Inflammatory Bowel disease: Ulcerative Colitis

Inflammatory Bowel disease: Ulcerative ColitisSarah HallajMay 24th 2010OutlinePresent my patientNutrition assessmentTestsUlcerative colitisTrivia questionsNutrition focused physical examination: PICTURES!Nutrition intervention, monitoring & evaluation

Nutrition AssessmentClient historySocial history: 28 year old white male who migrated from Ukraine, Eastern Europe with the rest of his family. He was a carpenter but is now unemployed with no insurance. He lives with his 2 sisters who usually do the cooking at home. His parents and brother were present at his hospital stay.

While the patient was sleeping, his brother would translate to his parents4Admit date: 2/3/2010Chief complaint:Diarrhea ( hematochezia: bloody soft stools) & weight loss of 23kg in 2 months

Initial diagnosis:Anal fissure & cachexia

So we got a physicians consult at the dietitians office to see this patient due to wt loss and low body wt Hematochezia is commonly associated with bleeding in the lower GI tract5Outpatient gastroenterology consultation Patient became ill in November 2009 with slow progressive worsening of his symptomsPatient was having over 15 bowel movements a day, sometimes awakening him from sleep at nightHe noted his inability to eat and eventually lost 23 kgStool studies were negative for any enteric pathogens, C. Diff, and Giardia antigenEndoscopic evaluation was consulted but refused because of financial concerns and anxiety about consequences of the testPatient did not experience any nausea, vomiting, chills or feversNo skin changesIn November pt albumin was 3.3, normal6Medication list in November 2009Mesalamine : anti-inflammatory (for ulcerative colitis or Cronhs disease), oralRowasa enemas: anti-inflammatory (for ulcerative colitis or Cronhs disease), rectal Prednisone (corticosteroids): anti-inflammatory, immunosuppressantLoperamide: anti-diarrheal Sulfasalazine: treats RA or rectal bleeding and diarrhea from ulcerative colitis

All these medications did not provide any benefits to the patients symptoms7Anthropometric measurementsHeight: 6ft 0inWeight: 48.44 kgBMI: 14.5IBW: 72.3 kg% IBW: 67 %Weight history: 72 kg in November 2009 33 % of weight loss in 2 months

ICD-9 code

Malnutrition coding reference from Providence Health & ServiceICD-9 Code: Other severe, protein-calorie malnutrition:

CriteriaCurrently at: Weight < 85% 67% of IBWSevere weight loss >7.5% in 3 months 33 % weight loss in 2 monthsDepressed visceral protein storesAlbumin 2.4 mg/dLPrealbumin 11 mg/dLSigns of muscle wastingArms, legs, chest, and templesUnderweight, BMI diarrheaSkin lesionsJoint painGrowth failure (esp. in children) About of the people diagnosed with ulcerative colitis have mild symptoms. Others suffer frequent fevers, bloody diarrhea, nausea, and severe abdominal cramps. Ulcerative colitis may also cause problems such as arthritis, inflammation of the eye, liver disease, and osteoporosis. It is not known why these problems occur outside the colon. Scientists think these complications may be the result of inflammation triggered by the immune system. Some of these problems go away when the colitis is treated Ulcerative colitis complications:Toxic megacolon: life-threatening complicationCancerToxic megacolon: rapid widening of part of the large intestine, causing abdominal pain, distention, tenderness, dehydration, fever & shock w/in few days

Patient with ulcerative colitis for 8yrs or longer are at greater risk of getting colon cancer

24If all failsSurgery to remove part or all of the colon

Removing the entire colon cures ulcerative colitisIf severe symptoms persist and medications (corticosteroids, anti-inflammatory, and immunosuppressive agents) dont help then25Ileal Pouch-Anal Anastomosis (IPAA):

http://www.mayoclinic.org/colostomy-sparing-surgery/ipaa.html Allows the patient to have normal bowel movementsRemoval of the entire colon and rectumPreservation of the anus & sphincter musclesThen surgeon constructs a pouch from end of small intestine and attaches directly to the anus(temporary ileostomy) 26IPAA contd IPAA might not be appropriate for each patientIt depends on the severity of the disease & the patients needs, expectations and lifestyle

QUESTIONS

Who is affected by ulcerative colitis?Some trivia questionsAt what age are people usually affected with ulcerative colitis?!? Who is affected by ulcerative colitis?It can occur in people of any age, but usually starts between the ages of 15 and 30, and less frequently between 50 and 70 years of age. It affects men and women equally and appears to run in families. A higher incidence of ulcerative colitis is seen in Whites and people of Jewish descent.20% of people with ulcerative colitis have a family member or relative with ulcerative colitis or Cronhs diseaseTrue or false?Ulcerative colitis is caused by emotional distress and/or sensitivity of certain food products

No, but these factors may trigger symptoms in some people Nutrition DiagnosisPES StatementsInadequate protein-energy intake related to altered GI function as evidenced by altered nutrition-related lab values: albumin 2.4 mg/dL, hemoglobin 10 gm/dL and bloody diarrhea

Malnutrition related to involuntary weight loss as evidenced by 33% weight loss in 2 months & 67% IBW

Nutrition-focused physical findingsPhysical appearanceMuscle and fat wasting: temple, chest and extremities

Appetite was improving as intake was significantly increasing as well as weight

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Nutrition InterventionPlaced calorie count order Added ensure supplementNutrition education: educated patient on low residue diet per MD order and provided handout from American Dietetic AssociationCoordination of nutrition care: talked with nurses to assure daily weights Answered patients questions

38ADA Low residue diet:Recommended foods: Yogurt, cheese, soy milk, rice milk, or almond milkTender, ground, & well cooked beef & other protein foods (tofu, fish, eggs, smooth nut butters)Refined white grainsWell-cooked vegetablesPeeled fruits & fruit juices w/out pulp

Dont confuse: low residue low fiber Residue: end result of digestive, secretory, absorptive, and fermentable processesLimit caffeine to GI distress

39EAL recommends: Consuming a diet with > 15 g/day of fermentable fiber resulted in improvements in ulcerative colitis

Fermentable fiber: germinated barley foodstuffs (GBF), oat bran fiber and ispaghula (psyllium) Each patient with ulcerative colitis is different. One food might cause a flare up for one person but not another. Individualized Avoid foods that cause symptoms to be worse

40Nutrition Monitoring & EvaluationCompleted follow-ups Monitored electrolytes Evaluated patients diet adequacy & POC

Discharge medication list:Ciprofloxacin: antibioticPrednisone (30 mgx2/day): anti-inflammatory, immunosuppressant Ferrous sulfate (325 mg) w/ vitamin C: treats iron-anemia deficiency Remicade (infliximab/etanercept): anti-arthritic, Crohns disease/ ulcerative colitis treatment

Pt was good candidate for Remicade after 7 days of lack of clinical response. This was ordered in an outpatient setting as pt was d/c to GI clinic for infusion of Remicade which is a more aggressive approachThis is when patient noted subjective improvement in the consistency of his stools, going from watery to more of pudding consistency (still blood in stool though)

42Suggest including a calcium with vitamin D supplement What nutrition interventions would you suggest to address nutrition issues caused by long term use of prednisone?

43References Refeeding Syndrome- Awareness, Prevention and Management 1:4 (2009): 1495-498. Head and Neck Oncology. BioMed Central, 26 Jan. 2009. Web. 15 May 2010. .Ulcerative Colitis. National Institute of Health, Feb. 2006. Web. 15 May 2010. . Medical Imaging Analysis 5.4 (2001): 237-54. Science Direct. Web. 15 May 2010. . CANNOM, REBECCA R., et al. "Inflammatory Bowel Disease in the United States from 1998 to 2005: Has Infliximab Affected Surgical Rates?." American Surgeon 75.10 (2009): 976-980. Academic Search Premier. EBSCO. Web. 17 May 2010. http://proxy.library.oregonstate.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=44682704&loginpage=Login.asp&site=ehost-live.Eat Right. American Dietetic Association, 1 July 2008. Web. 21 May 2010. .Food Medication Interactions. 15th ed. Birchrunville: Food-Medication Interactions, 2008. Print.International Dietetics and Nutrition Terminology Reference Manual. 2nd ed. Chicago: American Dietetic Association, 2009. Web. 16 May. 2010. .

http://newsblog.mayoclinic.org/2008/10/27/new-mre-imaging-for-liver-disease/

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