Complications of Ulcerative Colitis

1. Complications of Ulcerative Colitis Leah Wendland Sodexo Mid-Atlantic Intern February 1st 2013

2. Objectives • Be able to identify intestinal complications of UC • Be able to identify an extraintestinal complication of UC • Identify a potential treatment of UC and potential side effects of this treatment

3. Ulcerative Colitis (UC) “Approximately 10% of ulcerative colitis (UC) patients require a colectomy within 10years of diagnosis”

4. Ulcerative Colitis (UC) a type of inflammatory bowel disease (IBD) that affects the lining of the large intestine (colon) and rectum

5. Intestinal Complications of UC • Malnutrition/Malabsorption • Bleeding • anemia • Intestinal Infections • Colorectal cancers • Colectomy

6. Extraintestional Complications • Arthritis • Diminished bone health • Liver and Gall Bladder disorders • primary sclerosingcholangitis (PSC) • cirrhosis • Thromboembolism • Kidney stones

7. Treatments for UC • Diet/Nutrition • Medication • Aminosalicylates • Corticosteroids • Immunosuppressants • Surgery

8. Long term effects of UC medication • Corticosteroids (prednisolone, methylprednisolone) • Weight gain, excessive facial hair, HTN, Hyperglycemia, osteoporosis/weakened bones • Anti-inflammatory • Aminosalicylates (mesalamine,balsalazide) • nausea, vomiting, diarrhea, heartburn and headache • Anti-inflammatory • Immunosuppresents (Azasan, Imuran) • Increased risk of infection/opportunistic infections • Anti-inflammatory

9. Nutrition Therapy for UC • Low- fiber diet during flare up • High-fiber diet while in remission • Possible lactose, gluten or wheat intolerance • Modify diet to fit needs of individual pt • No nuts, seeds, skins, popcorn etc.

10. AS 47 y/o F • Admitted 12/14 to post acute care/rehab floor • Patient admitted to this floor for PT 2° deconditioning • Antibiotic therapy

11. PMH • Ulcerative Colitis • s/pcolectomy 2° severe colitis • HTN • GERD • Recurrent renal stones • Arthritis • Appendectomy • Ulcerative Colitis • Diagnosis 1996 • 16 years w/o major complications

12. Medical Diagnosis • S/P total colectomy with end ileostomy • c/b rupture of Hartmann’s stump • With perihepatic and intra-abdominal abscesses • Requiring antibiotic therapy • Deconditioning

13. Colectomy with End Ileostomy

14. Hartmann’s Stump

15. Location of Abscesses

16. Social History • Single • Lives alone • Has 2 grown children • No reported drug or tobacco use

17. Nutrition Assessment Anthropometric Subjective/Objective Pt consuming >75% meals Stage 2 wound on buttock Surgical wound on abdomen (healing) Intra-abdominal abcesses • Ht: 5’2” (156cm) • Wt: 193# (87.6kg) • Adj Wt: 130# (59kg) • BMI: 34

18. Nutrition Related Medication • Multivitamin • Hydrochlorothiazide • Folic Acid • Ranitidine • Zofran

19. Labs

20. Nutrition Dx Increased Nutrient Needs r/t wound healing a/e/b Stage 2 wound on buttock and surgical abdominal wound Unintentional Wt. Loss r/t medical course with low intake and increased needs a/e/b pt reporting ~20# wt loss in <1month

21. Diet and Estimated Needs • Regular Diet • >75% intake first visit • Ensure Complete TID • Caloric Needs: 30-35kcal/kg • 30-35x adj BW59kg= 1770-2065kcal • Protein Needs: 1.3-1.5g/kg • 1.3-1.5gx adj BW 59kg= 77-89g

22. Intervention and M/E • Nutrition Intervention: • Rec Ensure Complete TID • Continue multivitamin, folic acid • Monitoring and Evaluation • PO/Supplement intake: pt to meet ≥75% estimated needs • Weight: Pt to maintain weight +/- 3% in one month • Lab Values: monitor nutrition related lab values WNL

23. Follow Up • 12/19: *my first contact • Reported N/V • Provided new diagnosis • Altered GI function r/tcolectomy and recent hospital course a/e/b Pt reporting N/V, hxileostomy and colectomy • Medications added • Warfarin • Provided ileostomy nutrition education as well as Vit K/ warfarin education

24. Evaluation of Compliance • AS was actively engaged in education • Asked questions • Provided feedback on supplement and food • Pt appeared to be motivated

25. Lab Values F/U

26. Follow Up Chart

27. Follow Up Chart cont.

28. Hospital Course

29. Updates

30. References • http://www.caet.ca/caet-english/education-ileostomy-guide.htm • http://www.askdrmakkar.com/ulcerativecolitis.htm • Forbes, A., Goldesgeyme, E., & Paulon, E. Nutrition in inflammatory bowel disease. Journal of Parenteral and Enteral Nutrition, 2011; 35(5), 571-580. • Peppercorn, M. Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults. UpToDate,2011 • Ma, C., Crespin, M., Proulx, M., DeSilva, S., Hubbard, J., & Hubbard, J. Postoperative complications following colectomy for ulcerative colitis: a validation study. BMC Gastroenterology,2012; • Comorbidity in inflammatory bowel disease (San Roman,Munoz ,2011) • Ardizzone, S., Puttini, P. S., Cassinotti, A., & Porro, G. B. Extraintestinal manifestations of inflammatory bowel disease. Digestive and Liver Disease, 2008; S253-S259. • Herrera, J. Hepatobiliary complications of inflammatory bowel disease. Practical Gastroenterology,2006 • Nguyen, G. C., & Sam, J. Rising prevalence of venous thromboembolism and its impact on mortality among hospitalized inflammatory bowel disease patients. American Journal of Gastroenterology, 2008; 2272-2280.

31. References cont. • Warner, B. Short and long term complications of colectomy. Journal of Pediatric Gastroenterology and Nutrition, 2009; 48(2), S72-S74. • Loftus, E. V., Friedman, H. S., Delgado, D. J., & Sandborn, W. J. Colectomy subtypes, follow-up surgical procedures, post surgical complications, and medical charges among ulcerative colitis patients with private health insurance in the united states. Inflammatory Bowel Disease, 2009; 15(4), 566-575. • Tappenden, K. Quest for excellence: inspiration from the illeum. Journal of Parenteral and Enteral Nutrition, 2010; 34(6), 716-722. • Camden, J., & Carucci, L. Internal illiacpseudoaneurysm rupture attributed to perforated hartmann's pouch diagnosed on ct. Open Journal of Radiology, 2012; 52-54. • Xue, H., Sufit, A., & Wischmeyer, P. E. Glutamine therapy improves outcome of in vitro and in vivo experimental colitis models. Journal of Parenteral and Enteral Nutrition,2011; 35(2), 188-197.

32. Questions? Thank you!! 