colon
reminding. Another practical definition of SBS is the inability to maintain
nutrition and hydration needs with normal fluid and food intake, regardless of
bowel length (Krause p.637).
Mr. Sim can be a candidate for SBS if his diet is not closely watched which
may worsen his condition because if removed part of his small bowel (ileum)
his absorption of vit B12 will decrease as well as other nutrients absorption
and metabolism of fats.
II. Understanding the Nutrition Therapy
13. What are the potential nutritional consequences of Crohns
disease?
Some of the potential nutritional consequences of Crohns disease include
protein, and vitamins such as folate, B6, B12 and trace minerals such as
magnesium and zinc mal absorption; Also fat vitamins due to lack of fat

metabolism. If the patient doesnt receive supplements and the appropriate

diet he may experience weight loss, muscle wasting, and dehydration and he
may probably need enteral or parental nutrition feeding.
14. Mr. Sims underwent resection of 200 cm of jejunum and proximal
ileum with placement of jejunostomy. The ileocecal valve was
preserved. Mr. Sims did not have an ileostomy, and his entire colon
remains intact. How long is the small intestine, and how significant
is this resection?
The length of the small intestine in an adult is approximately 400cm long. As
long as the terminal ileum remains intact, resection of large sections of
jejunum is tolerated well. If more than 100cm of the terminal ileum is
resected that major mal-absorption problems, severe diarrhea, and
malnutrition occur.
15. What nutrients are normally digested and absorbed in the
portion of the small intestine
That has been resected?
The nutrients include calcium, folate, fat soluble vitamins, free fatty acids,
vitamin B12, sodium and water.
III. Nutrition Assessment
16. Evaluate Mr. Sims % UBW and BMI.
%UBW: 140#/168# x 100= 83% = mild degree of malnutrition.
BMI: 64Kg/(1.75m)2= 21 kg/m2 Normal weight
According to his UBW he is currently at 83% which means he has a mild degree of
malnutrition. His BMI says he is within normal range however, since he has lost
weight the last couple of weeks this BMI is not accurate and if he continues in this
condition he will advance to severe malnutrition.

17. Calculate Mr. Sims energy requirements.

Using the Harris Benedict Formula his nutrient needs (REE) are as follow:
Male: 66 + (13.7 x 64kg) + (5 x 175cm) (6.8 x 35)= 1514kcals
Disease state: REE x Activity Factor x Injury Factor: 1514 x 1.3 x 1.5=
2952kcals
Total Energy needs: 2952 or 2955kcals/day.
18. What would you estimate Mr. Sims protein requirements to be?
Because of his current condition and surgery he will need more protein for
healing and to restore his protein needs.
If his protein intake is 2g per Kg he will need: 128 grams of proteins per day.

19. Identify any significant and/or abnormal laboratory

measurements from both his
hematology and his chemistry labs.
Albumin is low because of the nutrient malabsorption including protein and
also due to the inflammation.
Total protein is low due to malabsorption
Prealbumin is low due to malnutrition
Transferrin is low due to iron deficiency (this is also due to poor absorption)
Total Iron binding capacity will be high because there is low iron
concentration in the body.
Transferring saturation is low for the same reason
CRP is high because of the inflammation condition
The osmolarity lab is low because of the dehydration (due to diarrhea).
Hemoglobin and ferritin are low because of poor absorption.
IV. Nutrition Diagnosis
20. Select two nutrition problems and complete the PES statement
for each.
First nutrition problem: poor protein levels
Involuntary protein deficiency related to Crohns disease due to protein
malabsorption as evidence by clinical lab values of Albumin, total protein,
transferrin, hemoglobin, ferritin outside of normal ranges.
Second nutrition problem: Dehydration
Involuntary dehydration related to Crohns disease due to inadequate fluid
and nutrient absorption as evidence by low osmolarity lab values.

V. Nutrition Intervention
21. The surgeon notes Mr. Sims probably will not resume eating by
mouth for at least
710 days. What information would the nutrition support team
evaluate in deciding the
route for nutrition support?
The nutrition support will depend on how much intestinal resection took
place, if his GI is functioning (motility, ileum resection) nutrient needs, if he is
able to eat by mouth, if there is presence of fistula, obstruction and if he is

currently having diarrhea or vomiting. They will also take into account fluid
needs to prevent dehydration.
22. The members of the nutrition support team note his serum
phosphorus and serum
magnesium are at the low end of the normal range. Why might that
be of concern?
If phosphorous and magnesium are low it confirms the patient has electrolyte
imbalance due to malabsorption, dehydration due to diarrhea and
inflammation. If these minerals are low then calcium and potassium may also
be affected and become imbalanced as well. In the long run, a deficiency in
these minerals will affect enzyme function including DNA synthesis. Energy
metabolism, nerve conduction, nutrients transportation such as iron and
calcium will be affected.
Chronic deficiency of magnesium and phosphorus can also lead to
magnesemia and phosphataemia. Therefore it will alter bone metabolism,
cardio-respiratory, hematological and nervous systems.
23. What is refeeding syndrome? Is Mr. Sims at risk for this
syndrome? How can it be
prevented?
Refeeding syndrome: a syndrome consisting of metabolic disturbances
that occur as a result of reinstitution of nutrition to patients who are starved
or are severely malnourished.
This condition may occur if the patient is aggressively fed npo or by nutrition
support such as parental nutrition. This condition will cause electrolyte
imbalance (loss of electrolytes), fluid retention and therefore it can be a life
threatening condition. This patient can be at high risk of refeeding syndrome
because he has two of the main risk factors which includes: malnutrition and
weight loss. The condition can be prevented by beginning slowly parental
nutrition and monitoring electrolyte levels, including serum glucose
(particularly because of the dextrose content in the given formula).
24. Mr. Sims was placed on parenteral nutrition support immediately
postoperatively, and
a nutrition support consult was ordered. Initially, he was prescribed
to receive 200 g
dextrose/L, 42.5 g amino acids/L, and 30 g lipid/L. His parenteral
nutrition was initiated
at 50 cc/hr with a goal rate of 85 cc/hr. Do you agree with the teams
decision to initiate
parenteral nutrition? Will this meet his estimated nutritional needs?
Explain. Calculate:
pro (g); CHO (g); lipid (g); and total kcal from his PN.

Yes Mr. Sims needs PN because he underwent intestinal resection and he is

already malnourished. Also his gut needs time to heal before the reintroduction of food into the digestive system. However, the prescription
seems to be a little low for his kcals needs because he is only receiving one
liter per day and the total kcals are 1150 (CHO: 680, PRO:170 and FAT 300)
when in reality he needs 2955 Kcals.
Actual Energy requirements: 2955 Kcals
Protein Requirements: 2grams x 64kg: 128g/day

Gms of dextrose, kcals provided and mg/kg/min

1000mL= 200gms dextrose
200gms Dex x 3.4kcals/g= 680kcals
200mgs dex / 35 yr old/ 1.44= 3.96gms/kg/min

Gms of protein, kcals and gm/kg

1000mL= 42.5gms AAs
42.5gms x 4=170kcals pro
42.5gms/ 35kg= 1.2 gm pro/kg
Lipids
30gms of fat x 10= 300kcals
o
o
o

Pro: 170 kcals / 1150 kcals= 15%

Cho: 680 kcals / 1150 kcals= 59%
Fats: 300 Kcals / 1150 kcals= 26%
Totals kcals: 1150 of TPN

VI. Nutrition Monitoring and Evaluation

26. Indirect calorimetry revealed the following information:
Measure
Mr. Sims data
Oxygen consumption (mL/min)
295
CO2 production (mL/min)
261
RQ
0.88
RMR
2022

What does this information tell you about Mr. Sims?

Mr. Sim has a high consumption of oxygen because the normal amount is
250mL/min. This is due to his high metabolic induced by Crohns Disease.
The CO2 production is also high due to his high metabolic condition (Normal
CO2 production is 200m/L. Also his respiratory Quotient falls within normal

range which is 0.7-1. Finally his RMR says its 2022 which is higher compared
to his recommendations.
30. Evaluate the following 24-hour urine data: 24-hour urinary nitrogen
for 12/20: 18.4 grams.
By using the daily input/output record for 12/20 that records the amount of
PN received,
calculate Mr. Sims nitrogen balance on postoperative day 4. How would you
interpret this
information? Should you be concerned? Are there problems with the
accuracy of nitrogen
balance studies? Explain.
42.5 pro/6.25 18.4 UUN + 3 Factor= -8.6
His nitrogen balance is negative which means he is not getting enough
protein intake in his diet. The Nitrogen balance should be a positive number
and therefore he needs to increase his protein intake in order to repair and
heal his bowel resection. Yes there are problems because his Nitrogen
balances are negative which can lead to further complications of his
conditions (bowel resection) by not healing properly and wasting muscle and
other tissue proteins.
31. On post-op day 10, Mr. Sims team notes he has had bowel
sounds for the previous
48 hours and had his first bowel movement. The nutrition support
team recommends
consideration of an oral diet. What should Mr. Sims be allowed to try
first? What would
you monitor for tolerance? If successful, when can the parenteral
nutrition be weaned?
The first oral diet that Mr. Sims should be allowed to try is clear liquids. The
diet would be small frequent meals to see the stomachs level of tolerance.
The nutrition department would look for symptoms such as nausea,
vomiting, diarrhea etc. If successful in his oral intake, the parental nutrition
can be wean after 2 or more weeks.
32. What would be the primary nutrition concerns as Mr. Sims
prepares for rehabilitation
after his discharge? Be sure to address his need for
supplementation of any vitamins and
minerals. Identify two nutritional outcomes with specific measures
for evaluation.

One of the primary nutrition concerns includes hyper-metabolism, poor

protein intake (negative nitrogen levels) hyperglycemia and insulin
resistance. Regarding vitamins and other nutrient needs, he most likely will
need vitamin B12, fat soluble vitamins and electrolytes. Two nutritional
outcomes with specific measures for evaluation is protein status (healing)
and dehydration which can be determined by weight loss or gain.