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Crohn’s Disease: Nutritional Management Case Report

This case report delves into the nutritional management of Crohn's Disease, a subcategory of Inflammatory Bowel Disease (IBD) characterized by gastrointestinal tract inflammation. Explore disease overview, etiology, signs and symptoms, complications, and evidence-based nutrition recommendations. Understand the impact of different dietary interventions like enteral nutrition, fish oil, glutamine supplements, and elimination diets based on systematic reviews and trial results. Discover how specific diets can improve symptoms and disease activity in Crohn's patients.

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Crohn’s Disease: Nutritional Management 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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