Case Report: Nutrition Support and Colorectal Cancer

Carli Onksen, MS
Aramark Dietetic Internship
ABC Hospital
3/9/14

2

Abstract:
Colon cancer is a prevalent cause of cancer death in the United States. Many patients
who are diagnosed with colon cancer will undergo surgery to remove the cancerous tumors as
well as a portion of the large intestine. Removal of the colon can cause a decrease in nutrient
absorption for some macro and micronutrients. In other cases, surgical complications can lead
to critical illness that requires the use of enteral and/or parenteral nutrition to help meet
nutrient needs. Artificial nutrition can be effective at reducing malnutrition. This case study
describes in detail that nutrition care process (NCP) relating to a patient with colon cancer who
underwent a partial colon resection with post-operative complications leading to critical illness
requiring both enteral and parenteral nutrition. Enteral nutrition was required to help meet
nutrient needs while the patient was NPO after surgery. Parenteral nutrition was required after
alteration of gastrointestinal function. Evidence-based nutrition recommendations were used
for the NCP including assessment, intervention, and monitoring and evaluation for this patient.

Disease Description:
Colorectal cancer is the second leading cause of death among cancers that affect both
men and women. Colorectal cancer is also the third most common cancer in both men and
women. In 2010 over 130,000 people in the US were diagnosed and more than 52,000 people
died from colorectal cancer
1
.
3

Colon cancer develops from mucosal colonic polyps. There are two types of colonic
polyps: hyperplastic and adenomatous. Nearly all colon cancers develop from adenomas.
Hyperplastic polyps can increase risk for colon cancer, but the effect is minimal. However, both
types of polyps are still risk factors for colorectal cancer. Of note, small polyps rarely contain
cancer
1
.
The cause of colorectal cancer is unknown; there are however several risk factors that
can increase your chance of developing colorectal cancer. These risks include genetic, dietary,
and lifestyle factors. Inflammatory bowel disease and immunodeficiency disorders also increase
risk of colon cancer. Risk is also increased with age and occurrence of other cancers. A diet with
high fat and high meat can lead to colon cancer, and risk is increased when that diet contains
little fruits, vegetables, and fiber. Lifestyle factors that can increase colon cancer risk are
obesity, smoking, and being sedentary
2
.
Signs and symptoms of colon cancer are diarrhea, constipation, change in bowel habits,
bloody stool, anemia, abdominal pain or tenderness, abdominal discomfort from gas, bloating,
cramps, intestinal obstruction, unplanned weight loss, and fatigue
2
.

Evidence-Based Nutrition Recommendations:
A study conducted in 2011 by Critselis, Panagiotakos, Machairas, Zampelas, Critselis,
and Polychronopoulos examined Parental Nutrition in cancer patients following extensive
abdominal surgery. It was an age and gender matched case-control study with 115 subjects.
4

Eighty-one case subjects and 34 controls both underwent abdominal surgery, but only the case
subjects underwent extensive abdominal surgery, the control subjects underwent moderate
and/or common abdominal surgery. The case subjects also received 8 days of TPN. The study
measured post-operative serum protein levels. Findings include mean pre-operative serum
protein levels were similar among both case and control subjects. Subjects who underwent
extensive abdominal surgery had lower serum protein levels compared with the control group.
The authors concluded that tailored nutrition support for extent of surgery, serum protein
levels, and age is needed in order to counteract hypoproteinemia in cancer patients undergoing
extensive abdominal surgery. Limitations of the study include a population bias due to the
patients being recruited from one single hospital
3
.
A study conducted in 2011 by Kutsogiannis et al. examined the use of TPN in critically ill
patients. In this multi-center observational study 226 intensive care units across the world were
included. A total of 2,920 subjects that were mechanically vented and critically ill in the
intensive care unit for at least 3 days were included in the study. The authors examined the
adequacy of calories and protein for patients receiving enteral and parenteral nutrition. There
were 3 groups in the study: early enteral nutrition, early parenteral nutrition and late
parenteral nutrition. Early enteral/parenteral nutrition is defined as nutrition support that
begins within 24-48 hours. The study found that the use of early or late TPN in critically ill
patients increases their calorie and protein intake. The study also found that the use of TPN did
not affect clinical outcomes such as length of hospital stay or mortality. Limitations of the study
include lack of randomization and concealment of the different forms of artificial nutrition.
5

Another limitation is that only 7 subjects calorie and protein requirements were assessed by
calorimetry
4
.
A 2009 article in the journal of Clinical Nutrition by Braga et al gives an overview of the
ESPEN guidelines of TPN for surgical patients. The guidelines report that several studies have
previously demonstrated that about 7-10 days of preoperative TPN can improve post-operative
outcomes in severely malnourished patients. In patients that are well-nourished or only mildly
malnourished, preoperative TPN provides little to no benefit. TPN is recommended in patients
who cannot meet their energy needs within 7-10 days through either PO intake or enteral
nutrition. TPN is only recommended if enteral nutrition is not an option, or a combination of
parenteral and enteral nutrition is also preferred to TPN alone. The recommendation of 25
kcal/kg of ideal body weight for patients is an appropriate estimate of daily calorie needs.
ESPEN also recommends that a full range of vitamin and mineral supplementation should be
added daily when combined with TPN
5
.
In conclusion, TPN can increase caloric and protein intake in patients. The articles listed
have different views on the benefits of TPN in surgical and/or cancer patients, but they are all in
agreement that there is little risk of providing energy through artificial nutrition when
appropriate compared with the risk of not providing nutrition at all to patients.

Case Presentation
6

The patient was a 66 year old male admitted to the hospital for a laparoscopic colon
resection related to previously diagnosed colon cancer. The laparoscopy was converted to an
open colon resection during surgery. Surgical findings were splenic flexure colon cancer. The
patient developed increased oxygen demands and was increasingly short of breath post-
operatively. The patient also had increased abdominal distension due to an ileus, so a
nasogastric tube was placed for decompression. Dietary saw the patient and completed a full
assessment on hospital day #3. The patient was still nothing by mouth (NPO), so dietary was
waiting on diet advancement or starting enteral/parenteral nutrition. The patients diet was
advanced to clear liquids, however, the patients respiratory status declined quickly on hospital
day #5, so he was transferred to the intensive care unit and intubated and sedated. The patient
was also diagnosed with Clostridium difficile while in intensive care. Trickle tube feedings of
Novasource Renal at 10 milliliters (mLs)/hour (hr) were initiated on hospital day #7. Novasource
renal formula was chosen because the patient was in acute renal failure. An exploratory
laparotomy was conducted and revealed multi-system organ failure on hospital day #8. Total
Parenteral Nutrition (TPN), was started on hospital day #9. TPN rate was reduced due to
volume overload on hospital day #16. The patient was extubated on hospital day #21 and TPN
was discontinued on hospital day #22. The patients diet was advanced to clear liquids and then
to Dysphagia 2 after a speech-language pathology consult. The patient experienced nausea with
meals and agreed to try a nutrition supplement, Boost Plus three times a day to better meet
nutrient needs. The patient was drinking all three supplements each day along with his further
advanced diet, Dysphagia 3. The patient discharged on hospital day #29 after his multi-system
organ failure had resolved.
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Nutrition Care Process: Assessment
Client History:
Past medical history for the patient includes sleep apnea, hypertension, diabetes,
tremor, ulcer, colon cancer, bilateral hearing loss, wears glasses, full dentures, and morbid
obesity. The patients social history includes non-smoker, no alcohol or drug use, and is a
Jehovahs Witness. No family medical history was listed.
Food/Nutrition-Related History:
The patient had some swallowing and dentition problems noted after being intubated
for an extended period of time. The patient had ill-fitting dentures after extubation likely from
weight loss. The patient also had nausea with some meals after extubation. The patient was
only eating up to 50% of his meals when he was seen on hospital day 25. However, by the time
he was discharged on hospital day 29 the patient was eating most of his meals as well as
drinking 3 Boost Plus nutrition supplements per day. The patient denied use of supplements
and no allergies to any foods were found.
Nutrition-Focused Physical Findings:
The patient had a limited appetite after intubation and experienced some nausea with
meals. The patient was also diagnosed with Clostridium difficile, which led to many bouts of
diarrhea during admission. The patient became fluid overloaded during his stay in the intensive
care unit, which led to his TPN rate being reduced by the physician. The physician was aware
8

that the patients nutrient needs were not being met, but the physician felt that the fluid
overload was more of a priority. The patient also likely experienced fat and muscle wasting
likely due to his weight loss during admission. The patient also had ill-fitting dentures after
extubation, so his diet was advanced to Dysphagia 2 for several days, and then advanced to
Dysphagia 3. His diet was never advanced to regular. For medical and nutrition events please
refer to Table 2.
Anthropometric Measurements:
The patient was 62 and weighed 141.6 kilograms (kg) (312 pounds) with a BMI of
40.06 kg/m
2
on hospital day #3. At discharge the patient weighed 127.5 kg (281 lbs) with a BMI
of 36.06 kg/m
2
. The patient lost approximately 31 pounds during his admission.
Biochemical Data, Medical Tests, and Procedures:
Table 1 examines nutrition-related laboratory values measured during the initial
assessment and all follow-ups by dietary. If the box is blank for a laboratory value, it was not
measured during that blood draw when lab results were reviewed.
The procedures the patient underwent during his hospital admission can be found in
Table 2, which lists his medical procedures and nutrition events. Of note, while the patients
albumin levels remained low throughout admission, they began trending upward on hospital
day 19, and on day 22 the patients prealbumin was within normal limits at 25.3 mg/dL.
Nutrient Needs:
9

The ESPEN guidelines for energy and protein needs in surgical patients are 25
kilocalories (kcals)/kg ideal body weight and 1.5 grams (g) protein/kg ideal body weight, or 20%
of estimated nutrient needs. During admission, the patients adjusted body weight of 98.6 kg
was used to calculate energy and protein needs. The patients estimated nutrient needs were
calculated to be 2050-2250 kcals per day (after rounding) and 140-155 g protein per day. Fluid
needs were calculated at 30 mls/kg for an individual aged 55-75. Fluid needs were therefore
4,320 mls/day. However, for patients in the intensive care unit, the attending physician decides
fluid needs. Equations for ESPEN recommendations as well as actual estimated needs during
admission can be found in Table 3
5
.
Aramark Nutrition Status Classification:
The patient was assessed for his nutritional risk status. At admit the patient was
classified at being moderately nutrition compromised with a total of 10 nutrition care priority
points. His points were based on his weight status, his diet, his diagnosis/condition and his
albumin level. The patient received 0 points for being NPO day 3, 4 points for having a BMI of
40.02 kg/m
2
, 3 points for having gastrointestinal surgery and 3 points for having an albumin of
2.6 g/dL. The patient did not receive any points in the weight loss or nutrition history category.
Based on the patients nutrition risk status classification, a follow-up should be scheduled in the
next 3-5 days
6
.
Malnutrition Identification:
The patient had severe adult malnutrition during his hospital admission. The ASPEN
guidelines for diagnosing adult malnutrition have 6 categories that indicate malnutrition. To
10

diagnose non-severe or severe malnutrition you need at least 2 out of the 6 categories met for
your patient. This patient lost greater than 5 percent of his body weight in 1 month and had
moderate generalized fluid collection, which represent severe adult malnutrition. The patient
also had insufficient energy intake while his TPN was reduced and provided approximately half
of the patients estimated energy and protein requirements
7
.

Nutrition Care Process: Nutrition Diagnoses
On initial assessment that patients main nutrition problem was identified: Altered
gastrointestinal function. Another nutrition diagnosis that could have been applied to this
patient was inadequate oral intake. The diagnosis statements (PES statements) were developed
by using the IDNT manual
8
.
1. Altered gastrointestinal function related to alteration in gastrointestinal structure as
evidenced by partial colon resection and abdominal distension.
2. Inadequate oral intake related to decreased ability to consume sufficient energy as
evidenced by NPO status.

Nutrition Care Process: Intervention(s)
Medical procedures the patient underwent during his hospital admission can be found
in Table 3.
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1. Enteral and Parenteral Nutrition: Enteral Nutrition (ND-2.1)
a. Concentration (ND-2.1.2)- 2 kcals/ml
b. Rate (ND-2.1.3)- 10 mls/hr (trickle feedings) Goal rate = 50 mls/hr
c. Schedule (ND-2.1.5)- continuous
d. Route (ND-2.1.6)- via nasogastric tube
The patient was currently NPO day 7 with abdominal distension, so trickle feedings at 10
ml/hr were initiated with tube feeding formula Novasource Renal. The tube feeding was to be
advanced per physician. At goal rate 50 mls/hr the tube feed would provide 2400 kcals, 109 g
protein, 864 mls of free water. The patient did not require extra water from tube feeding
flushes because IV fluids (D5W) were running at 125 mls/hr. The above recommendations were
based on the patients estimated nutrient needs.
2. Enteral and Parenteral Nutrition: Parenteral Nutrition/IV Fluids (ND-2.2)
a. Composition, concentration, rate (ND-2.2.1, ND-2.2.2, ND-2.2.3)- Central
continuous TPN running at 90 mls/hr to provide 140 g amino acids and 400 g
dextrose. TPN to provide 1920 kcals when at goal rate of 90 mls/hr. No lipids
needed due to Propofol providing additional 773 kcals from fat.
The patient was not tolerating his tube feeding, and was NPO again while remaining
intubated and sedated. Gastrointestinal function was altered so TPN was initiated to
help meet nutrient needs.
3. Medical Food Supplements (ND-3.1)
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a. Commercial beverage (ND-3.1.1)- Added a higher calorie and higher protein
nutrition supplement drink Boost plus three times a day.
Boost plus was ordered for the patient because he was experiencing lack of appetite
and nausea after being extubated. The supplement would help with meeting the patients
estimated nutrient needs.
4. Coordination of Nutrition Care: Collaboration and Referral of Nutrition Care (RC-1)
a. Collaborate with other nutrition professionals (RC-1.3)-Speech-language
pathology was consulted to evaluate the patients swallow abilities after being
extubated.
Due to prolonged intubation the patient needed a consult from speech-language
pathology in order to advance his diet. The patient had ill-fitting dentures after
intubation, likely due to weight loss. The patient was approved to begin with a clear
liquid diet and if tolerated to advance to a Dysphagia 2 diet.

Nutrition Care Process: Monitoring and Evaluation
Due to the patients nutritional risk status, monitoring and evaluation was conducted
every 1-4 days. Enteral nutrition, parenteral nutrition, and total food and beverage intake were
monitored and evaluated at each visit.
1. Food and Nutrient Intake: Enteral Nutrition Intake (FH-1.3.1)- Tube feeding rate and
orders were evaluated to determine total nutrient intake. As the patient was never
13

advanced beyond 10 mls/hr of the Novasource renal formula, his nutrient needs were
not being met. Recommendations were made to advance the tube feeding as tolerated.
2. Food and Nutrient Intake: Parenteral Nutrition Intake (FH-1.3.2)- The TPN was initiated
at 25 mls/hr to prevent refeeding syndrome. Recommendations were made to continue
to advance the TPN rate until the goal rate was reached. The TPN was advanced to 42
mls/hr the next day, and then to 63 mls/hr the day after that. The next day the TPN was
advanced to goal rate of 90 mls/hr. The day after the TPN rate was reduced to 65 mls/hr
to decrease fluid intake in the patient due to fluid overload and generalized anasarca.
Recommendations were then made to advance the TPN rate as medically warranted.
3. Food and Nutrient Intake: Total Energy Intake (FH-1.1.1)- The patients intake at meals
and amount of Boost Plus nutrition supplements were assessed daily through nursing
records, and then assessed by dietary during monitoring and evaluation.
Recommendations were made to encourage PO and supplement intake.
Recommendations for discharge were to continue to encourage PO intake. The patient also
wanted to continue his weight loss due to his previously being morbidly obese. The patient
was counseled on healthy weight loss tips. When the patient was discharged from the
hospital he was transferred to a short-term rehabilitation facility. No follow-up information
was available after discharge.

Conclusion:
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Patients with colon cancer and colon cancer resections can become malnourished,
either through surgical complications, such as the case with this patient, or through altered
gastrointestinal function related to partial removal of the colon, or blockages caused by the
cancer tumors. Early nutrition intervention through enteral nutrition or parenteral nutrition can
help prevent malnutrition, or reverse malnutrition. The patient was likely better able to heal
after his surgeries due to his protein intake through artificial nutrition and eventually oral
nutrition.
The patient was discharged after a 29-day hospital stay where he received oral, enteral,
and parenteral nutrition in an effort to meet nutrient needs and prevent adult malnutrition.
While the patient still experienced malnutrition, there is little doubt that his nutrition and
medical status would have worse had he not received artificial nutrition during his admission.
15

Appendix:
Table 1: Laboratory Values
Day: 3 7 9 11 14 16 18 21 28
Na HIGH
BUN HIGH HIGH HIGH HIGH HIGH HIGH HIGH
CR HIGH HIGH HIGH HIGH HIGH HIGH HIGH
BGs HIGH HIGH HIGH HIGH HIGH HIGH HIGH HIGH
GFR LOW LOW LOW LOW
Albumin LOW LOW LOW LOW LOW LOW LOW
K LOW LOW LOW
H/H LOW LOW
TBILI LOW
Fe LOW
Ferritin HIGH
B12 HIGH
Folate HIGH
Phos HIGH
AST HIGH LOW

Table 2: Medical Procedures/ Nutrition Events:
16

Hospital Day 1 Laparoscopic- converted to open- Colon
resection
Hospital Day 2 Nasogastric tube placed to Low Intermittent
Wall Suction
Hospital Day 4 Bowel movement, patient positive for C. Diff
Hospital Day 5 Patient Intubated and Sedated on Propofol
Hospital Day 7 Enteral nutrition started- trickle feedings
Hospital Day 8 Open Abdominal Surgery (omentectomy)-
abdomen left open with wound vac
TPN started at 25 mls/hr
Hospital Day 9
Hospital Day 10 Abdominal wound dressing change
Hospital Day 11 TPN rate advanced to 42 mls/hr
Hospital Day 12 Abdominal wound dressing change
TPN advanced to 63 mls/hr
Hospital Day 13 TPN rate advanced to goal rate 90 mls/hr
Hospital Day 15 Abdominal wound closure
Hospital Day 16 TPN rate reduced to 65 mls/hr
Hospital Day 17 Bowel Movement
Hospital Day 19 Severe anemia- no blood products given due
to religion
17

Hospital Day 20 Patient extubated and off sedation
Hospital Day 22 Patient decided to receive blood transfusion
Diet advanced to clear liquids and Dysphagia 2
solids- start with clears
C. Diff resolved
Hospital Day 23 TPN discontinued
Hospital Day 25 Diet advanced to Dysphagia 3
Started Boost Plus TID
Hospital Day 29 Patient discharged from hospital

Table 3: Anthropometrics and Selected Macronutrient Requirements
At admission:
ABW = 141.6 kg
IBW = 86.4 kg
Adjusted BW = 98.6 kg
Kcals Protein Fluid
During admission: 21-23 kcals/kg adjusted BW
= 2070-2267 kcals
1-1.1 g/kg ABW
= 140-155 g/kg
30 mls/kg
=4320mls
18

ESPEN guidelines: 25 kcals/kg IBW
=2160 kcals
1.5 g/kg IBW
= 130 g/kg


19

References:
1. Colorectal (Colon) Cancer. Centers for Disease Control and Prevention Website. Updated
March 3, 2014. http://www.cdc.gov/cancer/colorectal/. Accessed March 5, 2014.
2. Lab Tests Online. Colon Cancer. 2011. Accessed March 8, 2014.
http://labtestsonline.org/understanding/conditions/colon/start/1.
3. Critselis E, Panagiotakos DB, Machairas A, Zampelas A, Critselis A, Polychronopoulos E.
Postoperatve Hypoproteinemia in Cancer patients Following Extensive Abdominal
Surgery Despite Parenteral Nutritional Support. Nutr Ca. 2011; 63(7): 1021-1028.
4. Kutsogiannis J, Alberda C, Gramlich L, Cahill NE, Wang M, Day AG, Dhaliwal R, Heyland D.
Early use of supplemental parenteral nutrition in critically ill patients: Results of an
international multicenter observational study*. Crit Care Med. 2011; 39(21): 2691-2699.
5. Braga M, Ljungqvist O, Soeters P, Fearon K, Weimann A, Bozzetti F. ESPEN Guidelines on
Parenteral Nutrition: Surgery. Clin Nutr. 2009; 28: 378-386.
6. Aramark Healthcare. Assessment and education policy #2: Nutrition status classification
worksheet. Patient Food Services: Policies and Procedures, Volume IV: 2007.
7. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus Statement: Academy
of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition:
Characteristics Recommended for the Identification and Documentation of Adult
Malnutrition (Undernutrition). JPEN. 2012; 36(3):275-283.
8. American Dietetic Association. Pocket Guide for International Dietetics & Nutrition
Terminology (IDNT) Reference Manual. 4
th
ed. Chicago, IL. 2013.