Nutritional Management of Diverticulitis with Abscess & Colon Resection

1. Nutritional Management of Diverticulitis with Abscess & Colon Resection Jessica Lacontora ARAMARK Dietetic Internship Southern Ocean Medical Center March 15, 2013

2. Case Report Presentation Contents • Disease Description • Evidence-Based Nutrition Recommendations • Case Presentation • Nutrition Care Process (NCP): ADIME • Conclusion

3. Disease Description • Diverticulosis -presence of herniations in the mucosal layer of the colon through muscle layer of the bowel • 1)Meckel’s diverticulum- found near the ileocecal valve & are present at birth • 2)Developed with advancing age- more common • Risk factors • History of constipation • High intake of red meat • Obesity • Low physical activity • Complications: diverticular bleeding and diverticulitis • Diverticulitis- inflammation of a diverticulum.

4. Symptoms Abdominal pain of the left lower quadrant Fever Nausea and Vomiting Elevated white blood cells CT scans Inflammation can cause: Perforation abscess formation Peritonitis Obstruction acute bleeding Sepsis Severity Mild -inflammation Deadly peritonitis caused by perforation. Surgical intervention high morbidity & mortality rates patients present with co-morbidities Disease Description continued

5. Disease Description continued • Common Comorbidities • Ulcerative colitis • Tumor or colon cancer • Obesity • Ischemic colitis • Irritable bowel syndrome (IBS) • Crohns disease • Angiodyplasia • Aging Complications • Neuropathy • Reduced gastric mobility • Diabetes • Kidney disorders • Cardiopulmonary This patient presented with coronary artery disease, hypoalbumenia, gout, dyslipidemia, benign prostate hypertrophy, arterial fibulation, hypertension, random hypotension (meds), & chronic kidney disease.

6. Disease Description continued • Rate of Occurrence • One of the most common conditions in America • One of the highest reasons for outpatient visits and inpatient admittance • Economic burden • This disease has increased among the under 40 population as a result of obesity and the western diet • appendicitis • 50% of people over 60 years old have diverticula with 10-25% developing complications such as diverticulitis • Inpatient hospitalization rates increased by 26% from 1998 to 2005.

7. Disease Description continued • Fiber • Fiber increases stool bulk in the intestine • Muscular pressure on intestinal walls rather then on the contents, which, form pockets or diverticula at weak points • Clinical trials have found that a high-fiber diet may reduce symptoms and have a protective role against future complications • Many forms of fiber and fiber supplements • Need more research

8. Evidence Based Nutrition Recommendations The Academy of Nutrition & Dietetics • Diverticulum • Nothing by mouth (NPO) with bowel rest until bleeding & diarrhea resolve • Begin oral intake with clear liquids • Nutritional supplement with protein, energy, vitamins, & minerals as needed • Poor nutritional status, or anemia- slowly begin low-fiber nutrition therapy • After- high-fiber diet & adequate fluid eudcation • Diverticulitis • High-fiber nutrition therapy of 6 to 10 g + (20 g to 35 g/day) • Add fiber to diet gradually to ensure tolerance • Emphasize sources of insoluble fiber • Supplement if dietary intake is insufficient • Probiotic and prebiotic • Ensure adequate fluid • Restriction of nuts, seeds, & corn is no longer recommended

9. Evidence Based Nutrition Recommendations According to the American Society for Parenteral and Enteral Nutrition (ASPEN) • Enteral nutrition (EN) first • Protein-calorie malnutrition & EN not feasible use parenteral nutrition (PN) as soon as possible following adequate resuscitation. • Antioxidant vitamins and trace minerals • Mild underfeeding initially at 80%

10. Evidence Based Nutrition Recommendations A systematic review of high fiber dietary therapy in diverticular disease Unlu et. al. • No study could demonstrate that fiber therapy can prevent the reoccurrence of diverticulitis • Multiple randomized demonstrated mixed results • A reduction in pain symptoms? • Reduction in constipation? • Use of methylcellulose – study small and not specific • Metamucil showed the largest reduction in symptoms (p<0.025) • Lactulose vs bran tablets - no difference in benefit • Lack of clear evidence for a high fiber diet in treatment of diverticular disease.

11. Evidence Based Nutrition Recommendations Obesity increases the risks of diverticulitis and diverticular bleedingStrate et. al. • Data from the Health Professional follow-up study • Identified 801 incidences of diverticular disease in 730,446 people • High BMI (p=0.07), waist to hip ratio and waist circumference were more likely to be sedentary, eat more fat and red meat and use analgesics • Positive association with obesity for both diverticulitis and diverticular bleeding (p=0.17) • For obese patients with diverticular disease, weight loss should be considered as part of the Nutritional Care Plan

12. Evidence Based Nutrition Recommendations Current indications and role of surgery in the management of sigmoid diverticulitisDr. Luca Stocchi • Reviewed of data regarding surgical management • Antibiotics - used as the first step in treating uncomplicated diverticulitis • Complicated diverticular disease often requires surgery • Laparoscopic surgery is increasingly accepted as the best surgical approach • Timing of surgery in relation to the diverticular attack has been subject to controversy due to stoma formation. • Current census wait till the 3rd or 4th • Patients who underwent surgery for uncomplicated diverticulitis has declined to 17.9 to 13.7% from 1991-2005 (p=0.0001). • Must approach each case differently as each patient will have varying comorbidities and compilations. • Limited by use of retrospective studies, data < 2005.

13. Case Presentation • January 25, 2013- 82 year old male presented to the outpatient GI office with abdominal pain for 1 week & rectal bleeding 2 days prior to admission • Sent to ER -> CT scan revealed diverticulitis with abscess • Past Medical Dx: higher risk for complications of bowel resection • Obesity – increased risk of diverticular disease • Arterial fibrillation • Hypertension with episodes of hypotension (meds) • Iron deficiency anemia • Chronic kidney disease with baseline creatinine around 1.5. • Coronary artery disease • Hypoalbuminemia • Gout • Dyslipidemia • Benign prostatic hypertrophy • Vitamin D deficiency

14. NCP: ADIME • Client History (CH-2.1) • March 2012 -Fall- nasal fracture, hand contusion • October 2012- UTI • Eye glasses & hearing impaired • Well the patient walks daily & drinks alcohol occasionally • His past medical history previous slide • Recent surgical intervention: • central venous line placed • sigmoid partial colon resection with total splenectomy • Cysto bilateral stent placed • Wife and adult children that are very supportive • While administering medical nutrition therapy (MNT) in compliance with the Academy of Nutrition and Dietetics, as well as, ARAMARK standards, the Nutrition Care Process was used to document patient care, as outlined by the International Dietetics and Nutrition Terminology Reference Manual (IDNT).

15. NCP: ADIME • Food/Nutrition Related History (FH-1.1.1) • During the majority of his stay the patient has been NPO for GI complications and surgical procedures • Advanced to a soft diet for 3 days 50-75% • The patient was placed on TPN once the gut was deemed unavailable • Wife reports good eater usually • No known food allergies • No problems with chewing or swallowing prior to admission • Developed dysphaga after being vented for an extended period of time • No supplement prior to admission • Prior to his TPN he was willing to start Ensure plus and/or Ensure clear with each meal • Good attitude and strong desire to go home

16. Prescribed Medications

17. NCP: ADIME • Nutrition-Focused Physical Findings (PD-1.1.5) • Week before –abdominal pain with reduced intake • No significant weight loss noted • Prior to admission -well nourished with good oral health • He presented with tenderness to the lower right quadrant of his abdomen • Appetite varied from poor to fair • He is motivated to eat with the concept of going home • Edematous -signs of muscle and fast wasting • Developed severe dysphaga • Swallowing ability improved over 3 days & his intake on March 15th, 2013 was 50% of his pureed diet.

18. NCP: ADIME • Anthropometric Measurements (AD-1.1) • 67 inches • 238 to 214 # - fluctuation • Edema which partially responsible for weight changes. • Current- 216 lbs, BMI 33, Obese I • Usual body weight 235# • Ideal body weight (IBW) 163 # • Current weight is 132% of IBW

19. NCP: ADIME • Biochemical Data, Medical Tests and Procedures • CT scan of the abdomen for obstruction or abscess • GI - surgical intervention • Swallow study (BD-1.4.23) 1 and 3 days post extubation • Metabolic panel (BD-1.8.2) • Acid base balance (AD-1.1.1) • CBC (BD-1.10) • PTT, Catheter tip culture, blood culture and fluid drain culture were ordered for fungal VRE and yeast infection suspicion • Glucose (BD-1.5.2) steroid medications • Mineral levels (BD-1.2.5-11)-adjustintravenous fluids (IVF)

20. NCP: ADIME • Nutrient Needs • Energy requirements (CS-1.1.1) were 1960-2450 kcal (20-25 kcal/kg) Energy requirements were calculated using 20-25 kcal/kg of current body weight in order to promote weight maintenance without over feeding or increasing vent dependence. • Protein (CS-2.2.1) requirements were 98-127 g (1-1.3g/kg) Since the patient was under stress and at risk for pressure ulcer wounds, his nutrient requirements for protein were elevated. • Fluid requirements (CS-3.1.1) were 2000 ml/day. • The patient also received a varying amount of fat calories from Propofol increasing his caloric intake while vented.

21. Lab Values

22. NCP: ADIME • ARAMARK Nutrition Status Classification • 15 nutrition care points = Status 4 -Severely compromised • 3 points for nutrition hx (poor appetite-50% of needs for >2 weeks) • 4 points for feeding modality (TPN/PPN and NPO >4 days) • 0 priority points for unintentional wt loss (hard to classify with edema) • 0 points for weight status as he was obese when admitted • 4 points for serum albumin ( 1.1-1.9 g/dL) • 4 points for diagnosis/condition (malnutrition, sepsis) • Follow up should be scheduled in 1-4 days • Diagnosis-Related Group (DRG) • Not used at Southern Ocean Medical Center • Tool to diagnose malnutrition • Increased reimbursement from Medicare • Other Protein Calorie Malnutrition (PCM) with an inadequate intake for  3 days and an albumin value of <3.5 g/dL.

23. NCP: ADIME • NCP: Nutrition Diagnosis • Upon initial assessment the patient, presented with multiple GI related problems. Interventions and recommendations were based on the primary nutritional diagnosis. The MD ended TPN prior to the pt being able to consume >50% of needs orally.

24. NCP: ADIME • NCP: Interventions • PTA - Antibiotic regimen • ER - CT scan • After admission- cysto bilateral stent placement, a partial sigmoid colon with low anterior resection and low pelvic colorectal anastomosis with total splenectomy, central venous line using ultrasound guidance • Propofol in varying amounts to maintain TASS -2 while vented • Enteral and Parenteral Nutrition: Parenteral Nutrition/IV Fluids - Formula/solution (ND-2.2.1) - Initial MD parenteral nutrition order for TPN included 72g protein, 276g dextrose and 250mL 20% fat emulsion. Recommended increase 72g (.75g/kg) to 116g (1.2 g/kg) protein. Will provide 1902 kcal (20 kcal/kg) • Goal-maintain lean body mass & support the immune system • TPN discontinued immediately upon extubation- speech pathologist/swallow evaluation • 4 days 50% or less intake- no nutritional support despite recommendations • Nutrition Education Content – Purpose of the nutrition education (E-1.1). Provided education on diverticular diet to prevent future inflammation and obstruction. • Medical Food Supplements– Commercial beverage (ND-3.1.1). Commercial beverage Ensure Plus, 8 oz BID with meals to provide an additional 700 kcals and 26g of protein daily and Ensure Clear BID to provide 400 kcal and 14g protein. Goal for intervention was to promote wound healing, maintain lean body mass and support immune system

25. NCP: ADIME • Nutrition Care Process: Monitoring and Evaluation • High nutritional risk follow-up 3 to 5 days. • Oral intake was monitored when diet order present. Parenteral nutrition orders and tolerance were monitored with each follow-up. • Food and Nutrition-Related History • Food and Nutrient Intake • Energy intake - Total energy intake (FH-1.1.1.1) Meet needs • Protein intake - Total protein (FH-1.5.2.1) Meet needs • Food and Nutrient Administration- • Parenteral nutrition intake – Formula/solution (FH- 2.1.4.2). Evaluated for total energy and protein intake. MD upped to 100g from • Medication and Herbal Supplement Use • Prescription medications were monitored including Propofol due to its addition of calories from fat. • Knowledge/Beliefs/Attitudes • Food and nutrition knowledge – Area and level of knowledge (FH-4.1.1) • Beliefs and attitudes- Food preferences (FH-4.2.12) • During periods of PO intake the patients preferences were noted to promote optimal intake (Greek Yogurt)

26. NCP: ADIME • Anthropometric Measurements • Body composition – Weight (AD-1.1.2) monitored daily via bed scale The patient’s weight was not a reliable predictor of malnutrition as he developed edema. Our goal was to maintain his body weight. • Biochemical Data, Medical Tests and Procedures • Lipid profile- Triglycerides (TG) (BD-1.7.7) monitored while on TPN and Propofol to avoid further cardiovascular disease progression and complications. Goal to keep TG under 250mg/dL • Protein profile- Albumin (BD-1.11.1). Monitored daily to evaluate effectiveness of nutritional therapy and state of malnutrition. Recommendations for discharge • High fiber diet, continued oral beverage supplement use, and monitor weight • Swallow improved but fatigue causes early satiety limiting intake • RN is gradually educating the patient and family on colostomy care • Continue to follow up 3-5 days or as needed per MD or RN request.

27. Conclusion • Diagnosis is common and difficult to manage resulting in a high reoccurrence rate with complications. = economical burden • Uncomplicated cases can often avoid surgical intervention with bowel rest and antibiotics. • Preexisting medical conditions make recovery from a bowel resection a challenge • ASPEN guidelines for PN in a CC patient should be utilized throughout MNT • PN began should be used when gut is deemed unavailable & the patient is stable • Monitor energy & protein intake, weight, wounds and labs each follow up session. • Risk factors - constipation, high intake of red meat, obesity & low physical activity. • Progressive disease-most prevalent in the elderly population • Increasing in the under 40 population-processed foods. • Opinions vary on the high fiber diet. More research needs to be conducted on high fiber diet and fiber supplementation for complications and prevention. • Intervention is key - Nutritional education on a healthy diet high in fruits, and vegetables should be provided at all ages especially for those with a history of constipation related to low fiber intake.

28. References Academy of Nutrition and Dietetics. Pocket Guide for International Dietetics & Nutritional Terminology (IDNT) Reference Manual; 3rd edition. Chicago IL, 2011. Academy of Nutrition and Dietetics: Evidence Analysis Library. Critical Illness Nutrition Practice Guidelines. A.N.D. Evidence Analysis Library website. Available at: <http://www.adaevidencelibrary.com/topic.cfm?cat=3016> Accessed February 20, 2013 ARAMARK Healthcare. Nutrition Assessment: Nutrition status classification worksheet. Patient Food Services: Policies and Procedures, Volume IV; Revised 3/10/10. Gearhart SL et. al. Common Diseases of the Colon and Anorectum and Mesenteric Vascular Insufficiency. Harrison’s principles of Internal Medicine. 16th ed. Columbus, OH: McGraw-Hill; 2005. Available from: http://www.accessmedicine.com/resourceToc.aspx?resourceID=4&part=12. Accessed February 11, 2013. Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 13th ed. St. Louis, MO: Saunders Elsevier; 2013. Diverticulosis and Diverticulitis. HHS: National Digestive Diseases Information Clearinghouse (NDDIC). Available at:<http://digestive.niddk.nih.gov/ddiseases/pubs/diverticulosis/index.aspx> Accessed February 21, 2013 Malnutrition Codes and Characteristics/Sentinel Markers. Academy of Nutrition and Dietetics Web site. Available at:<http://www.eatright.org/Members/content.aspx?id=6442451284&terms=DRG>Accessed February 21, 2013. Martindale RG, McClave SA, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition: executive summary. Crit Care Med 2009;37:1757-61 MD Guidelines. Diverticulitis and diverticulosis of the colon: Comorbid conditions. 2012 Reed Group. Available at: http://www.mdguidelines.com/diverticulosis-and-diverticulitis-of-colon/comorbid-conditions. Accessed: March 10, 2013. Pronsky ZM. Food-Medication Interactions, 16th ed. Birchrunville, PA: Food-Medication Interactions; 2010. Stocchi, Luca. Current indications and role of surgery in the management of sigmoid diverticulitis. World of Gastroenterology; 2010; 16(7) 804-817. Accessed: February 9, 2013. Strate et. al. Obesity increases the risks of diverticulitis and diverticular bleeding. Gasteroenterology. 2009; Jan 136 (1): 115-122. Accessed: February 9, 2013. Unlu, Cagdas et.al. A systematic review of high-fiber dietary therapy in diverticular disease. Int J Colorectal Disease. 2012; 27:419-427. Accessed: February 9, 2013. Weizman, AV & GC Nguyen. Diverticular disease: Epidemiology and management. Can J Gastroenteral; 2011; 25(7) 385-389. Accessed: February 9, 2013.

29. Questions?