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Nutritional Management of Crohn’s Disease

Nutritional Management of Crohn’s Disease. By Stephanie Fawbush. Why Crohn’s Disease?. Family history of GI problems Friends with Crohn’s Many questions about nutritional guidance from these friends and family. Crohn’s: Discussion of Disease. What is Crohn’s Disease?.

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Nutritional Management of Crohn’s Disease

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  1. Nutritional Management of Crohn’s Disease By Stephanie Fawbush

  2. Why Crohn’s Disease? Family history of GI problems Friends with Crohn’s Many questions about nutritional guidance from these friends and family

  3. Crohn’s:Discussion of Disease

  4. What is Crohn’s Disease? • Form of inflammatory bowel disease (IBD) • Autoimmune, chronic inflammatory condition of the GI tract • Marked by an abnormal response by the body’s immune system • Diseased segments separated by normal bowel segments • “skip lesions”

  5. IBD: Crohn’s vs. Ulcerative Colitis

  6. Facts About Crohn’s • Affects an estimated 0.1-16/100,000 people • IBD has an overall health care cost of more than $1.7 billion • One of the 5 most prevalent GI disease burdens in the US • 75% of Crohn’s patients will need surgery in their lifetime

  7. The GI Tract • Upper GI • Esophagus • Stomach • Duodenum • Lower GI • Small Intestine • Large Intestine • Colon

  8. The GI Tract • The main functions of the GI system are: • Digestion • Absorption

  9. Digestion • Oral phase • Mastication and mixing of food with salivary fluid and enzymes. • Gastric phase • Pepsin and gastric acid start to form the bolus into chyme. • Chyme delivered to the small intestine for mixing with enzymes. • Intestinal phase • Disaccharides, peptidases, and cholecystokinin

  10. Stomach • Secretes protease and hydrochloric acid • The food bolus is churned in the stomach through peristalsis. • 40 minutes to 4 hours • Main function is digestion • Small amounts of absorption

  11. Absorption Passage of molecular nutrients into the bloodstream from the intestinal cells

  12. Small Intestine • Site of chemical digestion and absorption • Three sections: • Duodenum • Jejunum • Ileum

  13. Large Intestine • Three sections: • Caecum • Colon • Rectum • Compacts and stores fecal matter before it is passed from the anus.

  14. A B S O R P T I O N

  15. Pathophysiology • Cause is not completely understood • Involves the interaction of the GI immunologic system and genetic and environmental factors • Increased exposure, decreased defense mechanisms, or decreased tolerance to some component of the GI microflora may occur • Major environmental factors include: • Resident and transient microorganisms in the GI tract • Dietary components

  16. Pathophysiology • Chronic inflammation from T-cell activation leading to tissue injury is implicated. • T-cells stimulate the inflammatory response. • Release nonspecific inflammatory substances, which result in direct injury to the intestine.

  17. Transmural inflammation results in thickening of the bowel wall and narrowing of the lumen. As Crohn’s disease progresses, it is complicated by: Obstruction or deep ulceration leading to fistulization Microperforation Abscess formation Adhesions Malabsorption Pathophysiology

  18. Signs & Symptoms Cramps Loss of appetite Tenesmus Diarrhea Weight loss Constipation Fistulas Ulcers Rectal bleeding Swollen gums Anemia Mouth sores Nutritional deficiencies Abscesses Anal fissures Hemorrhoids Fever Fatigue Eye inflammation Joint pain

  19. Diagnosis • Multistep process • Includes assessing: • Patient’s medical history • Physical exam • Lab values • Medical tests

  20. Diagnosis • Main risk factors include: • Genetics (Jewish population) • Smoking (doubles the risk) • Diet • Infectious agents • Immunological factors

  21. Diagnosis:Physical Exam • Signs include: • Abdominal mass • Skin rash • Swollen joints • Weight loss • Mouth ulcers • Diarrhea • Constipation • Loss of appetite

  22. Diagnosis:Lab Tests Albumin C-reactive protein Erythrocyte sedimentation rate Fecal fat Hgb Complete blood count

  23. Diagnosis:Procedures Colonoscopy Barium enema CT scan Endoscopy MRI Enteroscopy Stool culture

  24. Prognosis No cure for Crohn’s disease Treatments available to make Crohn’s more manageable for patients Times between flare-ups can be decreased through medical and nutritional management

  25. Complications of Crohn’s Fistulas Malabsorption Obstruction Colon cancer

  26. Medication Management • Anti-diarrheal agents • Diphenoxylate, loperamide, and codeine • Anti-inflammatory drugs • 5-ASA agents (Asacol, Canasa, Pentasa), Sulfasalazine (Azulfidine) • Constipation management • Laxatives, Metamucil, Citrucel • Pain management • Tylenol • Corticosteroids • Budesonide • Antibiotics • Ampicillin, sulfonamide, cephalosporin, tetracycline, metronidazole • Anti-TNF alpha therapy • Remicade • Biologic therapy • Humira, Cimzia, Tysabri

  27. Surgical Management Bowel resection Total abdominal colectomy Colostomy Ileostomy Total proctocolectomy with ilesotomy

  28. Crohn’s:Medical Nutrition Therapy

  29. MNT • Patients are considered to be at significant nutritional risk: • Est. 60-75% of patients will experience malnutrition • Nutrition therapy is used to: • Reduce the inflammatory response in the disease • Correct deficiencies • Ensure adequate maintenance of nutritional status • Multidisciplinary approach

  30. MNT: Objectives Restore and maintain the patient’s nutritional status. Replace fluid and electrolytes lost Monitor mineral and trace element levels carefully Promote weight gain or prevent losses Reduce the inflammatory process Replenish nutrient reserves Promote healing

  31. Assessment • First step in the Nutrition Care Process • Includes: • Anthropometrics • Biochemical data • Clinical data • Diet history

  32. Assessment:Calorie Needs • Kcal/kg • Range from 15 kcal/kg-45 kcal/kg • Harris-Benedict equation: • Men: 66 + 13.7W + 5H - 6.8A=REE x stress factor x activity factor • Women: 65.6 + 9.6W + 1.8H – 4.7A= REE x stress factor x activity factor

  33. Assessment:Protein Needs • Protein is important to prevent muscle wasting and malnutrition. • Impact of protein-calorie malnutrition as a prognostic factor is demonstrated as greater mortality in IBD patients. • Calculated using gm protein/kg • Range from 1-2 gm/kg

  34. Diagnosis • ‘PES statement’ • Problem/nutrition diagnosis, etiology, and signs/symptoms. • Diagnoses that could apply to a patient with Crohn’s: • Inadequate oral intake (NI-2.1) • Inadequate fluid intake (NI-3.1) • Malnutrition (NI-5.2) • Inadequate mineral intake (NI-5.10.1) • Underweight (NC-3.1) • Unintended weight loss (NC-3.2)

  35. Interventions • Improved nutritional status can reduce side effects of Crohn’s and improve quality of life. • Nutrition education is key • Extent of nutrition intervention will depend on: • Functional status of the GI tract • Extent of diarrheal output • Obstruction • Surgical procedures • Bleeding

  36. Interventions • When a patient is admitted with a severe Crohn’s flare, the following nutritional progression is recommended: • Nutrition support: enteral feedings or total parenteral nutrition. • Progress to low-fat, low-fiber, high-protein, high-kilocalorie, small, frequent meals with return to normal diet as tolerated.

  37. Interventions:Low Fiber Diet • Maintain a low-fiber diet while experiencing a flair. • Once flairs have been resolved, return to a normal diet. • Gradually add small amounts of foods with fiber back into diet as tolerated. • Small amounts of whole grain foods and higher-fiber fruits and vegetables.

  38. Interventions:Low Fiber Diet • Recommended foods during a Crohn’s flair: • Milk: Low fat milk products (skim milk, low fat cottage cheese, low fat yogurt) • Grains: Grains with less than 2 grams of fiber per serving (refined grains, white rice, white bread) • Vegetables: Well cooked vegetables without seeds, potatoes without skin, and lettuce • Fruit: Fruit juice without pulp, canned fruit in juice/light syrup, peeled fruits • Fat: Less than 8 tsp fats per day • Meat: Well cooked meats, eggs, smooth nut butters, and tofu

  39. Interventions:Low Fat Diet Helpful if the patient has trouble digesting or absorbing fat. Can help prevent uncomfortable side effects, such as diarrhea, bloating, and cramping. However, some studies recommend that fat should only be avoided if the patient is experiencing steatorrhea.

  40. Interventions:Other Recommendations • Maximize calorie and protein intake. • Encourage the patient to eat small meals or snacks every 3-4 hours. • Other recommendations could include: • Avoiding foods high in oxalate • Increasing antioxidant intake • Supplementation with omega-3-fatty acids and glutamine • Using probiotics and prebiotics

  41. Interventions:Nutrition Support • TEN with a liquid formula • TEN can be used in combination with oral feeds. • Tube feeds with added glutamine • Polymeric formulas • Low fiber formulas • Nocturnal tube feeds • Times when the gut cannot be used • Perioperative PN may reverse malnutrition

  42. Interventions:Exclusive Enteral Nutrition (EEN) • Providing the patient with liquid formulas only and stopping oral feedings. • Carried out six-to-eight weeks • Demonstrated to lead to mucosal healing. • Result in fewer exacerbations and trips to the hospital. • Well-proven therapy for the management of Crohn’s disease in the pediatric population.

  43. Interventions:Supplementation Vitamin D Vitamin E Zinc Calcium Magnesium Folate Thiamine Vitamin B12 Ferritin Iron

  44. Interventions:Supplementation • Four labs to pay special attention to: • Vitamin D • Ferritin • Iron • Zinc

  45. Monitoring & Evaluation • Nutrition care indicators will reflect a change as a result of nutrition care. • Things that can be monitored and evaluated include: • Food/nutrition-related history outcomes • Anthropometric measurement outcomes • Biochemical data, medical tests, and procedure outcomes • Nutrition-focused physical finding outcomes

  46. Crohn’s:Presentation of the Patient

  47. The Patient: J.P. • J.P. was a 43 year old white female • Admitted to PPMC on October 25, 2012 • Dx: Crohn’s flair • She presented with several weeks of loose stools containing mucous and blood along with abdominal pain. • PMH: Crohn’s disease & asthma • PSH: Tonsillectomy

  48. About J.P. Diagnosed with Crohn’s in 2006 Controlled on Pentasa ever since with only intermittent symptoms Began to have increased symptoms of abdominal pain, frequent blood/mucous bowel movements, and oral ulcers in August 2012. At admission, having blood/mucous bowel movements every hour. Decreased oral intake 2/2 abdominal pain

  49. Crohn’s:Medical Hospital Course

  50. Medical Hospital Course • J.P. experienced interventions regarding the following medical problems while in the hospital: • Crohn’s flare • New enterovaginal fistula • Hemorrhoids • Anal fissure • Bilateral avascular necrosis w/o collapse of subchondral plate

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