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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 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
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”
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
The GI Tract • Upper GI • Esophagus • Stomach • Duodenum • Lower GI • Small Intestine • Large Intestine • Colon
The GI Tract • The main functions of the GI system are: • Digestion • Absorption
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
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
Absorption Passage of molecular nutrients into the bloodstream from the intestinal cells
Small Intestine • Site of chemical digestion and absorption • Three sections: • Duodenum • Jejunum • Ileum
Large Intestine • Three sections: • Caecum • Colon • Rectum • Compacts and stores fecal matter before it is passed from the anus.
A B S O R P T I O N
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
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.
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
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
Diagnosis • Multistep process • Includes assessing: • Patient’s medical history • Physical exam • Lab values • Medical tests
Diagnosis • Main risk factors include: • Genetics (Jewish population) • Smoking (doubles the risk) • Diet • Infectious agents • Immunological factors
Diagnosis:Physical Exam • Signs include: • Abdominal mass • Skin rash • Swollen joints • Weight loss • Mouth ulcers • Diarrhea • Constipation • Loss of appetite
Diagnosis:Lab Tests Albumin C-reactive protein Erythrocyte sedimentation rate Fecal fat Hgb Complete blood count
Diagnosis:Procedures Colonoscopy Barium enema CT scan Endoscopy MRI Enteroscopy Stool culture
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
Complications of Crohn’s Fistulas Malabsorption Obstruction Colon cancer
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
Surgical Management Bowel resection Total abdominal colectomy Colostomy Ileostomy Total proctocolectomy with ilesotomy
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
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
Assessment • First step in the Nutrition Care Process • Includes: • Anthropometrics • Biochemical data • Clinical data • Diet history
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
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
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)
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
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.
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.
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
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.
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
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
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.
Interventions:Supplementation Vitamin D Vitamin E Zinc Calcium Magnesium Folate Thiamine Vitamin B12 Ferritin Iron
Interventions:Supplementation • Four labs to pay special attention to: • Vitamin D • Ferritin • Iron • Zinc
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
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
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
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