Question

M.K. is a 22-year-old male who comes to the health care provider for complaints of frequent diarrhea and abdominal pain. He had appendicitis with appendectomy at age 9. He currently takes no medications.

Subjective Data

• Frequently has abdominal pain and diarrhea

Objective Data

Physical Examination

• Temperature 99.9° F, pulse 78, respirations 16, blood pressure 114/62
• Height 5’3”, weight 100 lb, BMI 17.7 kg/m²

Diagnostic Studies

• Lab values
  • WBC                      11,600/µL
  • RBC                        3.4 million/µL
  • Hematocrit         33%
  • Hemoglobin       10 g/dL
  • Platelets              190,000/µL
  • ESR                         34 mm/hr
  • Sodium                 132 mEq/L
  • Potassium           3.2 mEq/L
  • HCO₃                     25.4 mEq/L
  • Chloride               99.5 Eq/L
  • Fecal occult blood tests negative

Discussion Questions

1. Describe the assessment you need to perform to determine what may be occurring with M.K.

2. Based on M.K.’s clinical manifestations and lab results, the health care provider suspects inflammatory bowel disease. Why?

3. What additional diagnostic studies may be ordered to confirm this diagnosis?

4. M.K. has a colonoscopy, which is normal, with no signs of disease or inflammation. He continues to have frequent abdominal pain and diarrhea and a 5-lb weight loss over the next two weeks. The health care provider then orders a capsule endoscopy. What is the rationale behind ordering a capsule endoscopy?

5. The capsule endoscopy results show areas of inflammation interspersed with areas of healthy tissue in the terminal ileum. These findings are characteristic of what disease?

6. Based on the diagnostic results, what is the most likely cause of M.K.’s anemia?

7. The health care provider prescribes mesalamine for M.K.’s inflammatory bowel disease. What does this medication do and how will it be administered?

8. What are the goals of nutritional therapy for patients with inflammatory bowel disease?

9. Describe three teaching points you could use to assist M.K. in improving his nutritional status.

Answer 1

1. Assessment includes history reagrding the frequency and typical duration of symptoms, observed aggravating and relieving factors, family history of similar illnesses. Patient will also have to undergo investigations like colonoscopy.

2. Inflammatory bowel disease is thought to be due to a disproportionate immune response within the bowel. The mojor types are Crohn's disease and ulcerative Colitis. The symptoms include abdominal cramps, fever, diarrhoea with mucoid or bloody stools which is present in this patient. Since the patient has multiple episodes, it is unlikely to be of infectious etiology. The WBC counts are elevated along with ESR and this too points to an inflammatory condition.

3. Complete blood count and ESR are already done. The patient will also need vit B12 assay, iron studies, stool culture to rule out chronic infections. Imaging studies including USG abdomen, CT and endoscopy will also help reach a diagnosis. Endoscopy is the most important among these.

4. The patient might be suffering from Crohn's disease which can have 'skip lesions'. This means that parts of diseased bowel may be alternatively present alongside normal bowel. This can be missed in routine endoscopy which only explores the large bowel.

5. Skip lesions are a feature of Crohn's disease.

6. Anemia is most likely due to chronic blood loss which leads to an iron deficient state.

7.Meslamine is usually give oorally along with meals in Crohn's. Off-laber rectal route is also done. It reduces the bowel inflammation.

8. Ensure adequate protein, calorie and micronutrient deficiences. Give the bowel time to heal and avoid trigger foods.

9. Avoid trigger foods that the patient has noticed to worsen his illness. . Eat regular meals. Ensure adequate protein and calorie intake. Take supplements to counter malabsorption. Avoid alcohol, caffeineted drinks and foods that are high in fiber.