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A Case Report

Crohn’s Disease: Nutritional Management. A Case Report. Jessica Serdikoff ARAMARK Distance Learning Dietetic Internship Holy Redeemer Medical Center January 04, 2013. Disease Management: Disease Overview. Subcategory of Inflammatory Bowel Disease (IBD)

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A Case Report

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  1. Crohn’s Disease: Nutritional Management A Case Report Jessica Serdikoff ARAMARK Distance Learning Dietetic Internship Holy Redeemer Medical Center January 04, 2013

  2. Disease Management: DiseaseOverview • Subcategory of Inflammatory Bowel Disease (IBD) • Inflammatory irritation of Gastrointestinal (GI) Tract • Ileum of small intestine, mostly

  3. Disease Management: Disease OverviewCrohn’svs Ulcerative Colitis Crohn’s Disease Ulcerative Colitis • Adjacent, isolated affected areas • Superficial • Affected areas that “skip” • Deep

  4. Disease Management: Etiology • Abnormal immune inflammatory reaction • Unknown • Elevated Tumor Necrosis Factor (TNF) • 21 genes associated • Environmental Trigger

  5. Disease Management: Epidemiology • Higher rates seen with/in: • Jewish ancestry • Age (13-30 years old) • Cigarette use • Developed countries, urban areas, & northern climates

  6. Disease Management: Signs & Symptoms • Abdominal pain (LRQ) • Diarrhea (increased water secretion) • Rectal bleeding  anemia • Weight loss • Fever

  7. Disease Management: Complications • Intestinal blockage • Swelling vs. Scar tissue formation • Tunneling ulcers / fistulas • Infection • Malabsorption  malnutrition • Short Bowel Syndrome (SBS)

  8. Evidenced-Based Nutrition Recommendations

  9. Systematic Review • Clinical trials and meta-analyses • Limitations • Insufficient data • Methodological limitations • No P-values cited • Implications • More research • Reduced need for drug therapy • Interventions investigated • Enteral Nutrition • Fiber • Fish Oil supplements • Glutamine Supplements • Elimination Diets Yamamoto T, Nakahigashi M, and Saniabadi AR. Review article: diet and inflammatory bowel disease – epidemiology and treatment. Aliment Pharmacol Ther. 2009;30:99-112.

  10. Enteral Nutrition • VS corticosteroids: mucosal healing vs. remission • Elemental vs. Non-Elemental: no difference • Fat chain length: mixed results • Fiber • Hospital admissions & surgeries • Remission • Fish Oil supplements • Inflammation • Weight gain • Glutamine supplements • Not effective • Elimination Diets • Inconclusive (mixed) results Yamamoto T, Nakahigashi M, and Saniabadi AR. Review article: diet and inflammatory bowel disease – epidemiology and treatment. Aliment Pharmacol Ther. 2009;30:99-112.

  11. Non-Randomized Open Trial – Enteral Nutrition • Subjects • 268 CD patients • Mean Age: 31.9 • 205 male (76%) • 50% <21 when dx • 2 groups: • <900kcal/day • >900kcal/day • Limitations • Not blinded • No true control • Gender distribution • Implications • Maintain remission • Minimal side effects RESULTS • Fewer hospitalizations with >900kcal • Ileal involvement • P=0.008 Watanabe O, Ando T, Ishiguro K, Takahashi H, et al. Eneteral nutrition decreases hospitalization rate in patients with Crohn’s disease. J Gastroen Hepatol. 2010;25(Suppl.1):S134-S137.

  12. Non-Randomized Open Trial – Elimination Diets • Subjects (n=29) • Mean Age: 39.3 • 11 male (38%) • 20 non-smokers (69%) • Common food exclusions: • Egg yolks & whites • Beef • Cheddar cheese • Pork • 4 weeks long • 4 food types excluded • Pre/Post-diet mCDAIS • >150=active disease • 70% decr.=significant Rajendran N and Kumar D. Food-specific IgG4-guided exclusion diets improve symptoms in Crohn’s disease: a pilot study. Colorectal Disease. 2011;13:1009-1013.

  13. Non-Randomized Open Trial – Elimination Diets • Limitations • Small sample size • Short duration • Limited sample of exclusions • Not blinded • Implications • Individualized care RESULTS • mCDAIS 171  97.5 (p=0.0001) • Stool frequency (p=0.0001) • Pain rating (p=0.030) • Well-being (p=0.45) • Reduced IgG4 seroreactivities(p=0.003) Rajendran N and Kumar D. Food-specific IgG4-guided exclusion diets improve symptoms in Crohn’s disease: a pilot study. Colorectal Disease. 2011;13:1009-1013.

  14. Double-Blind Crossover Intervention Diet • Pilot Study • 79 CD patients • 20 healthy controls • Intervention Study • 40 CD patients • 16 male (40%) • Mean Age: 41 • 12 weeks total • 6 weeks sham diet • 6 weeks exclusion diet • mCDAIS-type data Bentz S, Hausmaa M, Piberger H, Kellermeier S, et al. Clinical Relevance of IgG Atibodies against Food Antigens in Crohn’s Disease: A Double-Blind Cross-Over Diet Intervention Study. Digestion. 2010;81:252-264.

  15. Double-Blind Crossover Intervention Diet • Limitations • Under-reporting • High drop-out rate • Inconsistent medications • No wash out period • Implications • May prove beneficial • More research needed RESULTS • Pilot • Significant differences • p<0.0001 • Intervention • Reduced stool frequency • (p=.004) • Improved well-being • (p=.07) Bentz S, Hausmaa M, Piberger H, Kellermeier S, et al. Clinical Relevance of IgG Atibodies against Food Antigens in Crohn’s Disease: A Double-Blind Cross-Over Diet Intervention Study. Digestion. 2010;81:252-264.

  16. Complaints: • Abdominal Cramping • Anorexia • Nausea • Vomiting Case Presentation 70 years old White Male Hx of GI pathology

  17. Client History Personal History Medical History • Age: 70 • Former smoker • Lives with wife • Retired • Myocardial Infarction • Gynecomastia • Anemia • Prostate Cancer • Myelofibrosis • CKD • GI History: • Ulcers Pancreatitis • Colitis GOO • Crohn’s Disease 7.5ft. small bowel • GI Bleeding

  18. Food/Nutrition-Related History • Anorexia / Decreased food intake • Modified diets • Supplement use • Anti-Inflammatory • Fish Oil • Omega-3 fatty acids • Glucosamine • For malabsorption • Folic Acid Vitamin C • Vitamin B12 Vitamin D3 • Vitamin B6 Calcium • Zinc • Poor nutrition quality of life

  19. Nutrition-Focused Physical Findings • Edentulous maxilla (dentures) • Depressed affect • Muscle wasting • Anthropometrics: • Height: 6’7” • Weight: • CBW: 97# • UBW: 115# • BMI: 15.22

  20. Biochemical Data, Medical Tests & Procedures

  21. Nutrition Needs ENERGY: Mifflin-St. Jeor Equation 1450-1550kcal/day PROTEIN: 1.3g/kg/day 55g/day FLUID: 1mL/kcal/day 1450-1550mL/day

  22. ARAMARK Nutrition Care Priority Points:

  23. DRG Coding Form

  24. Nutrition Diagnosis Inadequate oral food & beverage intake(NI-2.1) related to altered GI function as evidenced by recent 16% weight loss vomiting shortened GI tract BMI=15.22 and NPO status during hospitalization.

  25. Interventions: Medical • ICU: Rehydration, IV potassium, protonix • GI Consult • Nephrology Consult • NPO • Billroth II hemigastrectomy & truncalvagotomy • 4.5ft small bowel removed

  26. Interventions: Nutrition • ND-1.2.2 Modify distribution, type, and amount of food and nutrients within meals or at specified time • NPO  TPN + NPO  TPN + Clears/Starches • Low fiber, low lactose house diet • Calorie Counts • ND-2.2.1 Parenteral Nutrition Solution • 1500mL, 200gm D, 75gm AA, 40gm Fat: 1420kcal • ND-3.1.1 Medical Food Supplements • Ensure Enlive BID • ND-3.2 Vitamin and Mineral Supplements • Standard MVI-mineral • Calcium + Vitamin D • Intravenous B12 + Iron

  27. Monitoring & Evaluation • FH-1.3.2.1 Parenteral Nutrition Formula/Solution • FH-1.1.1.1, FH-1.5.2.1 Energy and Protein Intakes • Calorie Counts • AD-1.1 Body Composition/Growth/Weight History • Weights 3x/week • 9# weight gain during hospitalization

  28. Monitoring & Evaluation, cont’d • BD: • 1.2: Electrolyte & Renal Profile • BUN, Cr, GFR: improved • 1.5: Glucose/Endocrine Profile • Casual & Fasting • 1.7.7: Triglycerides, serum • WDL • 1.10: Nutritional Anemia Profile • Hb & Hct: declined  IV iron • 1.11: Protein Profile • Albumin & Prealbumin: improved

  29. Summary • Case Study: JH • Discharged after 37 days • PO=75% needs • 10# weight gain • Crohn’s Disease • Increased risk malnutrition • Preferred treatment: EN • Oral: low fiber/low fat vs. IgG4 exclusions • Supplementation • Bottom Line: Individualized care • More research

  30. Reference List • Crohn’s Disease. National Digestive Diseases Information Clearinghouse Web site. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/. Updated January 18, 2011. Accessed December 13, 2012. • Mayo Clinic Staff. Crohn’s disease. Mayo Clinic Web site. http://www.mayoclinic.com/health/crohns-disease/DS00104. Updated August 9, 2011. Accessed December 13, 2012. • What is Crohn’s Disease? Crohn’s & Colitis Foundation of America Web site. http://www.ccfa.org/what-are-crohns-and-colitis/what-is-crohns-disease/. Accessed December 13, 2012. • Crohn’s Disease and Ulcerative Colitis. The Nutrition Care Manual Web site. http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=19449. Accessed December 13, 2012. • Short Bowel Syndrome. National Digestive Diseases Information Clearinghouse Web site. http://digestive.niddk.nih.gov/ddiseases/pubs/shortbowel/. Updated April 30, 2012. Accessed December 13, 2012. • The Nutrition Care Manual. The Academy of Nutrition & Dietetics Nutrition Care Manual Web site. http://www.nutritioncaremanual.org/index.cfm. Accessed December 14, 2012. • Moorthy D, Cappellano KL, and Rosenberg IH. Nutrition and Crohn’s disease: an update of print and Web-based guidance. Nutrition Reviews. 2008;66(7):387-397. • Seetharam P, Rodrigues G. Short bowel syndrome: A review of management options. Saudi J Gastroenterol. 2011;17:229-35. • McClave SA, Martindale RG, Vanek WV, McCarthy M, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. JPen-Pareneter Enter. 2009;33(3):285-290;302-304. • Watanabe O, Ando T, Ishiguro K, Takahashi H, et al. Eneteral nutrition decreases hospitalization rate in patients with Crohn’s disease. J GastroenHepatol. 2010;25(Suppl.1):S134-S137. • Yamamoto T, Nakahigashi M, and Saniabadi AR. Review article: diet and inflammatory bowel disease – epidemiology and treatment. Aliment PharmacolTher. 2009;30:99-112. • Rajendran N and Kumar D. Food-specific IgG4-guided exclusion diets improve symptoms in Crohn’s disease: a pilot study. Colorectal Disease. 2011;13:1009-1013. • Bentz S, Hausmaa M, Piberger H, Kellermeier S, et al. Clinical Relevance of IgGAtibodies against Food Antigens in Crohn’s Disease: A Double-Blind Cross-Over Diet Intervention Study. Digestion. 2010;81:252-264. • Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Chicago, IL: American Dietetic Association; 2011. • Pronsky ZM, Crowe JP Sr. Food Medication Interactions. 16th ed. Birchrunville, PA: FOOD-MEDICATION INTERACTIONS; 2010. • How Does Measurement Compare to Equations? The Academy of Nutrition and Dietetics Evidence Analysis Library. http://andevidencelibrary.com/topic.cfm?cat=1071. Accessed December 16, 2012.

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