Question

Crohn's Disease

           TC is district manager for a national flooring company. She travels weekly for her job. She is 38 years old.She was admitted to the hospital for weakness, severe abd pain and distention. She is 5'7" and weighs 100 lb on admission. She reports a weight loss of about 35 lb since her most recent small bowel resection for Crohn's disease, about 6 months ago. She reports that she can only tolerate 2-3 bites of food at a time, but tries to eat as often as possible which is 3-4 times daily. She is tired and lethargic and is considering taking a medical leave of absence from work because she is having a hard time keeping up with her travel schedule. The Gastrointestinal doctor diagnoses the patient with Short Gut Syndrome: she has 3 feet of small intestine left after her most recent bowel resection. On further evaluation, she is noted to have a SBO on admission. Because of her medical history, conservative management of the SBO is discussed and a NG tube to suction for decompression is placed. She is started on corticosteroids, normal saline (IVF) at 75ml/hr (x24hr), ciprofloxacin and azathioprine. The medical team has consulted the RDN (you) for a recommendation for long term TPN. The patient is scheduled to have a central line placed.

Her current labs are as follows:

Glucose: 110 mg/dl

Albumin: 2.5 mg/dl

Hemoglobin: 9 mg/dl

Hematocrit: 32%

PAB: 10 mg/dl

1.    Calculate the following and interpret the results

IBW               %IBW            %UBW           BMI

2.    Calculate TC's kcal, protein and fluid needs. (Use Mifflin St Joer or Harris Benedict Equation). Be sure to use an appropriate SF/AF. Justify your answers.

3.    Based on her history and laboratory values, what do you conclude regarding her nutritional status/risk?

4.    Describe the action and potential side effects of each of the following: corticosteroids, IVF, ciprofloxacin and azathioprine.

5.    Would performing a NPFE be helpful? Why or why not?

6.    She may experience nausea/vomiting, weight loss, malabsorption, anemia, and bone disease. Why might each of these occur?

           

           

7.    Are there any other vitamin or mineral issues that the RDN should consider? Why?

8.    Why is the medical team recommending TPN and not TF? Do you agree with this course of action? Why or why not?

9.    Do you anticipate that TC will ever be able to meet her needs by oral intake alone? Why or why not?

10. Assume she gets 25 % of her calorie and protein needs met from food eaten during the day. Recommend nutrition support to meet the remainder of her protein, calorie and fluid needs. Show your work. (write the actual TPN prescription)

11. Write sample menu for her providing 25% of her estimated kcal, protein and fluid needs

12. Write PES statement appropriate for TC.

Answer 1

Ans -1}

• IBW - Male  IBW = 50 kg + 2.3 kg for each inch over 5 feet. Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet. The IBW and ABW are used to calculate medication dosages when the patient is obese.

• % IBW - (Actual body weight/Ideal body weight) × 100 = % IBW

Eg. :- woman who is 5'2" and wt. 125 pound ( 125/110)× 100= 113% IBW .

• % UBW - percent UBW = current body weight/UBW x 100.

• BMI = kg/m2 where kg is a person's weight in kilograms and m2 is their height in metres squared. A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9.

Ans -2} TC's kcal and fluid needs are :-

The formula is Energy (in Kcal) = 4x (Proteins and carbohydrates mass in grams) + 9 x mass of fat in grams.

Maintenance Fluid Calculation for Children

1. For infants 3.5 to 10 kg the daily fluid requirement is 100 mL/kg.
2. For children 11-20 kg the daily fluid requirement is 1000 mL + 50 mL/kg for every kg over 10.
3. For children > 20 kg the daily fluid requirement is 1500 mL + 20 mL/kg for every kg over 20, up to a maximum of 2400 mL daily.

Ans-3} conclusion :- Many symptoms can signal problems with the GI tract, including: abdominal pain, blood in the stool, bloating, constipation, diarrhea, heartburn, incontinence, nausea and vomiting and difficulty swallowing, according to the NIH. Among the most widely known diseases of the digestive system is colon cancer.

Ans-4} Action and potential side effects are -

# corticosteroid :- Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones.

Side effects -

• osteoporosis (fragile bones),
• hypertension (high blood pressure)
• diabetes
• weight gain
• increased vulnerability to infection
• cataracts and glaucoma (eye disorders)
• thinning of the skin
• bruising easily

# IVF :- IVF works by using a combination of medicines and surgical procedures to help sperm fertilize an egg, and help the fertilized egg implant in your uterus. First, you take medication that makes several of your eggs mature and ready for fertilization.

Side effects -

allergic reactions

vaginal bleeding

blood in urine, bloating

breast tenderness

bruising from shots

cramping,

headaches

infection

pelvic pain

constipation or mood swings.

# Ciprofloxacin :- Ciprofloxacin acts on bacterial topoisomerase II (DNA gyrase) and topoisomerase IV.Ciprofloxacin is a broad-spectrum antibiotic of the fluoroquinolone class. It is active against some Gram-positive and many Gram-negative bacteria.

Side effects -

• nausea.
• vomiting.
• stomach pain.
• heartburn.
• diarrhea.
• vaginal itching and/or discharge.
• pale skin.
• unusual tiredness.

# Azathioprine :- It is used in rheumatoid arthritis, granulomatosis with polyangiitis, Crohn's disease, ulcerative colitis, systemic lupus erythematosus, and in kidney transplants to prevent rejection.

Side effects -

• diarrhea.
• rash.
• fever.
• tiredness.
• muscle aches.
• liver damage.
• dizziness.
• low blood pressure.