Click 1
Kaitlyn Click
Professor Matuszak
KNH 411
16 September 2014
Lower GI Disorders Case Study #11
Case Questions:
I. Understanding the Disease and Pathophysiology
1. What is inflammatory bowel disease? What does current medical literature indicate regarding its etiology?
Inflammatory bowel disease (IBD) is an autoimmune, chronic inflammatory condition of the gastrointestinal tract; IBD is actually the term designating a syndrome consisting of two diasnoses: ulcerative colitis and Crohn’s disease (Nelms, Sucher, Lacey & Roth, 2011, p. 377). Ulcerative colitis (UC) primarily affects the colon and rectum while Crohn’s mostly affects the ileum and colon. The diagnoses are very similar but have individual differences as well. IBD is mostly prevalent in the Northern Hemisphere, where it affects approximately 5 to 15 US citizens of 100,000 people. Both males and females are prone to the disease and it is highest in those of Caucasian and Ashkenazi ancestry. Complete etiology is currently unknown, however, the understanding is that many factors can cause IBD. These factors include several environmental factors such as smoking, infectious agents, intestinal flora, and physiological changes in the small intestine. Genetic factors and associations also play a strong role in susceptibility of IBD in both innate and acquired immune response cases. Approximately 5% to 15% of patients have positive family history. Also, identical twins have a much higher percentage than fraternal twins (Nelms, Sucher, Lacey & Roth, 2011, p. 415-417).
2. Mr. Sims was initially diagnosed with ulcerative colitis and then diagnosed with Crohn’s. How could this happen? What are the similarities and differences between Crohn’s disease and ulcerative colitis?
Mr. Sims was initially diagnosed with ulcerative colitis and then with Crohn’s disease six months later when he was in the hospital for over two weeks. The initial diagnosis of UC could have been determined because of the peak onset age difference between the two diseases. Mr. Sims was 35 years old which suggests UC with a peak onset of 20 to 30 years of age, where as Crohn’s peak onset age is around the teens or twenties. Many signs and symptoms are also similar such as diarrhea, abdominal pain, fever, and weight loss. Lastly, many of the tests to determine the disease overlap such as fecal markers of inflammation: calprotectin (Cal), lactoferrin (Lf) lab results, imaging tests of wireless capsule endoscopy and colonoscopy, and other procedures such as mucosal biopsies. The chart below shows the differences between the two diagnoses and the italicized phrases indicate the similarities between the two (Nelms, Sucher, Lacey & Roth, 2011, p. 416-419).
Table 15.3
Ulcerative Colitis / Crohn’s DiseaseEtiology / Abnormal immune response resulting in inflammatory damage of gastrointestinal mucosa; genetic susceptibility;
association with ex-smokers / Abnormal immune response resulting in inflammatory damage of gastrointestinal mucosa; genetic susceptibility;
association with cigarette smoking
Epidemiology / Both sexes affected equally; higher prevalence in North America; highest incidence in Ashkenazi Jews;
approx. 10% of those with UC have a 1st degree relative with the disease; peak onset 20-30 years w/secondary peak in middle age / Both sexes affected equally; higher prevalence in North America; highest incidence in Ashkenazi Jews;
peak onset is teens to twenties
Pathology / GI tract unable to distinguish foreign from self-antigens; characterized by chronic inflammation of colonic mucosa and submucosa, atrophy and possible dysplasia limited to colon; extent of disease varies and may only involve the rectum left side of colon to splenic flexure, or entire colon / Localized inflammation in bowel mucosa progressing through bowel wall; tends to be localized in terminal ileum and colon but can involve any portion of the GI tract
Signs and Symptoms / Bloody diarrhea with mucus
Abdominal and/or rectal pain
Fever
Weight loss
Possibly constipation and rectal spasm
Arthritis
Dermatological changes
Ocular manifestations / Chronic diarrhea
Abdominal pain and cramping
Blood and/or music in stool
Anorexia
Weight loss
Malnutrition
Fever
Delayed growth in adolescents
Complications / Severe bleeding
Toxic colitis
Toxic megacolon
Strictures
Perforation
Intolerance to immunosuppression
Colonic strictures
Dysplasia
Carcinoma / Malabsorption
Malnutrition
Abdominal fistulas and abscesses
Intestinal obstruction
Bacterial overgrowth (blind loop syndrome)
Gallstones
Kidney stones
Urinary tract infections
Thromboembolic complications
Perianal disease
Neoplasia
Diagnosis / Abdominal ultrasound
MRI
CT
Antiglycan antibodies (ASCA/ANCA)
Cal, Lf, PMN-e / Clinical presentation—CDAI score
Abdominal ultrasound
MRI
CT
Antiglycan anitbodies (ASCA/ANCA)
Cal, Lf, PMN-e
Prognosis / Chronic with repeated exacerbations and remissions; nearly 30% of those with extensive UC require surgery; patients with localized UC have prognosis, surgery rarely required, and life expectancy normal / Rarely cured, but characterized by intermittent exacerbations; approximately 70% require surgery
Treatment / Reduce acute and chronic inflammation eventually resulting in remission; Drugs: immunosuppressants, adrenocorticosteroids, anti-inflammatory, biologic therapies, antidiarrheals, steroids; surgery: colectomy, subtotal colectomy, total proctolectomy with Brooke ileostomy, restorative proctocolectomy with ileal pouch-anal anastomosis / Based on severity of disease; drugs: immunosuppressants, antibiotics, steroids, methotrexate, biologic therapies; surgery: surgical removal of affected areas—may include ileocolic resections, segmental resections, total proctocolectomy and ileostomy
(Nelms, Sucher, Lacey & Roth, 2011, p. 416-417)
3. A CT scan indicated bowel obstruction and the Crohn’s disease was classified as severe-fulminant disease. CDAI score of 400. What does a CDAI score of 400 indicate? What does a classification of severe-fulminant disease indicate?
Crohn’s disease is described using the CDAI, which stands for Crohn’s Disease Activity Index. Many factors are evaluated using this index such as but not limited to abdominal pain, diarrhea, labs, and weight loss. Patients that have a score of over 150 are having a flare-up, where as those with a score over 300 are having severe exacerbation. Mr. Sims’ score of 400 indicates that he is at a moderate-severe stage of the disease. This means that he has failed to respond to treatment used for the mild-moderate stage or he has more major symptoms of fevers, significant weight loss, abdominal pain or tenderness, intermittent vomiting and nausea, or significant anemia. A severe-fulminant classification is the next stage with a CDAI greater than a score of 450. This stage of the disease indicates that individuals have persisting symptoms in spite of the introduction of steroids or biologic agents as outpatients, or patients with high fever, continuation of vomiting, intestinal obstruction, rebound tenderness, evidence of an abscess, or cachexia (Nelms, Sucher, Lacey & Roth, 2011, p. 418-419).
4. What did you find in Mr. Sims’ history and physical that is consistent with his diagnosis of Crohn’s? Explain.
Mr. Sims’ medical history indicates that his initial diagnostic workup showed acute disease within the least 5-7 cm of jejunum and first 5 cm of ileum. Crohn’s affects mainly the colon and ileum but can involve any portion of the GI tract(Nelms, Sucher, Lacey & Roth, 2011, p. 417). Also, he reports that once he went back to school, he was experiencing more diarrhea and abdominal pain, as well as a fever now. He has also lost a considerable amount of weight in the last six months, going from around 166-168 lbs to 140 lbs. Also, he has abdominal distension and extreme tenderness with rebound and guarding. These are all signs and symptoms associated with Crohn’s disease (Nelms, Sucher, Lacey & Roth, 2011, p. 416).
National Digestive Diseases Information Clearinghouse (NDDIC). (n.d.). Retrieved September 13, 2014, from
5. Crohn’s patients often have extraintestinal symptoms of the disease. What are some examples of these symptoms? Is there evidence of these in his history and physical?
Examples of extraintestinal symptoms, or disease manifestations outside the GI tract, include osteopenia and osteoporosis, dermatitis, rheumatological conditions such as ankylosing spondylitis, ocular symptoms, and hepatobiliary complications (Nelms, Sucher, Lacey & Roth, 2011, p. 418). His history and physical did not show any signs of these symptoms.
6. Mr. Sims has been treated previously with corticosteroids and mesalamine. His physician had planned to start Humira prior to this admission. Explain the mechanism for each of these medications in the treatment of Crohn’s.
Corticosteroids are anti-inflammatory drugs that are also immunosuppressive, meaning they reduce the activity of the immune system. They closely resemble the naturally occurring hormone, cortisol, which the body produces in the adrenal glands. Normal production is slowed down if corticosteroids are taken. These are usually prescribed to patients with moderate to severe symptoms.
Mesalamine, on the other hand, is a form of medication classified as aminosalicylates, which contain 5-aminosalicyclic acid, which helps to control inflammation. This medication is usually prescribed to patients with mild symptoms and with Crohn’s disease with ileal and colon involvement (Nelms, Sucher, Lacey & Roth, 2011, p. 419).
Humira is a prescription drug used to alleviate the signs and symptoms of Crohn’s disease. Crohn’s patients produce too much of a protein called TNF, also known as tumor necrosis factor. Too much of this protein can cause the inflammation that causes the pain, diarrhea, and symptoms associated with the disease. Humira works to target and block this protein and reduce the inflammation. This medication is also immunosuppressive and could make fighting potential infections more difficult.
Crohn's & Colitis. (n.d.). Retrieved September 13, 2014, from
Learn how HUMIRA works for moderate to severe Crohn's disease. (n.d.). Retrieved September 13, 2014, from
National Digestive Diseases Information Clearinghouse (NDDIC). (n.d.). Retrieved September 13, 2014, from
7. Which laboratory values are consistent with an exacerbation of his Crohn’s disease? Identify and explain these values.
There are a couple of laboratory tests that can be indications that there was an exacerbation of Crohn’s disease. Assessing the RBC and WBC count can be an indicator. Usually, if the WBC count is on the high side, there was inflammation or infection present. A low RBC count can indicate possible anemia as well, which can be consistent with Crohn’s as well. An elevated C-reactive protein level can also indicate inflammation, as well as low albumin levels indicating severe or long-standing symptoms. Mr. Sims’ RBC count is in the normal range but on the lower end. Similarly, his WBC count is within the range but on the higher end. His C-reactive protein is consistent with the exacerbation because it is much higher than the reference range. His albumin level is lower then the range. Also, ASCA is a marker to distinguish between Crohn’s and UC, and Mr. Sims was positive. Lastly, his hemoglobin and hemocrit levels are low which can indicate anemia. These values show that he is experiencing severe symptoms, inflammation, and infection due to his diagnosis of Crohn’s disease and they are consistent with an exacerbation (Nelms, Sucher, Lacey & Roth, 2011, p. 418-419).
Reference Range / 2/15RBC (x103/mm3) / 4.2-5.4 F
4.5-6.2 M / 4.9
WBC (x103/mm3) / 4.8-11.8 / 11.1
C-reactive protein (mg/dL) / <1.0 / 2.8
Albumin (g/dL) / 3.5-5 / 3.2
ASCA / Neg / +
Hemoglobin (Hgb, g/dL) / 12-15 F
14-17 M / 12.9
Hemocrit (Hct, %) / 37-47 F
40-54 M / 38
How do you diagnose Crohn's disease? | Beth Israel Deaconess Medical Center. (n.d.). Retrieved September 14, 2014, from
8. Mr. Sims is currently on several vitamin and mineral supplements. Explain why he may be at risk for vitamin and mineral deficiencies.
Mr. Sims is currently taking a multivitamin daily. Patients with Crohn’s disease, such as Mr. Sims, are at risk for a number of vitamin and mineral deficiencies. Some of these vitamins and minerals include vitamin B12, water-soluble vitamins, fat-soluble vitamins, folate, calcium and vitamin D, iron, magnesium, and zinc. First, since vitamin B12 is absorbed in the lower ileum, Mr. Sims is at risk of a B12 deficiency because of his surgical removal of 5-7 cm of jejunum and 5 cm of ileum previously. A diet low in fiber can result in a deficiency of vitamin C if not enough fruit is being eaten. Fat-soluble vitamins are a concern with steatorrhea. Calcium and vitamin D are a concern if there is long-term steroid use or decreased intake of dairy foods as a result of a lactose-restricted diet. Folate deficiency can be caused from medications used to treat IBD. Additionally, magnesium and zinc deficiency can occur when there is intestinal loss or high-volume diarrhea. And lastly, iron deficiency can occur from blood loss and malabsorption. Mr. Sims should continue to take his supplements because he already lacks fruits and vegetables in his diet. A nutrition consult to educate him on what fruits and vegetables would be appropriate for him could help with these deficiencies as well (Nelms, Sucher, Lacey & Roth, 2011, p. 420).
Crohn's & Colitis. (n.d.). Retrieved September 14, 2014, from
9. Is Mr. Sims a likely candidate for short bowel syndrome? Define short bowel syndrome, and provide a rationale for your answer.
Short bowel syndrome (SBS) is “decreased digestion and absorption that result from a large resection of the small intestine” (Nelms, Sucher, Lacey & Roth, 2011, p. 377). There are about four cases per 1 million considered to be SBS each year. Common causes for SBS include malignancy, harm from radiation therapy, multiple resections from Crohn’s disease, vascular accident, and trauma. Many factors are taken into consideration such as the remaining small intestine, colon and ileocecal valve presence, health of the remaining GI tract, and individual cases. Also, if there was more than 70% of the GI tract removed, there are severe nutritional and metabolic complications as a result. O’Keefe also defined SBS as “intestinal failure results from surgical resection, congenital defect or disease-associated loss of absorption and is characterized by the inability to maintain protein, energy, fluid, electrolyte, or micronutrient balances when on a conventionally accepted, normal diet” (Nelms, Sucher, Lacey & Roth, 2011, p. 424). Even though Mr. Sims is experiencing severe diarrhea and symptoms that would match up with SBS, I would not consider him a candidate yet because he has not had any surgeries or significant indicators. However, I do think that he is at a high risk of developing SBS if he continues to experience symptoms and inflammation without proper treatment and dietary consultation. His previous resection of his jejunum and ileum put him at a greater risk as well.
10. What type of adaptation can the small intestine make after resection?
There are three phases of adaptation that the small intestine goes through after resection. The first phase is the first postoperative period that can last about 7 to 10 days. This phase is characterized by extensive fluid and electrolyte losses with large amounts of diarrhea. Patients are dependent on parenteral nutrition, which provides necessary nutrients and manages the fluid and electrolyte balance. The second phase can last several months. This phase is characterized by a reduction in diarrhea and initial stages of adaptation of the bowel. Enteral nutrition can be introduced in this phase and a slow transition to oral intake. Lastly, the third phase continues with adaptation. Increased blood flow, secretions, and cell growth characterize this phase. The inner lumen of the small intestine begins to increase in length, diameter, and villous height. This phase lasts 1 to 2 years. Enteral feeding is continued and supports the adaptation (Nelms, Sucher, Lacey & Roth, 2011, p. 425).
11. For what classic symptoms of short bowel syndrome should Mr. Sims’ health care team monitor?
Since Mr. Sims is already experiencing, his health care team should continue to monitor his fluids and electrolytes, as well as the nutrients that he could be losing. This could lead to malabsorption and malnutrition that can be dangerous for Mr. Sims in his current state. His vitamin B12 and bile salts should be monitored because loss of ileum prevents absorption and reabsorption, respectively. This could also lead to fat malabsorption. Therefore, on top of monitoring his micronutrients, it is important that his health care team monitor his macronutrients as well. Nutritional and metabolic complications are possible if the ileocecal valve can no longer control intestinal motility and prevention of translocation of bacteria from the colon to the small intestine. The health care team should closely monitor vitamins A, D, E, K, and nutrients including sodium, magnesium, iron, zinc, selenium, and calcium if his diarrhea continues (Nelms, Sucher, Lacey & Roth, 2011, p. 425).
12. Mr. Sims is being evaluated for participation in a clinical trial using high-dose immunosuppression and autologous peripheral blood stem cell transplantation (autoPBSCT). How might this treatment help Mr. Sims?
The clinical trial using high-dose immunosuppression and autologous peripheral blood stem cell transplantation could help Mr. Sims by being an effective way to induce remission of his Crohn’s disease. There is still some controversy about the treatment, however, even in the incidences of relapse, the patients were able to control the disease activity with low doses of conventional therapy and corticosteroids. The treatment should be further analyzed but seems to currently do more good than harm.
Hasselblatt, P., Drognitz, K., Potthoff, K., Bertz, H., Kruis, W., Schmidt, C., ... Kreisel, W. (2012, October). Remission of refractory Crohn's disease by high-dose cyclophosphamide and autologous peripheral blood stem cell transplantation. Retrieved September 14, 2014, from
II. Understanding the Nutrition Therapy
13. What are the potential nutritional consequences of Crohn’s disease?
There are many potential nutritional consequences of Crohn’s disease. Crohn’s is characterized by affecting the normal digestion and absorption of nutrients. It may also increase caloric, protein, and micronutrient needs, which can lead to malnutrition in may cases. Further consequences include inadequate energy intake, inadequate oral intake, impaired nutrient utilization, food-medication interaction, and altered nutrition-related lab results. Malnutrition can lead to anorexia, anemia, osteoporosis, a compromised immune system, and lack of wound healing. Due to the many problems that can arise from improper intake and absorption of nutrients, nutrition therapy is very important in management and treatment of Crohn’s disease. Furthermore, many deficiencies (discussed in the vitamin and mineral paragraph above) come from severe diarrhea, which accompanies Crohn’s and can contribute to the malabsorption and malnutrition issues. When there is inflammation, protein and energy needs are greater, sometimes by 150% and should be closely monitored (Nelms, Sucher, Lacey & Roth, 2011, p. 419-420).