Case Study – NutritionManagement of Patients   with Crohn’s Disease        Siti Hawa Mohd Taib        Dietetic Department
Introduction• Causes and pathogenesis of nutritional  deficiencies  – Inadequate intake     • Primary reason is thought to...
Introduction• Causes and pathogenesis of nutritional  deficiencies  – Increased metabolic requirement    • Increased energ...
Nutrition and Clinical             Outcome• Nutritional deficits are associated with adverse  clinical outcome  –   linear...
Case MY• 11 year old Chinese girl electively admitted last  Dec 2011 for further investigation of chronic  abdominal pain ...
Case MY• Colonoscopy/OGDS (23/12/2011)  – Colitis, pseudopolyps attenuation or loss of vascular    pattern, and stricture ...
Case LC• 13 year old Chinese boy• He was referred from Seremban General Hospital early  November 2011 for prolonged fever ...
Nutrition Assessment• Client History  – Personal history – personal data  – Health history     • Diagnosis     • Medical t...
Anthropometric    Nutrition Assessment Measurement                 • Body composition/growth/weight history               ...
Weight History                             Weight Loss              35              30Weight (kg)   25              20    ...
Anthropometric             Measurements                            MY                  LCWeight            20.3 kg        ...
Nutrition Focused Physical Findings                          MY                            LCOverall        • Mild contrac...
Nutrition Assessment• Biochemical data, Medical tests and  procedures  – Electrolytes and renal profile     • Prevention o...
Biochemical Data                Inflammatory Profile        Platelet                       CRP                         ESR...
Nutrition Assessment• Food/nutrition-related history  – Food and Nutrient intake     • Energy intake     • Food and bevera...
Food/Nutrition-Related          History                           MY                         LCDiet History    • Intake <½...
Food/nutrition-related           history• Medication and herbal supplement use    – Steroids    – Vitamin supplements•   K...
Nutrition Diagnosis     Malnutrition RT inadequate intakeMY   of protein and energy AEB 33%     weight loss in 1 year peri...
Nutrition Intervention• Goals  – To correct nutritional disturbances  – To promote adequate growth, and  – Modulate inflam...
Nutrition Intervention• Strategies : FOOD AND/OR NUTRIENT DELIVERY        Malnutrition RT          MEDICAL FOOD SUPPLEMENT...
Enteral Nutrition• Nutritional therapy offers numerous benefits in the  management of CD.   – A reduction in proinflammato...
Partial EN• Exclusive EN suppresses inflammation in  active Crohn’s disease but partial EN does  not• Long term nutritiona...
Oral Supplement• To administer these supplements outside  mealtimes• Supplements are meant to increase total  food intake ...
Hospital Course: MY 10/12                                  12/12 • Oral supp + Overnight                • Refused NG – ↑Or...
Hospital Course: MY16 -21/12                  30/12• PN and NG feeding        • Full feed at 80 mL/hour at night• NBM for ...
Hospital Course: LC                    24/11                 6/1217/11                                     • EnSure® 4-5 c...
CASE LC       22/3                                   28/3       • Enterocutaneous fistula              • PN and         fo...
PN in Crohn’s Disease• Consider PN only when enteral is  ineffective (ESPGHAN, 2004)• High proportion of those requiring P...
On Discharge                             MY                          LC                 ADMISSION        DISCHARGE   ADMIS...
Long Term Nutrition Issues• Osteoporosis• Obesity• Metabolic complications
Learning Points• Nutrition plays a role in the treatment of  patients with Crohn’s Disease• Attention to growth and nutrit...
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Siti hawa tahir crohns disease-treatment and long term outcome in crohns

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Siti hawa tahir crohns disease-treatment and long term outcome in crohns

  1. 1. Case Study – NutritionManagement of Patients with Crohn’s Disease Siti Hawa Mohd Taib Dietetic Department
  2. 2. Introduction• Causes and pathogenesis of nutritional deficiencies – Inadequate intake • Primary reason is thought to be protein-energy malnutrition caused by reduced caloric intake and anorexia [Griffiths, 2004] – Increased cytokines during inflammation [Griffiths, 1998] • Nausea • Pain (abdominal pain, oral ulcers) – Fear of precipitating abdominal pain • Fasting secondary to hospitalizations – Increased losses • Protein-losing enteropathy – resulting in hypoalbuminemia • Chronic blood loss
  3. 3. Introduction• Causes and pathogenesis of nutritional deficiencies – Increased metabolic requirement • Increased energy expenditure – Malabsorption • Inflammation of the jejunum – Medications • Steroids – Osteoporosis – Muscle loss
  4. 4. Nutrition and Clinical Outcome• Nutritional deficits are associated with adverse clinical outcome – linear body growth and sexual maturation in children – fistula and wound healing – nitrogen balance, – bone decalcification – Postoperative morbidity rates and slower functional recovery can occur in patients who suffer from nutrient deficiencies [Campos, 2003]
  5. 5. Case MY• 11 year old Chinese girl electively admitted last Dec 2011 for further investigation of chronic abdominal pain for more than 1 year associated – Appendicectomy done Oct 2010 – Associated with intermittent fever x 1 year – Vomiting x 1/12 – Reduced appetite and weight loss• Dietitian referral for nutritional rehab
  6. 6. Case MY• Colonoscopy/OGDS (23/12/2011) – Colitis, pseudopolyps attenuation or loss of vascular pattern, and stricture formation – HPE: mild non-specific gastritis, chronic duodenitis, non-specific mild chronic colitis• Colonoscopy (2/2/2012) – There’s area of an abnormal looking mucosa at the level of D3 and this area appear to be a stricture – HPE : Histopathological findings suggestive of Crohn’s disease
  7. 7. Case LC• 13 year old Chinese boy• He was referred from Seremban General Hospital early November 2011 for prolonged fever associated with chronic abdominal pain for past 4 months – Late August 2011- admitted in KPJ hospital for emergency appendicectomy – TRO intestinal TB and Crohn’s Disease – OGDS and Colonoscopy (17/11/2011) – multiple ulcers seen over caecum and terminal ileum with cobblestone appearance and remaining colon and rectum appear normal• Dietitian referral for nourishing fluid
  8. 8. Nutrition Assessment• Client History – Personal history – personal data – Health history • Diagnosis • Medical treatment/therapy – Social history • Socioeconomic factors • Social support
  9. 9. Anthropometric Nutrition Assessment Measurement • Body composition/growth/weight history • Weight and height • Weight change • Weight loss is very common in patients with Crohn’s • TSF and MUAC • Growth pattern • Comparative standards –reference body weight
  10. 10. Weight History Weight Loss 35 30Weight (kg) 25 20 15 10 5 0 UBW CBW MY 31 20.3 LC 30.9 25.5 MY LC Lost 10 kg in 12 Lost 5.4 kg in 4/12 months (17% weight loss) (33% weight loss)
  11. 11. Anthropometric Measurements MY LCWeight 20.3 kg 25.5 kg (<3rd percentile) (<3rd percentile)Height 131.5 cm 148 cm (3rd percentile) (25th percentile)Expected weight 35 kg 40 kgMUAC 14.0 cm 15.0 cmTSF 3.4 mm 3.8 mm
  12. 12. Nutrition Focused Physical Findings MY LCOverall • Mild contracture ® kneeappearance • Kyphosis - able to fully flex the spine but refused to straighten her backExtremities, • Poor muscle mass and • Poor muscle massmuscles and fat stores and fat storesbones • Wasting at gluteus, thenar and hypothenar musclesDigestive • Oral ulcers -3 • Abdominal painsystems • Abdominal pain • Poor appetite • Poor appetite • BO - • BO – diarrhea • Vomiting • VomitingEyes and Head • Temporal wasting • Temporal wasting
  13. 13. Nutrition Assessment• Biochemical data, Medical tests and procedures – Electrolytes and renal profile • Prevention of refeeding syndrome – PO4, K, Mg – Nutritional anemia profile – GI profiles • LFT – Inflammatory profile – C-reactive protein, ESR, Platelet – Vitamin profile – Vitamin D
  14. 14. Biochemical Data Inflammatory Profile Platelet CRP ESR 10^9 L mg/dL mm/hr (2-10) (150-400) (<0.8)MY 773 - 25.8LC 663 60 12.2
  15. 15. Nutrition Assessment• Food/nutrition-related history – Food and Nutrient intake • Energy intake • Food and beverage intake • Enteral nutrition intake – Diet History – Avoidance behavior - avoidance of specific foods, restrictive eating – Food and nutrition knowledge and adherence
  16. 16. Food/Nutrition-Related History MY LCDiet History • Intake <½ usual portion • Intake < ½ usual • Picky with her food portion choices – dislike porridge • Usual preference of • Social issues?? spicy foods • EnSure (vanilla) ~ 4 - 6 • Soft diet scoops/day • Usually not a milk drinkerIntake• Energy ~750 -900 kcal/day ~1000 kcal/dayAverage energy intake of children with active CD was 400 kcal/daylower (Thomas, 1993)and ranges 55–80% of their expected caloricintake (Aiges,1989)
  17. 17. Food/nutrition-related history• Medication and herbal supplement use – Steroids – Vitamin supplements• Knowledge, belief and attitudes• Behavior• Social network• Physical activity and functions
  18. 18. Nutrition Diagnosis Malnutrition RT inadequate intakeMY of protein and energy AEB 33% weight loss in 1 year period Malnutrition RT inadequate intakeLC of protein and energy AEB 17% weight loss in 4 months period
  19. 19. Nutrition Intervention• Goals – To correct nutritional disturbances – To promote adequate growth, and – Modulate inflammatory response
  20. 20. Nutrition Intervention• Strategies : FOOD AND/OR NUTRIENT DELIVERY Malnutrition RT MEDICAL FOOD SUPPLEMENT inadequate intake of AND ENTERAL NUTRITION MY protein and energy AEB • Nourishing fluid during the 33% weight loss in 1 day with EnSure Chocolate year • Overnight enteral nutrition Malnutrition RT MEDICAL FOOD SUPPLEMENT inadequate intake of • Nourishing fluid with EnSure LC protein and energy AEB chocolate 17% weight loss in 4 months Encouraging adequate intakes of protein, calories, vitamins, and minerals is an important step in maintaining the health of the patient
  21. 21. Enteral Nutrition• Nutritional therapy offers numerous benefits in the management of CD. – A reduction in proinflammatory cytokine production in the mucosa and alteration of intestinal microflora (Day AS, 2008; MacDonald, 2005).• Polymeric vs elemental – Tube feeding, both elemental and polymeric, has a remission- inducing effect in pproximately 50% to 70% of individuals (Dray & Marteau, 2005; Ludvigsson, 2005; Zachos et al, 2001).• Oral Supplement vs EEN – Adherence to EEN is often difficult – Patient motivation remains an essential prerequisite
  22. 22. Partial EN• Exclusive EN suppresses inflammation in active Crohn’s disease but partial EN does not• Long term nutritional supplementation, although beneficial to some patients, is unlikely to suppress inflammation and so prevent disease relapse (Johnson, 2006)
  23. 23. Oral Supplement• To administer these supplements outside mealtimes• Supplements are meant to increase total food intake and not to replace a meal or part of a meal
  24. 24. Hospital Course: MY 10/12 12/12 • Oral supp + Overnight • Refused NG – ↑Oral NG supp, KIV PNInitial Goals• To optimize nutritional status• To prevent 13/12 refeeding • Parents agreed for overnight NG x 12 hrs syndrome and Parenteral Nutrition • c/o diarrhea with Osmolite®, feed changed to peptide-based formula
  25. 25. Hospital Course: MY16 -21/12 30/12• PN and NG feeding • Full feed at 80 mL/hour at night• NBM for scope • Overfeeding with PN -To wean off PN 4/1-16/1/2012 17/2 • Off PN - weight - static • 2/2 – 2nd colonoscopy • Refused EnSure® chocolate • Discharged with • ↑ Night feed to 100 mL/hour x 12 Nutren Optimum as H oral to NG 4x/day • Changed feed to Nutren Optimum • Day - Oral to NG 2x
  26. 26. Hospital Course: LC 24/11 6/1217/11 • EnSure® 4-5 cans/day • Oral supp at• Oral supp 1-2 • Meals: ½ - full usual EnSure® cans/day portion chocolate • Off PN • Partial PN • Discharged Early March 2012 • Recurrent abdominal pain and back pain • Developed RIF swelling - Fistula • 16/3 - Wt ↓ 26.0 kg • Overnight NG feeding with Osmolite®. Initial rate 25 ml/H, target up to 85 ml/H • Oral supp –Fortijuice 2 bottles/day
  27. 27. CASE LC 22/3 28/3 • Enterocutaneous fistula • PN and formed – colostomy bag Continuous NG • NBM x 1/52 - Commence PN feeding with Osmolite12/4 2/4• Discharged with • Off PN oral supp • Full feed at 80 mL/hour• Weight – 30 kg • KIV Overnight continuous feeding • Weight – 28 kg
  28. 28. PN in Crohn’s Disease• Consider PN only when enteral is ineffective (ESPGHAN, 2004)• High proportion of those requiring PN for malnutrition in CD have substantial and prolonged malnutrition (Mehanna, 2008) – at risk of the refeeding syndrome• PN should therefore be introduced cautiously and progressively with close monitoring
  29. 29. On Discharge MY LC ADMISSION DISCHARGE ADMISSION DISCHARGEAnthropometric•Weight •20 kg •24.6 •25.5 •30.5•MUAC •15cm •18 cm •15 cm •16 cm•TSF •3.2 mm •6.8 mm •3.8 mm •5.6 mmInflammatorymarker 25.8 1.6 12.2 <0.4•CRP mg/dL(<0.8)Medications Calcium lactate 200mg BD Prednisolone 40mg OD Vitamin D 1200U OD Mesalazine 250mg BD Folic acid 5mg OD, Azathioprine 12.5mg OD Omeprazole 25mg OD, Ursodeoxycholic acid Prednisolone 25mg OD 250mg BD Mesalazine 250mg BD Ferrous Sulphate 200mg Ferrous Fumarate 400mg OD BD
  30. 30. Long Term Nutrition Issues• Osteoporosis• Obesity• Metabolic complications
  31. 31. Learning Points• Nutrition plays a role in the treatment of patients with Crohn’s Disease• Attention to growth and nutrition at diagnosis, and during ongoing management is of critical importance in children and adolescents

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