Crohns Disease and Diet

Compliance
A Case Study
Claudia Gumina
Keene State College Dietetic Intern
objectives
To understand the diagnosis and progression of the
patient studied.
To review Crohns disease and its dietary
management.
To understand the reason behind the different
interventions applied to this patient.
The Patient
30 y/o male re-admitted on 04/13 after 5 days of being
discharged.
Reason for re-admission:
CC of recurrent abdominal pain later attributed to
Crohns exacerbation with small bowel obstruction
PMH: Crohns Disease and medication-related
pancreatitis. Off therapy for the past 5-6 years.
Had previously been on pentasa, steroid therapy and
imuran, which was responsible for his pancreatitis.





Social hx
Pt worked as a barber unable to work in the past few
months.
Recently signed up for ObamaCare.
Lived alone since break-up with fiance, from which pt
reported having PTSD.
Diet hx, meds and labs



Pt reported he had not been able to eat anything since
04/12 NPO for 1 day at admission.
Reports of frequent, loose BMs, which were his usual.



All labs WNL, except for his Cr (0.57)


Meds
At home In the hospital
None Enoxaparin
Hydrocortisone
Hydromorphine
Anthropometrics
At admission:
Height: 61
Weight: 61 kg 134 lb.
BMI: 17.1
UBW:
63.5 kg on 04/07 4% wt loss in one week
78 kg before disease exacerbation 22% wt
loss in 3 months.

Needs
Calculated 2 days after admission
when we began seeing the pt.
Energy: 1900-2300 kcals (31-35
kcal/kg based on Nutrition Issues in
Gastroenterology, 2003)
Protein: 60-90 g/day (1-1.5
g/kg/day)
Fluids: 2100 ml/day (35 ml/kg)

Kellie Ann Aiden. "Nutritional Considerations in Inflammatory Bowel
Disease." Practical Gastroenterology (2003): 33-54. Web.
Diagnosis
Inadequate food and beverage intake
related to altered GI function, as
evidenced by a BMI <18.5, involuntary
weight loss and diarrhea.
Intervention
Provide TPN
Provide education on IBD Crohns Nutrition
Provide supplements
Calorie counts


Monitor/evaluate
PO tolerance
Wt changes
Bowel issues
Braden

Crohns Disease
A disease of unknown cause.
Occurs when the bodys immune system mistakenly
attacks and destroys healthy cells.
In the case of Crohns, the cells affected are those of
the lower GI tract.
The inflammation causes the intestinal wall to
thicken, leading to a variety of issues.
Symptoms
Crampy, abdominal pain
Pt described it as, A baby kicking through his skin.
Loss of appetite
Persistent, watery diarrhea
Weight loss
Pain with passing stool
Tests
KUB


CAT Scan

Colonoscopy
Treatment
Medical Treatment
Medication:
Antidiarrheal
Steroids
Biologic therapy Ramicade
Surgery:
Bowel Resection
AND DIET


Crohns disease nutritional
management
Nutritional Risks
Fluid and electrolyte losses due to diarrhea are critical
issue.
Inadequate intake due to GI symptoms and losses due
to malabsorption and exudates can result in weight
loss, deficiencies or malnutrition. Nutrient
malabsorption depends on affected area (small vs.
large intestine). Folate, B12, calcium, potassium may
be deficient.

Krauses Food and Nutrition Therapy. 12
th
Edition.
Crohns disease nutritional
management
Dietary Management
During exacerbation, a liquid diet, enteral nutrition or
bowel rest (NPO) is recommended. TPN may be
needed with bowel obstruction, short bowel syndrome
or surgery.
Progress to low residue/low fiber. High calories if
weight regain is desired.
PT progression
Pt progression: Day 1
04/13
Day of Admission
KUB showed SBO and Crohns
exacerbation.
IV Dilaudid for pain.
Wt: 61 kg
Pt NPO for bowel rest.
Meds: Hydrocortisone,
hydromorphone.



Lab Value
Glucose 100
Sodium 138
Potassium 3.7
Magnesium Not
Available
Phosphorus Not
Available
Triglyceride
s
Not
Available
Surgery deferred at this point.
Pt Progression: Day 2
04/14
No new wt.
Increased pain meds. Pt
ambulating.
Pt screened as a high risk.
Meds: Hydrocortisone,
hydromorphone and lorazepam.
Diet: NPO

Lab Value
Glucose 91
Sodium 143
Potassium 4.0
Magnesium Not Available
Phosphorus Not Available
Triglycerides Not Available
PT progression: Day 3
04/15
KUB: worsening SBO w/ 2 loops of edematous
segments of short bowel in the upper abdomen.
Pt reports pain level at 8/10 Requesting more
pain meds.
Meds: Hydrocortisone, hydromorphone, lorazepam,
solu-medrol, metrodinazole and ciprofloxacin.
Diarrhea 3-7 days.
Diet: NPO (now for 4 days)

PT progression: Day 3
04/15
Pt assessed!
Wt loss of 17 kg in 3 months.
IBW: 78 kg UBW: 78 kg BMI: 17.1
Wt Loss %: 22


Needs
Energy: 1900-2300 kcals (31-35 kcal/kg)

Protein: 60-90 g/day (1-1.5 g/kg/day)

Fluids: 2100 ml/day (35 ml/kg)

Lab Value
Glucose 90
Sodium 142
Potassium 3.5
Magnesium 1.8
Phosphorus 3.4
Triglycerides Not Available
No order for TPN yet. Awaiting medical decision.
PT progression: Day 4
04/16
Wt: 62.1 kg
Meds: Meds: hydromorphone, lorazepam, solu-
medrol, infliximab (TNF Blocker) and
ciprofloxacin
Diet: NPO
Lab Value
Glucose 102
Sodium 143
Potassium 3.1
Magnesium 2.1
Phosphorus 4
Triglycerides 60
PT progression: Day 4
04/16
Intervention:
TPN to begin via PICC









Goal:
Meet needs
Maintain weight
Nutrient Goal TPN: 1.8 L Current TPN: 1 L
Formula Clinimix 5/25 Clinimix 5/20 w/ lipids
Protein 90 g 1.5 g/kg 360
kcal
50 g 0.8 g/kg 200
kcal
Carbohydrate 450 g 5 mg/kg/min 1530
kcal
300 g 2.2
mg/kg/mi
n

1020
kcal
Fat 21 g 214 kcal 50 g 500 kcal
Total Kcal 2104 1509
Pt Progression: Day 5
04/17
No new wt.
Meds: hydromorphone, lorazepam,
solu-medrol, ciprofloxacin and
oxycodone.
Palliative care consult!
Diet advanced to low fiber per pts
request.
WHAT?!
Pt ordered large lunch and soda.
Second meal stopped on its way.
Lab Value
Glucose 125
Sodium 140
Potassium 3.2
Magnesium 1.9
Phosphorus 3.5
Triglycerides Not Available
Pt Progression: Day 5
04/17
Intervention
PN advanced to goal.
Pt advised to eat smaller meals and take it slow.

Goal TPN: 1.8 L
Clinimix 5/25
90 g 1.5 g/kg 360
kcal
450 g 5 mg/kg/min 1530
kcal
21 g 214 kcal
2104
Nutrient
Formula
Protein
Carbohydrate
Fat
Total Kcal
Pt progression: day 6
04/18
Palliative consult ordered!
Pts behavior described as, drug-seeking.
Pt had a hx of chronic use of Clonazepam, which he
obtained from his mothers supply.
Oxycodone and steroids doses increased.
Pt progression: day 6
04/18
Wt: 62.3 kg
Pt still consuming excessive
amounts of food.
Meds: hydromorphone,
lorazepam,clonazepam, solu-
medrol (60 mg), ciprofloxacin,
oxycodone (55 mg),
gabapentin, metronidazole,
sertraline.
Diet: Low Fiber

Lab Value
Glucose 157
Sodium 142
Potassium 3.2
Magnesium 2.1
Phosphorus 4.0
Triglycerides Not Available
Pt progression: day 6
04/18
Intervention
Because pt was meeting his needs and more w/
increased PO intake, TPN was going to be kept for
only 1 more day, but
Pt Progression: day 7
04/19
Diet: NPO (due to increased pain)
but not compliant. CAT Scan
showed more dilation of distal
bowel segments.
Wt: 62.5 kg
Meds: clonazepam, solu-medrol
(60 mg), ciprofloxacin, oxycodone
(55 mg), gabapentin,
metronidazole, sertraline, nicotin,
thiamin, B12.
Pt refused insulin.
Complaining of hunger.

Lab Value
Glucose 142
Sodium 143
Potassium 3.9
Magnesium Not Available
Phosphorus Not Available
Triglycerides Not Available
Pt Progression: day 7
04/19
Intervention
Pt had to be continued on TPN
Discussed risks of excessive eating w/ pt. Again.
Pt Progression: day 8
04/20
Wt: 67.7 kg
Meds: clonazepam, solu-medrol
(60 mg), ciprofloxacin,
oxycodone (55 mg), gabapentin,
metronidazole, sertraline,
nicotin, thiamin, B12,
ondasentron.
Diet: Full Liquids
Pt pulled PICC line overnight.

Lab Value
Glucose 116
Sodium Not Available
Potassium Not Available
Magnesium Not Available
Phosphorus Not Available
Triglycerides Not Available
Pt Progression: day 8
04/20
Intervention
Since pulled PICC line overnight start PPN.
Also, provide high kcal, high protein, low lactose
supplements (Ensure)
Current TPN
2 L Clinimix 4.25/5
Protein 82g

1.2 g/kg 326 kcal
CHO 96
g
1 mg/kg/min 326 kcal
Total Kcal: 867
Nutrient
Formula
Protein
Carbohydrate
Fat
Total Kcal
Pt Progression: day 9
04/21
Wt: 66.3 kg
Up 5 kg edema in feet and scrotum
Eating large meals and drinking
excessive fluids (2 L TPN + 1 L PO)
Pt complaining of sore throat Thrush
Meds: clonazepam, solu-medrol (60
mg), oxycodone (55 mg), gabapentin,
metronidazole, sertraline, nicotin,
thiamin, B12.
Diet: low fiber

Lab Value
Glucose 117
Sodium 143
Potassium 5.2
Magnesium 3.3
Phosphorus Not
Available
Triglyceride
s
Not
Available
Pt Progression: day 9
04/21
Intervention
Portions modified to 6 small meals/day
D/C PPN
Calorie count started
Supplements adjusted.

Pt Progression:day 10
04/22
Wt: No new wt
Diet: Low-Fiber
Pt still ordering excessive amounts of food.
Meds: clonazepam, solu-medrol (60 mg), oxycodone
(55 mg), gabapentin, metronidazole, sertraline,
nicotin, thiamin, B12.

Pt Progression:day 10
04/22
Intervention
Calorie Count: 2091 kcal 97 g of protein
100% of needs met with PO intake
Supplements d/c to limit amount of food consumed
Pt Progression: day 11
04/23
Wt: 68.4 kg
Worsening GI symptoms ? of surgery. Pt not
interested.
Pt meeting w/ surgical and palliative team.
Meds: clonazepam, solu-medrol (60 mg), oxycodone
(55 mg), gabapentin, metronidazole, sertraline,
nicotin, thiamin, B12.
Diet: clear liquids d/t increased pain

Pt Progression: day 11
04/23
Intervention
Provided ensure clear and advised on small,
frequent meals again since pt did not follow previous
diet advance.
No plans to re-start PPN.
Pt Progression: day 12
04/24
Diet: clear liquids
Wt: 69.1 kg
Meds: clonazepam, solu-medrol (60 mg), oxycodone (55
mg), gabapentin, metronidazole, sertraline, nicotin,
thiamin, B12.
Pt eating solid foods, asking for more medication.
Very agitated.
It was found out pt was taking his home meds at the
hospital.
Pt Progression: day 12
04/24
Intervention
Provide Ensure Clear in between meals.
Await medical care plan.
Pt Progression: day 13
04/25
Pt discharged.
Advised to contact PCP for pain management.
Prednisone and remicade prescription for 30 days.
Pt became verbally abusive when unable to get
oxycodone.
Escorted out of the hospital by security.
Thank you
Questions?