Case Study Report: Medical Nutrition Therapy for Crohn’s Disease

1. Case Study Report: Medical Nutrition Therapy for Crohn’s Disease Allison Krippene Sodexo Dietetic Intern May 2, 2013

2. Crohn’s Disease • One of two main forms of Inflammatory Bowel Disease • Affects about 500,000 Americans • Can occur at any age, though onset typically occurs between 15 and 30 years of age • No cure

3. Crohn’s Disease • Characterized by patchy areas of inflammation called skip lesions • Skip lesions can occur anywhere along the GI tract and are often separated by segments of healthy tissue

4. Crohn’s Disease

5. Possible Etiologies • Genetics • Up to 20% of individuals with Crohn’s Disease have a first-degree relative who also has the disease • Abnormal Immune Responses • Environmental Factors • Oral Contraceptive use (still being investigated) • Smoking • There is little evidence to support diet as a risk factor for Crohn’s Disease

6. Symptoms of Crohn’s Disease • Symptoms are usually related to the area of the GI tract that is affected • Often include abdominal pain, cramping, loss of appetite, nausea, vomiting, diarrhea, and/or weight loss

7. Medical Management • Anti-inflammatory agents and immunosuppressants (corticosteroids) • Monoclonal antitumor necrosis factor (anti-TNF) agents (infliximab) • Antibiotics often used to treat complications of Crohn’s Disease

8. Complications • Physical complications: • Fistulas • Ulcers • Abscesses • Hemorrhaging • Obstruction

9. Complications • More chronic complications: • Cancer in the affected areas • Anemia • Malabsorption • Malnutrition

10. Factors Affecting Nutrition Status in Crohn’s Disease • Area of the GI tract that is affected • Degree of inflammation • GI symptoms (nausea, vomiting, diarrhea, malabsorption, etc.) • Wounds • Surgery • Medications These factors, and malnutrition, can all influence a patient’s energy and protein needs.

11. Vitamins and Minerals • Deficiencies can occur due to inadequate intake, malabsorption, drug-nutrient interactions • Vitamins: vitamin B12, folic acid, fat soluble vitamins (steroid use may also influence vitamin D deficiency) • Minerals: iron, calcium, potassium, zinc, selenium

12. Medical Nutrition Therapy • Energy needs: 30-35kcal/kg • Protein needs: 1.2-2.0g/kg • Monitor serum levels of micronutrients to determine need for supplementation • Often recommended that patients take a daily multivitamin

13. Medical Nutrition Therapy • Low-fiber/low-residue diet during acute flare-ups • Omega-3 fatty acids • Prebiotics (FOS, inulin, pectin) • Probiotics (VSL#3) • Antioxidants • MCTs may be beneficial with fat malabsorption

14. Nutrition Support At times when nutritional requirements cannot be met through oral intake, an alternative route of feeding may be required. • Enteral Nutrition • Can improve nutritional status and promote weight gain

15. Nutrition Support • Parenteral Nutrition • May be required due to complications • Allows for bowel rest when needed

16. Presentation of Patient J.S. • 26 year-old Hispanic male • Prior Medical History: Crohn’s Disease (diagnosed 7 months prior to present hospital admittance), noncontributory family history

17. Presentation of Patient J.S. • Complained of nausea and vomiting for 2-3 days, leading him to seek treatment at St. Luke’s Hospital’s emergency room • CT scan obtained, revealing Crohn’s flare-up with microperforation of the bowel

18. Medical/Surgical Course • Patient admitted, started on antibiotic therapy • Per gastroenterology: NPO for bowel rest and recommended possible TPN in light of low albumin (1.7g/dL) • Obstruction series x-ray suggested ileus pattern

19. Nutritionally-Relevant Abnormal Labs

20. Medical/Surgical Course • One week later, second CT revealed ascites, suggested abscess formation • Antibiotic therapy continued, percutaneous abscess drainage performed • Corticosteroid therapy initiated

21. Prescribed Medications

22. Medical Nutrition Therapy • Patient met criteria for moderate malnutrition (38% weight loss x4 years, limited food acceptance, BMI = 17.5kg/m2) • Need for bowel rest indicated • TPN initiated

23. Medical Nutrition Therapy • TPN Initiated at: • 300ml D30% • 350ml 15% AA (amino acids) • 150ml 20% lipids • TPN Goal: • 1100ml D30% • 450ml 15% AA • 250ml 20% lipids Goal provided 1892kcal, 68g protein, 1800ml fluid, dextrose infusion rate = 4.3mg/kg/min, lipid infusion rate = 0.9g/kg

24. Medical Nutrition Therapy • Patient received TPN for 9 days until his condition improved allowing him to tolerate an oral diet and the course of his medical treatment was complete • Once appropriate for oral intake, low-fiber/low-residue diet recommended

25. Medical Nutrition Therapy • Prior to discharge, patient tolerating regular diet with 75% meal completions • Ensure Plus TID • TPN discontinued • Need for education not indicated

26. Nutritionally-Relevant Labs at Time of Discharge

27. After Discharge • Patient was required to continue steroid therapy for one more week following discharge • Follow-up appointment scheduled 3 weeks later to determine patient’s progress

28. Questions?