Mr. S is a 35-year-old male admitted for partial bowel resection due to an abscess and exacerbation of Crohn's disease. His history and physical findings are consistent with Crohn's, including weight loss, diarrhea, abdominal pain, and fever. Nutritional consequences of Crohn's include protein and calorie deficits from poor appetite and malabsorption. He was previously prescribed a low-fiber diet to prevent bowel obstruction from stenosis. He is at risk for short bowel syndrome if a large portion of his small intestine is removed. Post-surgery, he will require enteral nutrition and monitoring of prealbumin levels to determine if nutritional needs are being met during adaptation.

1. Matt S is a 35 y/o male presented with acute severe RUQ, LUQ, RLQ, LLQ pain
secondary to abscess and acute exacerbation of Crohn’s Disease. Admitted for partial
resection of bowel.
History: Diagnosed with Crohn’s Disease 2 ½ years ago. Recently had episodes of
diarrhea accompanied by abdominal pain. Hypertension diagnosed 3 years ago. Denies
smoking and alcohol use.
Anthropometric: Ht: 5’ 9” Wt: 140# Usual weight before illness: 166#
Temperature: 101.5 BP: 125/82 HR: 81 bpm RR: 18
Medications (Home): Mesalamine (Had planned to initiate Humira)
Social: Married, lives at home with wife and son age 5. Denies alcohol use, smoking.
Nutrition: Reports fairly good appetite for last year but poor the past month. Lost almost
25 pounds after hospitalization 2 ½ years ago and had regained it. Now has lost it again.
Allergic to milk. Followed low-fiber diet for several months after initial. Takes
multivitamin supplement daily.
Diet Order: NPO with TPN post operatively
Laboratory: Blood Lipid Panel:
Albumin 3.2 g/dl Cholesterol 149 mg/dl
Prealbumin 11.0 mg/dl LDL-c 101 mg/dl
Glucose 82 mg/dl HDL-c 48 mg/dl
Na+ 136 mEq/L CBC:
K+ 3.7 mEq/L Hgb 12.9 g/dl
Cl- 101 mEq/L Hct 38.9%
Creat 1.8 mg/dl MCV 87 fl
BUN 11 mg/dl WBC 11.1x103
/mm3
AST 35 U/L RBC 4.9x106
/mm3
ALT 22 U/L Ferritin 16 ng/ml
Alk Phos 120 U/L PT 15 sec
CRP 2.8 mg/dl Vit D 22.7 ng/ml

2. Questions:
1. What in Mr. S’s history and physical findings are consistent with the diagnosis of
Crohn’s? The components of Mr. S’s history and physical findings that are consistent
with Crohn’s include: high CRP lab values, unexplained weight loss, diarrhea, abdominal
pain, and fever.
2. What are the potential nutritional consequences of Crohn’s Disease? There are
many potential nutritional consequences of Crohn’s Disease. These consequences
Lab Test Patient Value Normal Range Reason for Deviation
Albumin 3.2 g/dL 3.5-5 g/dL (Low) edema, malabsorption,
diarrhea, malnutrition, low protein
intake, stress
Prealbumin 11.0 mg/dL 18-38 mg/dL (Low) acute catabolic states, stress,
infection, surgery, malnutrition, low
protein intake
Glucose 82 mg/dL 70-99 mg/dL WNL
Sodium 136 mEq/L 135-145 mEq/L WNL
Potassium 3.7 mEq/L 3.5-5 mEq/L WNL
Chloride 101 mEq/L 98-107 mEq/L WNL
Creatinine 1.8 mg/dL 0.4-1.2 mg/dL (High) muscle damage, starvation,
acute and chronic renal disease
BUN 11 mg/dL 8-23 mg/dL WNL
AST 35 U/L 10-37 U/L WNL
ALT 22 U/L 4-40 U/L WNL
Alkaline
Phosphatase
120 U/L 40-120 U/L WNL
C-Reactive
Protein
2.8 mg/dL <0.8 mg/dL (High) arterial inflammation,
bacterial infection, Crohn’s Disease
Cholesterol 149 mg/dL 120-199 mg/dL WNL
LDL
Cholesterol
101 mg/dL <100 mg/dL (High) high fat diet, acute trauma
HDL
Cholesterol
48 mg/dL <40 mg/dL=low
>60 mg/dL= high
WNL
Hemoglobin 12.9 g/dL 14.6-17.5 g/dL (Low) anemia, many systemic
diseases
Hematocrit 38.9% 41-51% (Low) anemia, blood loss, hemolysis,
over hydration
MCV 87 um^3 78-93 um^3 WNL
WBC 11.1
x10^3/mm^3
3.2x10^3 -10.6
x10^3/mm^3
(High) bacterial infection,
hemorrhage, trauma or tissue injury
RBC 4.9
x10^6/mm^3
4.6-
6.1x10^6/mm^3
WNL
Ferritin 16 ng/mL 30-320 ng/mL (Low) Iron deficiency anemia
PT 15 sec 12.0-15.5 sec WNL
Vitamin D 22.7 ng/mL 20-80 ng/mL WNL

3. include: insufficient protein and calorie intake due to decreased appetite and/or avoiding
meals because of fear of pain, malnourishment, protein losses from possible fistulas, and
also negative nutritional effects of treatment with corticosteroids. These negative effects
from treatment with corticosteroids include: glucose intolerance, protein catabolism, and
excessive calcium and potassium loss.
3. Why was Mr. S previously prescribed a low fiber diet in the period following
diagnosis? Mr. S was most likely prescribed a low fiber diet due to stenosis in the bowel.
Stenosis is the narrowing of the intestinal lumen, therefore, in order to keep things
properly moving through if the lumen is narrow it is important to eat things that are thin
enough to pass easily through the small lumen. Fiber is avoided because it is thick and
could easily cause a blockage in a narrow lumen.
4. Is Mr. S a candidate for short bowel syndrome (SBS)? Explain your rationale. Mr.
S may be a candidate for short bowel syndrome if the doctors remove around 65-75% or
more of the small intestine. The patient was admitted for partial resection of the bowel
therefore has some sort of risk for short bowel syndrome. Crohn’s disease mainly affects
the small intestine so if the patient was coming in for a partial resection of the bowel it
would be a partial resection of the small intestine to help with the Crohn’s disease.
5. If patient develops SBS subsequent to surgery, what is the recommended MNT?
He will be NPO and on TPN for 7-10 days before transitioning to solid foods.
Discuss MNT during the adaptation period and then after adaptation.
Recommended MNT for the patient during the adaptation period is elemental tube
feeding with small amounts of solid foods in order to maintain bowel function. The tube
feeding is needed to maintain nutrient intake and can usually be done throughout the
night to properly supplement the nutritional needs of the patient. Trophic hormones such
as gastrin and enteroglucagon, nutrients such as glutamine and EFAs, and drugs such as
PG anaglogues, spermine and spermidine all are things that stimulate adaptation. After
the adaptation period MNT would be to restrict fluids with meals, lactose free diet due to
patient’s milk allergy, low fiber, 35-40 kcal/Kg, 1.5 g of protein/Kg/day, and oral
supplements for Ca, Mg, and Zn.
6. Calculate Mr. S’s energy and protein requirements post-op (when he is on TPN).
Energy Requirements: 2,038 Kcal/day (Mifflinx1.3)
Protein Requirements: 95g/Kg/day (1.5 g/Kg due to stress from surgery)
7. How will you adjust this requirement when he begins to eat solid food (assume
SBS)? What will you monitor to determine if this is correct? To adjust this
requirement when the patient begins to eat solid foods, the recommedation would be to
increase Kcal requirements 2,240 Kcal/day following the MNT recommendations for
SBS as 35-40 Kcal/day. Protein would continue to be 95g/Kg/day or 1.5gpro/Kg. To
monitor if protein and energy requirements are correct or not, one would monitor
prealbumin levels.
Assessment:
35 y/o Male Dx: Crohn’s Disease 2 ½ years ago, hypertension 3 years ago
Ht: 5’9” Wt: 140lbs BMI: 20.7 (normal)
Wt hx: unexplained weight loss of 26lbs

4. Current complaint: pain secondary to abscess, acute exacerbation of Crohn’s Disease,
episodes of diarrhea, abdominal pain, acute severe RUQ, LUQ, RLQ, and LLQ pain
Physical exam: 101.5 temperature, HR 81 bpm, RR 18
Nutritional Needs:
Energy: 2, 038 Kcal/day (Mifflinx1.3)
Protein: 95g/Kg/day (1.5 g/Kg due to stress from surgery)
Social: married, lives at home with wife and son- age 5
Labs: ALB 3.2 g/dL (low), Pre-Albumin 11.0 mg/dL (low), glucose 82 mg/dL (normal),
Na+ 136 mEq/L (normal), K+ 3.7 mEq/L (normal), Cl- 101 mEq/L (normal), Creat 1.8
mEq/L (high), BUN 11 mg/dL (normal), AST 35 U/L (normal), ALT 22 U/L (normal),
Alk Phos 120 U/L (normal), CRP 2.8 mg/dL (high), Cholesterol 149 mg/dL (normal),
LDL 101 mg/dL (high), HDL 48 mg/dL (normal), Hgb 12.9 g/dL (low), Hct 38.9% (low),
MCV 87 um^3 (normal), WBC 11.1x10^3/mm^3 (high), RBC 4.9x10^6/mm^3 (normal),
Ferritin 16 ng/mL (low), PT 15 sec (normal), Vit D 22.7 ng/mL (normal)
Meds (Home): Mesalamine (anti-inflammatory in Crohn’s), and had planned to initiate
Humira, also takes daily multivitamin supplement. (Symptoms from oral intake of
Mesalamine could include abdominal cramping, diarrhea, and more.)
Nutritional Information:
Reports fairly good appetite for last year, poor last month. Allergic to milk. Prescribed
low-fiber diet, followed for several months after. Denies smoking, alcohol use, takes
multivitamin supplement daily.
Clinical Diagnosis:
Altered GI function (NC-1.4) r/t Crohn’s Disease AEB medical dx and hx, diarrhea,
abdominal pain, fever, unexplained weight loss, high CRP lab values.
Intervention:
1. Focus on sufficient protein and sufficient kcal intake in order to maintain weight
and nutritional health status.
2. Suggest outpatient follow-up appointment with doctor. Conduct interview to see
if patient’s symptoms have dissipated.
3. Educate the patient again on the importance of a low fiber and lactose free diet
with Crohn’s disease.
Monitoring/ Evaluation:
1. Evaluate interview from outpatient appointment with medical doctor in order to
see possible improvements.
2. Have patient record 48-hour diet recall in order to monitor proper eating habits.

5. Behavioral Diagnosis:
Low adherence to nutrition-related recommendations (NB-1.6) r/t recent recurrence of
episodic symptoms AEB recent unexplained weight loss, abdominal pain, and diarrhea.
Intervention:
1. Educate the patient on the importance of adherence to a supportive diet for
Crohn’s disease.
2. Create goals for the patient to achieve related to proper diet with Crohn’s disease.
Monitoring/ Evaluation:
1. Require a 48-hour diet recall to monitor patient’s adherence to diet
recommendations.
2. Patient interview over the phone to ask patient about working towards their
written goals, and achievements of short-term goals.

6. Reference:
Massironi, S., Rossi, R. E., Cavalcoli, F.A., Valle, S.D., Fraquelli, M., & Conte, D.
Nutritional deficiencies in inflammatory bowel disease: Therapeutic approaches.
Clinical Nutrition. 2013;32(6)
Summary
Background & aims
Malnutrition is common in inflammatory bowel diseases (IBD), mainly in Crohn's
disease (CD) because the small bowel is primarily affected. We reviewed the literature to
highlight the importance of proper nutrition management.
Methods
A PubMed search was performed for English-language publications from 1999 through
2012. Manuscripts comparing nutritional approaches for IBD patients were selected.
Results
We identified 2025 manuscripts: six meta-analyses, 170 clinical-trials, 692 reviews. The
study findings are discordant. In adult CD, enteral nutrition plays a supportive role,
steroid therapy remaining the first choice treatment. In CD children enteral nutrition may
represent the primary therapy. As regards parenteral nutrition, there are no large
randomized studies, although mild improvements in morbidity have been described as a
result of parenteral nutrition in malnourished surgical IBD patients. Specific
micronutrient deficiencies are common in IBD. A number of factors may contribute to
micronutrient deficiencies, and these include: dietary restriction, disease activity and
surgery.
The possible therapeutic roles of omega-3 fatty-acids, probiotics and prebiotics have been
studied, but the results are still preliminary.
Conclusion
Protein-energy malnutrition and micronutrient depletion are clinical concerns in IBD
patients. Enteral nutrition, parenteral nutrition and micronutrient supplementation are
cornerstone of the multidisciplinary management of IBD patients.
I chose this article because it discusses the nutritional issues related to IBD but
focuses mainly on Crohn’s disease. It talks about the nutrients one loses with Crohn’s and
the importance of supplementing these deficiencies back into the patient with diet.