Inflammatory Bowel disease: Ulcerative Colitis Sarah Hallaj May 24th 2010 Outline Present my patient Nutrition assessment Tests Ulcerative colitis Trivia questions Nutrition focused physical examination:
PICTURES! Nutrition intervention, monitoring & evaluation Nutrition Assessment Client history Social history: 28 year old white male who migrated from Ukraine, Eastern Europe with the rest of his family. He was a carpenter but
is now unemployed with no insurance. He lives with his 2 sisters who usually do the cooking at home. His parents and brother were present at his hospital stay. Admit date: 2/3/2010 Chief complaint: Diarrhea ( hematochezia: bloody soft stools) & weight loss of 23kg in 2 months Initial diagnosis:
Anal fissure & cachexia Outpatient gastroenterology consultation Patient became ill in November 2009 with slow progressive worsening of his symptoms Patient was having over 15 bowel movements a day, sometimes awakening him from sleep at night He noted his inability to eat and eventually lost 23 kg Stool studies were negative for any enteric
pathogens, C. Diff, and Giardia antigen Endoscopic evaluation was consulted but refused because of financial concerns and Medication list in November 2009 Mesalamine : anti-inflammatory (for ulcerative colitis or Cronhs disease), oral Rowasa enemas: anti-inflammatory (for ulcerative colitis or Cronhs disease), rectal Prednisone (corticosteroids): antiinflammatory, immunosuppressant Loperamide: anti-diarrheal
Sulfasalazine: treats RA or rectal bleeding and diarrhea from ulcerative colitis Anthropometric measurements Height: 6ft 0in Weight: 48.44 kg BMI: 14.5 IBW: 72.3 kg % IBW: 67 % Weight history: 72 kg in November 2009 33 % of weight loss in 2 months
ICD-9 code Malnutrition coding reference from Providence Health & Service ICD-9 Code: Other severe, protein-calorie malnutrition: Criteria Currently at: Weight < 85%
67% of IBW Severe weight loss >7.5% in 3 months 33 % weight loss in 2 months Depressed visceral protein Albumin 2.4 mg/dL stores Prealbumin 11 mg/dL
Signs of muscle wasting Arms, legs, chest, and temples Underweight, BMI <19 BMI: 14.5 Food/nutrition-related history Prior to Nov. 09 patient was consuming over
2500 kcal/day Prior to hospitalization patient would consume moms cooked meals 5-6 small meals ~ 1300-1400 kcal/day Due to inadequate oral intake, added ensure supplement and started patient on calorie count Estimated Energy requirements Using the Mifflin equation: 1650 kcal (34 kcal/kg)
Added 200 kcal for weight gain Total = 1850 kcal/day (38 kcal/kg) Protein requirements=58.1- 72.7 g/day (1.21.5 g/kg ) Biochemical data Days PO4 K+ Mg
Day 2 2/4/10 Album in Prealb umin Hemo globin
Weigh t (kg) 2.4 11.0 10 48.44
Day 3 2/5/10 2.2 WNL WNL 49.2 Day 5
2/7/10 WNL WNL WNL 50.00 Day 6 2/8/10
3.6 4.2 1.8 Day 8 3.2 d/c 2/10/10
4.3 2.3 Refere PO4 nce mg/ range dL 2.3- 2.4
11.0 10.6 K+ mmol /L Mg mg/ dL
Albu min mg/ dL Prealbumi n mg/dL Hemoglobi n gm/dL
Hospital Hospital Hospital day day day day 2: 3: 4:
5: 844 kcal/day & 27 gm Pro 2947 kcal & 116 gm Pro 2872 kcal & 117 gm Pro 3000 kcal & 97 gm Pro Current diet order: General Refeeding syndrome Is defined as: severe electrolyte and fluid
shifts associated with metabolic abnormalities in malnourished patients refeeding either orally, parentally or enterally. Due to patients low phosphorus, he was at risk of refeeding syndrome Tests: Sigmoidoscopy Magnetic Resonance Elastography (MRE) Chest x-ray: normal Human immunodeficieny virus (HIV):
negative Hepatitis B surface antigen: non-reactive Stool output: no ova or parasites Quantiferon gold: false positive (BCG vaccination) TSH & T4: WNL What is Sigmoidoscopy? Is when a doctor inserts an endoscope (a long, flexible, lighted tube connected to a computer and TV monitor) into
the anus to see the inside of the colon and rectum. The doctor will be able to see any inflammation, bleeding, or ulcers on the colon wall. What is Magnetic Resonance Elastography (MRE)? Phase-contrast-based MRI imaging technique that can directly visualize and quantitatively measure propagating acoustic strain waves in tissue-like materials subjected to harmonic mechanical excitation.
Produces color-coded images known as elastograms that indicate tissue elasticity or stiffness. This is significant because during a physical examination, palpation can be effective in detecting tumors, but is restricted to parts of the body that are not accessible to the Results Sigmoidoscopy showed severely inflamed tissue up to 40cm and 3 circular punched out
ulcers in the rectum MRE showed gastric distention & thickwalled inflamed rectosigmoid colon MD Diagnosis Inflammatory bowel disease Ulcerative colitis Inflammatory Bowel Disease (IBD) Is a general name for
diseases that cause inflammation in the small intestine and colon. It can be difficult to diagnose because its symptoms are similar to other intestinal disorders. Two types of IBD include: ulcerative colitis and Crohns disease
What is ulcerative colitis Is a disease that causes chronic inflammation and ulcers in the lining of the rectum and colon. Ulcers form where inflammation has killed the cells that usually line the colon, then bleed and produce pus. Inflammation in the colon also causes the colon to empty frequently, causing diarrhea and abdominal pain. When the inflammation occurs in the rectum and
lower part of the colon it is called ulcerative proctitis. If the entire colon is affected it is called pancolitis. If only the left side of the colon is affected it is called left-sided or distal colitis. Symptoms of ulcerative colitis Anemia Fatigue Weight loss Loss of appetite Rectal bleeding
Loss of body fluids and nutrient => diarrhea Skin lesions Joint pain Growth failure (esp. in children) Ulcerative colitis complications: Toxic megacolon: life-threatening complication Cancer If all fails
Surgery to remove part or all of the colon Removing the entire colon cures ulcerative colitis Ileal Pouch-Anal Anastomosis (IPAA): Allows the patient to have normal bowel movements http://www.mayoclinic.org/colostomy-sparing-surgery/ipaa.html IPAA contd
IPAA might not be appropriate for each patient It depends on the severity of the disease & the patients needs, expectations and lifestyle QUESTIONS Who is affected by ulcerative colitis? Who is affected by ulcerative
colitis? It can occur in people of any age, but usually starts between the ages of 15 and 30, and less frequently between 50 and 70 years of age. It affects men and women equally and appears to run in families. A higher incidence of ulcerative colitis is seen in Whites and people of Jewish descent. True or false? Ulcerative colitis is caused by emotional
distress and/or sensitivity of certain food products Nutrition Diagnosis PES Statements Inadequate protein-energy intake related to altered GI function as evidenced by altered nutrition-related lab values: albumin 2.4 mg/ dL, hemoglobin 10 gm/dL and bloody diarrhea
Malnutrition related to involuntary weight loss as evidenced by 33% weight loss in 2 months & 67% IBW Nutrition-focused physical findings Physical appearance Muscle and fat wasting: temple, chest and extremities Nutrition Intervention Placed calorie count order
Added ensure supplement Nutrition education: educated patient on low residue diet per MD order and provided handout from American Dietetic Association Coordination of nutrition care: talked with nurses to assure daily weights Answered patients questions ADA Low residue diet: Recommended foods: Yogurt, cheese, soy milk, rice milk, or almond
milk Tender, ground, & well cooked beef & other protein foods (tofu, fish, eggs, smooth nut butters) Refined white grains Well-cooked vegetables Peeled fruits & fruit juices w/out pulp EAL recommends: Consuming a diet with > 15 g/day of fermentable fiber resulted in improvements in
immunosuppressant Ferrous sulfate (325 mg) w/ vitamin C: treats iron-anemia deficiency Remicade (infliximab/etanercept): antiarthritic, Crohns disease/ ulcerative colitis treatment What nutrition interventions would you suggest to address nutrition issues caused by long term use of prednisone? Suggest including a calcium with vitamin D supplement
References Refeeding Syndrome- Awareness, Prevention and Management 1:4 (2009): 1495-
498. Head and Neck Oncology. BioMed Central, 26 Jan. 2009. Web. 15 May 2010. . Ulcerative Colitis. National Institute of Health, Feb. 2006. Web. 15 May 2010. . Medical Imaging Analysis 5.4 (2001): 237-54. Science Direct. Web. 15 May 2010. . CANNOM, REBECCA R., et al. "Inflammatory Bowel Disease in the United States from 1998 to 2005: Has Infliximab Affected Surgical Rates?." American Surgeon
75.10 (2009): 976-980. Academic Search Premier. EBSCO. Web. 17 May 2010. http://proxy.library.oregonstate.edu/login?url=http://search.ebscohost.com/login.aspx ?direct=true&db=aph&AN=44682704&loginpage=Login.asp&site=ehost-live . Eat Right. American Dietetic Association, 1 July 2008. Web. 21 May 2010. . Food Medication Interactions. 15th ed. Birchrunville: Food-Medication Interactions, 2008. Print.
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