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  • A group of conditions known as inflammatory Bowel DiseasesCrohn’s diseases are inflammatory condition of the gastrointenstinal tract
  • Cause is unknown but researchers believe it is the result of an abnormal reaction by the body’s immune systemGenetics – more prevalent in Jewish population.Environmental factors – Antibiotics, NSAIDs, Infectious agents, Stress, Diet, SmokingOral aphthous ulcerations: Recurrent oral ulcerationPyrodermagangrenosa: a condition that causes tissue to become necrotic, causing deep ulcers that usually occur on the legs. Fistula is an abnormal connection between two organs or between an organ and the outside
  • Factors that will influence nutritional requirements are;Severity of disease, Extent of stool output, malabsorption, etc., current medication regimen, previous medical and surgical history, quality and quantity of nutrient intake
  • Total Parental Nutrition
  • Increased IP is a common feature in Pts with CD (about 30-65%) It is suggested as a marker of impending relapseMagnitude of alteration in IP correlates with the activity of the disease
  • The total energy requirement was supplied in the form of 20 % from protein, 55 % from carbohydrate, and 25% from fats.1/3 (0.5 g/kg IBW/day) of the protein requirement was supplied in the form of glutamine or whey protein
  • All the patients were treated with standard drug regimen.
  • Intra epothelial lymphocytes (IELs) are seen in the epithelium as darkly stained nuclei
  • Presentation_Crohn's_Disease

    1. 1. Presentation 1 Kayoko Zahn Distance Student University of Alabama
    2. 2. Crohn’s Disease • • • • • Overview Causes of Symptoms Diagnosis & Treatment Nutrition Management Primary Research
    3. 3. Overview • Inflammatory Bowel Diseases (IBD) • 1 million Americans are affected • 2 major forms – Crohn’s Disease – Ulcerative Colitis • Differences? Source: NIDDK website – Both cause inflammation in intestines – Ulcerative Colitis: generally affects lower bowel (colon and rectum) – Crohn’s Disease: ANY portion of the GI tract
    4. 4. Causes of Symptoms • Unknown – Genetics? Environmental factors? • Associated with – – – – – Osteoporosis, Low vitamin K may cause osteopenia. Malnutrition Altered immune function; Arthritis Gallstones Liver disease • Symptoms – – – – Abdominal pain, diarrhea, fever Inflammation in the eyes or mouth Oral aphthous ulcerations, pyroderma gangrenosa Fistula
    5. 5. Diagnosis & Treatment • Tests for diagnosis – Blood tests – Stool tests – Flexible sigmoidoscopy and colonoscopy • Treatment – 1. Controlling inflammation, 2. Correcting nutritional deficiencies, 3. Relieving symptom • Options – Medications – Nutrition supplements – Surgery
    6. 6. Nutrition Management • 60-70% of patients with Crohn’s disease experience malnutrition. • Food avoidance / Food aversions and Misinformation / Confusion about Food are prevalent in patients with IBD. • Potential nutrient deficiencies of IBD include: – Energy, Protein, Fluid, Electrolytes, Iron, Magnesium, Calcium, Vitamin D, Vitamin B12, Folate, Copper, Zinc, Vitamin A
    7. 7. Nutrition Management • No diet has been specified for prevention or treatment of Crohn’s disease. • Dietary recommendation must be individualized to Pt’s needs/risk based on the nutrition assessment. • Energy – Estimated energy range for adults 25-35 kcal/kg, depending on disease state • Protein – 1.0 – 1.5 g/kg/d, depending on disease state • Vitamins – Use DRIs, Pts may need higher levels of Vitamin B12, Folate, Thiamin, Riboflavin, Niacin, Vitamin C, E, D, and K • Minerals – Use DRIs, Pts may need higher levels of Zinc, Magnesium, Selenium and Potassium
    8. 8. Nutrition Management • During exacerbation: – Nutrition support: Enteral feedings or TPN – Return to normal diet, progress to low-fat, lowfiber, high-protein, high-kilocalorie, small, frequent meals – Vitamin/Mineral Suppl. Include: Vitamin D, Zinc, Calcium, Magnesium, Folate, Vitamin B12, Iron
    9. 9. Primary Research • Benjamin J, et al. Glutamine and whey protein improve intestinal permeability and morphology in patients with Crohn's disease: a randomized controlled trial. Dig Dis Sci. 2012;57(4):1000-12.
    10. 10. Glutamine and whey protein improve intestinal permeability • Background – Increased intestinal permeability (IP) has been implicated in the disease activity and relapse of Crohn’s disease. – Glutamine is the major fuel and nitrogen source for the enterocytes. • Hypothesis – Does oral glutamine supplementation improve IP in patients with Crohn’s disease? What are the effect of glutamine on IP and intestinal morphology Crohn’s disease? • Study Design – A Randomized, Controlled Open-Label Trial
    11. 11. Glutamine and whey protein improve intestinal permeability • Inclusion criteria – Pt’s with Crohn’s disease in remission phase • Exclusion criteria – Pt’s with Crohn’s disease in active phase, taking protein suppl., associated systemic diseases such as liver disease, kidney disease, DM • Groups(0.5 g/kg ideal body weight / day) – 1. Glutamine group (GG) – Oral glutamate – 2. Active Control Group (ACG) – Whey Protein • Duration – 2 months • Method – IP was assessed by (1) lactulose mannitol excretion ration (LMR) in urine and (2) morphometry
    12. 12. Glutamine and whey protein improve intestinal permeability 162 132 Glutamine (n=15) (n=14) (n=30) Whey Protein (n=15) (n=14)
    13. 13. Glutamine and whey protein improve intestinal permeability • Primary Outcome Parameters – Improvement in intestinal permeability (IP) was assessed by measuring lactulose mannitol excretion ration (LMR) • Secondary Outcome Parameters – Changes in the intestinal morphology – Changes in plasma glutamine levels
    14. 14. Glutamine and whey protein improve intestinal permeability Lactulose Mannitol Excretion Ration (LMR) Median 0.071 0.029 Glutamine Median 0.067 0.033 Whey Protein
    15. 15. Glutamine and whey protein improve intestinal permeability Significant increase in Villous Crypt Ratio (VCR) GG: Baseline 2.33 2 mo 2.68 ACG: Baseline 2.26 2 mo 2.49 Decrease in Intra Epithelial Lymphocytes (IELs)
    16. 16. Glutamine and whey protein improve intestinal permeability • Plasma Glutamine – No significant difference in Pts and HC (Healthy Control) at baseline and at the end of 2 months • Activity – Two patients in each group went to the active phase from the remission phase • Adverse Reaction – 7 from Glutamine group and 2 from Whey group had an increase of stool frequency.
    17. 17. Glutamine and whey protein improve intestinal permeability • Conclusion – Showed glutamine as well as whey protein improved IP and mucosal structure. – Suggested glutamine is as effective as a high protein diet to improve IP of Crohn’s disease patients.
    18. 18. References 1. MedlinePlus: Crohn's Disease. U.S. National Library of Medicine National Institutes of Health. Web site. Accessed on October 29, 2013. 2. Crohn's Disease. National Digestive Diseases Information Clearinghouse (NDDIC). Web site. Accessed on October 29, 2013. 3. Moorthy D, Cappellano KL, Rosenberg IH. Nutrition and Crohn's disease: an update of print and Web-based guidance. Nutr Rev. 2008;66(7):387-97. 4. Nutrition Care Manual: Crohn's Disease & Ulcerative Colitis. Academy of Nutrition and Dietetics. Web site. Accessed on October 29, 2013. 5. Wiese DM, Lashner BA, Lerner E, DeMichele SJ, Seidner DL. The effects of an oral supplement enriched with fish oil, prebiotics, and antioxidants on nutrition status in Crohn's disease patients. Nutr Clin Pract. 2011;26(4):463-73.
    19. 19. Thank you for your attention. Please let me know if you have questions.