Crohn’s Disease

1. Crohn’s Disease By Kristin Weil and Jade Miles

2. What is Crohn’s Disease? • A type of inflammatory bowel disease (IBD) • Inflammation of the digestive tract • Affects all layers of the mucosa • Can affect anywhere from the mouth to the anus • Most common area is the combination of the ileum and the colon • Diseased area not always continuous

3. Crohn’s Disease • Cause: unknown • Auto-immune • Who does it affect? • Affects men and women equally • African-Americans have decreased risk • Symptoms occur between ages 15 to 30 • Signs and Symptoms • Severe abdominal pain • Diarrhea • Rectal bleeding • Weight loss • Fever

4. Research Article: MNT • Controlled trial comparing two types of enteral nutrition in treatment of active Crohn’s disease: elemental v polymeric diet • Objective: To compare how efficient both an elemental enteral diet (EED) and polymeric defined formula diet (PFD) are on disease activity and nutritional status of a patient with Crohn’s disease. • Design: Prospective randomized clinical trial

5. MNT Research Article Continued • Participants: 30 patients from two hospitals met the criteria: • Active Crohn’s disease (CDAI > 150) • Malnutrition and/or non-responsive to steroids • Didn’t fall into any exclusion criteria categories • No significant differences in age, sex, duration or activity of disease, or previous complications or surgery • Independent Variables: EED (Vivonex HN) or PFD (Realmentyl or Nutrison) • Dependent Variables: Nutrition status and disease activity

6. MNT Research Article Continued • Methods: • Patients randomly placed into EED or PFD group • Nasogastric TF; no other food or caloric drinks allowed. Medications d/c during study • Therapeutic period lasted from 4-6 wks with the median being 30 days • Used CDAI to assess activity of Crohn’s disease once/wk • Fecal output measured for 3 continuous days 3 times • Colonoscopy before nutrition support initiated and after therapeutic period • Measurements to assess inflammation • HGB, alb, and transferrin levels and anthropometric data gathered on days 0, 14, 21, and 28

7. MNT Research Article Continued • Results: • Remission of Crohn’s disease (CDAI < 150) in 21 of 30 patients by week four - 10 from EED vs. 11 from PFD • Significant decrease in fecal output was similar in both groups • Colonoscopic lesions ameliorated with no significant difference between the groups • All patients had dramatic increase in inflammation • Body wt, triceps skinfold, creatinine index, and albumin levels improved in both groups • Conclusion: • No significant difference between a polymeric or elemental enteral formula. • Enteral nutrition support may help achieve clinical remission of active Crohn’s disease

8. Research Article: CAM Title: The Relation between Antioxidant Status and Alterations in Fatty Acid Profile in Patients with Crohn Disease and Controls Objective To investigate if there is a correlation between serum antioxidant levels and fatty acid profile in patients with active CD or inactive CD and in controls Design Observational Study Design Variables Independent: Active or Inactive CD Dependent: Association of the serum antioxidant levels and the fatty acid profile

9. CAM Research Article Continued Methods 3 groups in study Active CD (12) Inactive CD (50) Control (70) Antioxidant status (taken from blood sample after overnight fast) Beta-carotene Copper Vitamin A Vitamin E Selenium Zinc Fatty Acid Profile (Ethylenediaminetetaacetic acid (EDTA) blood sample after overnight fast) Saturated fatty acids Polyunsaturated fatty acids Monosaturated fatty acids Dietary Intake Food Frequency Questionnaire (FFQ)

10. CAM Research Article continued Results Conclusion There is a correlation between serum antioxidant status and fatty acid profile Results may play role in pathophysiology or treatment of CD Further research needs to be conducted

11. Matthew Sims: Assessment • Anthropometrics • Age: 35 • Sex: Male • Height: 5’9” (175 cm) • Weight: 140 lbs (64 kg) • BMI: 20.7 • IBW: 160 lbs • %IBW: 88% • %UBW: 83% (loss over 6 mos)

12. Matthew Sims: Assessment • Medical History • Complaint: Exacerbation of abdominal pain and diarrhea • Diagnosed with Crohn’s Disease 2 ½ years ago • Previously hospitalized for 2 wks • Allergies: possibly milk • Underwent resection of 200 cm of jejunum and proximal ileum with placement of jejunostomy • Placed on parenteral nutrition

13. Matthew Sims: Assessment • Medication History • Previously took corticosteroids • 6-mercaptopurine • Immunosuppressive drug • Usually treats leukemia • Side effects: headache, weakness or achiness, darkening of skin, loss of appetite or weight • Multivitamin

14. Matthew Sims: Assessment • Social History • Both Matthew and his wife purchase and prepare the food • Nutrition History • Since being diagnosed with CD went on low fiber diet, and drank Boost between meals to increase his calorie intake • Had difficulty eating due to his abdominal pain and diarrhea • Previously saw a dietitian to • Decrease diarrhea • Create ways to keep him from being dehydrated • Gain weight

15. Matthew Sims: Assessment • Recent dietary Intake: • AM: Cereal, small amount of skim milk, toast or bagel, juice • AM snack: Cola, sometimes crackers or pastry • Lunch: Sandwich (ham or turkey) from home, fruit, chips, cola • Dinner: Meat, pasta or rice, some type of bread, rarely eats vegetables • Bedtime snack: Cheese & crackers, cookies, cola • 24 hr recall • Clear liquids

16. Matthew Sims: Assessment • Biochemical Analysis • Mild depletion of protein levels • High c-reactive protein • Low HGB, HCT and Ferritin • Anemic

17. Matthew Sims: Assessment • Parental Nutrition • Initiated at 50 ml/hr with a goal rate of 85 ml/hr • Composition • 200 g/L dextrose = 1,387 kcal/day • 42.5 g/L protein = 347 kcal/day 2,285 kcal/day • 30 g/L lipid = 551 kcal/day • Needs • Energy needs: 2,628 kcal/day • Protein needs: 77 grams/day

18. Diagnosis • Clinical [NC-3.2]:“Involuntary weight loss related to abdominal pain and diarrhea as evidenced by severe weight loss of 28 pounds in past 6 months.”

19. Intervention • Normalize alb, TTHY, transferrin, HGB, HCT, and ferritin levels • Current parenteral formula is not meeting patient’s kcal needs. - Recommend different formula providing 2,650 kcals instead of 2,285 kcals • Prevent any further weight loss & improve weight status

20. Monitor/Evaluate • Monitor albumin, prealbumin, transferrin, HGB, HCT, ferritin, and c-reactive protein levels • ADAT from clear liquids to regular diet. Wean patient from parenteral nutrition - discontinue once he is meeting 75% of kcal needs from oral diet -Consider TF if not meeting all of his needs orally within 3 days, or TPN if not tolerating • Follow-up with outpatient RD in 1 week and monitor weight status

21. References • “Crohn’s Disease.” National Digestive Diseases Information Clearinghouse (NDDIC). Retrieved November 17, 2008. http://digestive.niddk.nih.gov/ddiseases/pubs/crohns/index.htm • Geerling, B., Houwelingen, A., Badart-Smook, A. Stockbrugger, R., Brummer, R. “The relation between anitoxidant status and alterations in fatty acid profile in patients with Crohn disease and controls.” Scandinavian J Gastroenterol 1999:34: 1108- 1116. • Mahan, L., & Escott-Stump, S. (2004). Krause's Food, Nutrition, & Diet Therapy. Philadelphia: Saunders. • Pagana, K., & Pagana, T. (2007). Mosby's Diagnostic and Laboratory Test Reference (8th Ed.). St. Louis: Elsevier. • Rigaud, D., et al. “Controlled trial comparing two types of enteral nutrition in treatment of active Crohn’s disease: elemental versus polymeric diet.” Gut 1991:32: 1492-1497.