Mr. S has been diagnosed with Crohn's disease based on his symptoms of diarrhea, fever, abdominal pain, weight loss, food intolerance, and anemia. He has undergone partial resection of his bowel and is recovering. Due to his unintended 15.7% weight loss and malnutrition, he requires increased calorie, protein, and fluid intake to aid his recovery. A low fiber diet is recommended initially to reduce abdominal pain. Close monitoring of his food intake and symptoms through a food diary will help evaluate his nutritional status and identify any foods that may trigger symptoms as he gradually resumes normal eating.

1. Devon Connelly
24 September 2015
Case Study #2 MNT 450
Crohn’s Disease
I have not given, received or used any unauthorized assistance on the assignment:
X

2. 1.) What in Mr. S’s history and physical findings are consistent with the
diagnosis of Crohn’s?
 Diarrhea
 Fever (101.5 F)
 Abdominal Pain
 Weight loss
 Intolerance to food (milk)
 Anemia
 Malnutrition
Diet Order: NPO with TPN post operatively
Lab Values Normal Range Patient Value Reason for Deviation
Albumin 3.5-5.0 gm/dl 3.2 d/dl Low Protein Intake
Prealbumin 18-38 mg/dl 11.0 mg/dl Low Protein Intake
Glucose 70-99 mg/dl 82 mg/dl Normal
Sodium 136-144 mEq/L 136 mEq/L Normal
Potassium 3.5-5.0 mEq/L 3.7 mEq/L Normal
Chloride 98-107 mEq/L 101 mEq/L Normal
Creatine 0.4-1.2 mg/dl 1.8 mg/dl Starvation
BUN 8-23 mg/dl 11 mg/dl Normal
AST 10-37 U/L 35 U/L Normal
ALT 4-40 U/L 22 U/L Normal
Alk Phos 40-120 U/L 120 U/L Normal
CRP <0.8 mg/dl 2.8 mg/dl Crohn’s Disease
Blood Lipid Panel:
Lab Values Normal Range Patient Value Reason for Deviation
Cholesterol 120-199 mg/dl 149 mg/dl Normal
LDL-C <100 mg/dl 101 mg/dl Malnutrition
HDL-c 40-60 mg/dl 48 mg/dl Normal
CBC:
Lab Values Normal Range Patient Value Reason for Deviation
Hgb 14.6-17.5 g/dl 12.9 g/dl Low Iron
Hct 41-51% 38.9% Normal
MCV 78-93 fl 87 fl Normal
WBC 3.2-10.6 x10^3/mm^3 11.1 x10^3/mm^3 Tissue Injury post-op
RBC 3.9-5.5 x10^3/mm^3 4.9 x10^3/mm^3 Normal
Ferritin 30-320 ng/ml 16 ng/ml Low Iron Intake

3. PT 12.0-15.5 sec. 15 sec. Normal
Vitamin D 15-75 ng/ml 22.7 ng/ml Normal
2.) What are potential consequences of Crohns Disease?
Crohn’s disease is inflammation and scarring of the small intestine and
untreated can cause ulceration, scarring and narrowing of the lumen. Crohn’s is a
transmural disease; it affects layers of tissues, which can cause long-term damage to
GI. Stenosis in lumen may result in ileum obstruction. Fistula may form, which may
result in overgrowth of bacteria, and subsequently, malabsorption. Tubal feeding
and even TPN may result if symptoms are severe enough.
3.) Why was Mr. S prescribed a low fiber diet in the period following diagnosis?
Fiber can be hard to digest and can cause abdominal pain. Fiber extends
motility of food through the GI and in turn, can increase inflammation. Less fiber
may also decrease mass of stool, which can decease pain in colon.
4.) Is Mr. S a candidate for SBS? Explain your rational.
Yes, Mr. S is a candidate for SBS. SBS is the inability to maintain nutrition and
hydration needs with normal fluid and food intake, regardless of bowel length.
Common complications of SBS include malabsorption of micronutrient and
macronutrients, frequent diarrhea, and weight loss, all symptoms of which Mr. S is
showing.
5.) If a patient develops SBS subsequent to surgery, what is the recommended MNT?
 Small and frequent meals
 Whole nutrients (50% CHO, 20-30% PRO, <40% fat)
 Avoid lactose, large amounts of concentrated sweets and
caffeine
 Limit dietary fat; substiture more MCT
 Low fiber intake
 Oral supplements of calcium, magnesium and zinc.
6.) Calculate Mr. S’s energy and protein requirement post-op.
About 35 kcal/kg body weight/day
35 kcal x 63.5 kg = 2222.5 kcals/day via TPN
At least a minimum of 1.5g protein/Kg body weight/day
1.5g protein x 63.5 kg = 95.25 grams of protein/day via TPN

4. 7.) How will you adjust this requirement when he begins to eat solid food? What
will you monitor?
Once Mr. S begins to eat solid foods, I would advise him to eat small and
frequent meals, but not more than his body can handle because it may cause more
malabsorption. Medication may be prescribed to slow GI motility, decease secretion,
or treat bacterial growth. Mr. S will be educated on the importance on MCT.
Assessment should quantify dietary intake as well as stool and urine output over 24
hours. We will monitor his albumin levels as well as his electrolyte levels to verify
absorption.
8.) ADIME
Nutritional Assessment:
35 y/o male. Ht: 5’9” Wt: 140 lbs (63.5 Kg) (166 lbs. before illness). BMI: 20.7
Wt. hx: 15.7% unintended weight loss. Temp: 101.5 F BP: 125/82 HR: 81 bpm RR: 18
Mr. S has experienced recent unintended weight loss (15%) due to malnutrition
and inadequate protein intake. Takes multivitamin daily, denies alcohol and tobacco use.
Mr. S requires an increase in protein (82.5-95.2g), calories (2200-2540 calories), fluid
intake (1000ml-2000ml/day), and multivitamin supplement (equations shown below).
Mr. S reports a healthy diet usually, with the month as an exception. Milk allergy and had
been on a low fiber diet. Mr. S was diagnosed with hypertension 3 years ago then the
Crohn’s disease 6 months later. He has been experiencing diarrhea and pain in the RUQ,
LUQ, RLQ, LLQ, and was admitted for partial resection of bowel. Rx is Mesalamine, but
had planned to take Humire. Mr. S is married, lives at home with him wife and son (age
5).
 Unintended weight loss: (Nutrition Problem Focus)
166 lbs – 140 lbs / 166lbs x 100 = 15.7% unintended weight loss
 Kcals recommendation:
35 – 40 Kcal/Kg/day
35 Kcal x 63.5 Kg = 2222.5 Kcals/day
40 Kcal x 63.5 Kg = 2540 Kcals/day
~2222.5 – 2540 Kcals/day
 Protein recommendation:
1.3 – 1.5 g/Kg to maintain N balance
1.3 g x 63.5 Kg = 82.5 g of protein/day

5. 1.5 g x 63.5 Kg = 95.2g of protein/day
~82.5 – 95.2 g of protein/day
 Fluids recommendation
1-2 L/day (1000 – 2000 ml/day)
Diagnosis:
Disordered eating pattern (NB-1.5) R/T poor appetite AEB daily multivitamin
supplementation without consistent food intake. Altered GI function (NC-1.4) R/T
Crohn’s disease AEB episodes of diarrhea, weight loss and food allergy.
Intervention
(Clinical):
Education is the form of intervention. He will be educated about the adverse effects and
benefits of certain foods (ie what to avoid and what to consume). Mr. S will be advised to
reintroduce small and frequent meals high in calories, low in fat (high MCT), and protein.
No lactose or dairy food. I recommend Mr.S to eat seafood as a good source of omega-3
for his inflammation (1 ounce salmon=~5.7g protein) and foods cooked with coconut or
palm kernel oil (high in MCT). Mr. S is advised to divided the number of meals he is able
to eat a day by the previously calorie and protein recommendations, while consciously
eating whole grain and wholesome foods. It is important that Mr. S eats foods that he
enjoys eating. Mr. S is recommended to keep a food diary of all the foods and fluids he
eats so he is more conscious of reaching these goals and we can assess his recovery based
off his food and liquid consumption. Based off his food diary and results, I can further
assess diet to regain desired weight. If weigh gain isn’t achieved then enteral support may
be prescribed (Ensure or Boost-lactose free) or even PN.
(Behavioral)
Due to the severe symptoms of diarrhea and abdominal pain that Mr. S experiences, this
may have had a significant effect on his unintended weight loss. I don’t recommend too
much fiber because that may also cause discomfort, but I would like to see his diet be
diversified with legumes (~4-5g/1 cup), and proteins like chicken (1 ounce=7g protein).
Journal of the Academy of Nutrition recommends peppermint oil, prebiotics and also
soluble fiber to help with symptoms. A multivitamin with folate, B6 and B12 (for
digestion aid); zinc, potassium and selenium (for aggregated loss from diarrhea). Food
diary is advised with how Mr. S felt after consuming that particular food.
Monitoring and Evaluation:
(Clinical)
Not only will Mr. S be educated on what to eat, portion size and how to keep a
food log but so will his wife. With a slow introduction of solids foods, it’s important to
consume consciously and document everything, including the after affects because diet is

6. an environmental factor that may trigger relapse. We need Mr. S to reach his
recommended macronutrients to regain weight and a food diary will help us reach this
goal. With his food diet we can monitor calorie, protein, CHO, lipid and water
consumption. I encourage Mr. S to continue taking a multivitamin and hydrate through
water or foods with high water content (ie Boost/Ensure, soups, sauce, etc.).Stool and
urine samples may be collected if necessary.
(Behavioral)
A food diary is recommended with details of how certain foods made him feel
immediately after and 1-2 hours after, until he consumes his next small meal. This way
we can evaluate what foods, liquids, medication or even vitamins are triggering
symptoms. Once certain trends occur that trigger symptoms, we will reevaluate his diet
and take out the food that seems to be upsetting his GI. If symptoms don’t subside,
corticosteroid, anti-inflammatory agent, immunosuppressant agent or antibiotic may be
prescribed. Stool and urine samples may be collected. Sigmoidoscopy, colonoscopy, CT
enterography, MR enterography or capsule endoscopy may also be assessed for
inflammation, fistulas, blockages or tearing that may be causing pain.
Work Cited:
Heizer, William D., Susannah Southern, and Susan McGovern. 'The Role Of
Diet In Symptoms Of Irritable Bowel Syndrome In Adults: A Narrative Review'.
Journal of the American Dietetic Association 109.7 (2009): 1204-1214. Web. 25 Sept.
2015.