ETIOLOGY

Abnormal immune

SIGNS & SYMPTOMS

Bloody diarrhea with

response resulting in inflammatory damage of GI mucosa Genetic susceptibility Association with exsmokers

PATHOLOGY
Chronic inflammation of

colonic mucosa Involves entire colon

mucus Abdominal and/or rectal pain Fever Weight loss Possibly constipation and rectal spasm Arthritis Dermatological changes Ocular manifestations

Admission diagnosis: Bloody diarrhea Admitted to Acute Medicine Pt complaints at admission:

2 weeks of abdominal pain and bloody

diarrhea

constant pain (rated 10/10 at admission); no increase in pain after

eating 10-15 lb wt loss in past 2 weeks sore throat and odynophagia Cough productive of greenish mucous

CT of abdomen/pelvis
Diffuse colonic wall thickening Consistent with pancolitis Erosive sacroiliitis Consistent with ulcerative colitis

VITALS:
Temperature: 100.6 Pulse: 119

Suspected SIRS/Sepsis

Age: 65 years Gender: Male Married Branch of Service: Air Force H/O 25 pack a year smoking; quit 8 years ago Drinks EtOH very rarely Anthropometrics:
Height: 180.3 cm Weight: 86 kg BMI: 26.5

Hypertension Sinusitis Hyperlipidemia Knee pain

204 202 200 198 196 194 192 190 188 186 184 182 1/1/2012 2/1/2012

Weight

Pt lost 9# in 1 month (4.5% of body weight)

Weight loss was likely due in part to dehydration Pt reports UBW of 200 lbs Current wt overweight at 110% of IBW, BMI of 26.5
3/1/2012 4/1/2012 5/1/2012 6/1/2012

Mother: died of some sort of metastatic cancer 9 siblings: died in fire during WWII 1 brother: died of MI at age 66 1 sister: died of renal failure 1 brother: still living

Abnormal NUTR Related Lab Tests Albumin Sodium Potassium Chloride Glucose WBC CRP Hematocrit

Patients value 2.1 g/dL 133 mEq/L 2.7 mEq/L 94 mEq/L 120 mg/dL 12.69x103 185 mg/L 30.9%

Normal value

Diagnosis

3.2-5.0 g/dL 135-145 mEq/L 3.5-5.0 mEq/L 100-106 mEq/L 60-115 mg/dL 3.8-11x103 <10 mg/L 42-52%

Severe depletion Hyponatremia, likely due to diarrhea Hypokalemia, likely due to diarrhea Hypochloremia, associated with hypokalemia Likely due to stress High, likely due to inflammation High, likely due to inflammation Low, likely due to loss of blood

Hemoglobin

10.2 g/dL

14-18 g/dL

Low, likely due to loss of blood

Pt considers himself a good cook and reports eating well at home Pt reported a poor appetite for 1 week PTA due to GI pain Pt tries to use Mrs. Dash and pepper since he has HTN, but still adds salt at the table. No Food Allergies

Severe diarrhea can result in malabsorption of all nutrients (especially Fe, Zn, Mg, and electrolytes) When infection/inflammation are present or when pt is febrile, energy and protein needs are higher (up to 150% of normal requirements)

In adults, enteral nutrition is recommended when use of medications is not feasible & additional nutrition is needed to improve or maintain nutritional status TPN is not necessary in most cases Energy needs estimated using HarrisBenedict or Mifflin-St. Jeor (stress factor 1.31.5) Protein needs are as high as 1.5-1.75 g/kg

Low-residue, lactose free diet Small, frequent meals Fat reduced with added MCT if steatorrhea is present Restriction of gas-producing, spicy, or fried foods & caffeinated beverages Add fiber and lactose as tolerated

Low fiber is generally only necessary during acute exacerbation or if stricture is present

All pts should receive a multivitamin

Increase protein intake Consider protein supplement or high protein formula Iron supplementation

Clear liquids until GI bleeding stops IV therapy to correct electrolyte imbalances

120 cc/hr of NS + 20 mEq KCl

Pt still on clear liquids & tolerating it well. Pt states he is eating 100% of his food and feels hungry DIAGNOSES:

Inadequate oral intake related to decreased ability to consume sufficient energy as evidenced by estimated energy intake from diet less than estimated nutritional needs.

Increased protein needs related to increased demand for nutrient (colitis, slight proteinuria) as evidenced by decreased albumin indicating increased metabolic needs.

RECOMMENDATIONS: Advance diet as tolerated to eventual healthful diet Provide Resource Breeze TID. Will change to Boost supplements when diet is advanced. If unable to advance diet past clear liquids in 1-2 days, consider nutrition support

2200-2500 kcal/day
Mifflin-St. Jeor, using current wt and AF/IF of 1.31.5

103-129 gram protein/day

Using current wt and 1.2-1.5 g/kg

Pt transferred to MICU Pts diet changed from clear liquids to NPO Pt receiving ice chips to aid with sore throat

Pt states abdominal pain is improving Bleeding has ceased, but sudden diarrhea persists Body Temperature decreases (99.4 F) Diet changed to General/Healthy Diet

PO intake slowly improves

On 6/29/2012, nursing notes report 100% of meals eaten

Pt moved from MICU to floor

No hematochezia Afebrile Pt eating general/healthy diet with good appetite Diet instructions upon discharge:

Resume previous diet

May eat yogurt to re-populate gut flora

DRUG Acetaminophen Ciprofloxacin

Purpose Pain reliever Antibiotic

Interactions Caffeine rate of absorption and effect of drug Ensure adequate fluid intake; Dont take drug with milk; Drug causes caffeine effect May cause dry mouth, metallic taste, N/V, & diarrhea; May take with meals to GI distress but food drug bioavailability. May cause GI irritation, N/V, abdominal pain, diarrhea, & flatulence. --

Metronidazole

Antibiotic

Potassium Chloride Cherry Lozenge

Electrolyte, Mineral supplement Relieve sore throat

Ondansetron

Anti-nauseant

May cause dry mouth, abdominal pain, constipation, diarrhea, headache & fatigue

Nutrition Care Indicator Weight

Albumin Sodium Potassium Chloride Glucose WBC Hematocrit Hemoglobin

Before 189.6 lbs

2.1 g/dL (1.7 g/dL) 133 mEq/L 2.7 mEq/L 94 mEq/L 120 mg/dL 12.69x103 30.9% (28.7%) 10.2 g/dL (9.4 g/dL)

After 197.31 lbs

none 141 mEq/L 3.9 mEq/L 105 mEq/L 110 mg/dL 7.6x103 33% 10.4 g/dL

Nutrition Goals:
Advance diet as tolerated to a general, healthy dietMET Pt to consume 75% or more of all meals/supplementMET

Expected Outcomes:
Albumin to gradually increase toward 3.2 g/dLUNSURE

Prevent Further Wt lossMET

Recommend monitoring albumin more frequently Education at discharge concerning colitis diet tips Prescribe iron supplement for patient

Nelms, M. N., Sucher, K., Lacey, K., & Roth, S. L. (2011). Nutrition Therapy & Pathiophysiology (2nd ed.). Belmont, CA: Wadsworth. American Dietetic Association. (2011). Pocket Guide for International Dietetics & Nutrition Terminology Reference Manual(3rd ed.). Chicago, IL: Author. Pronsky, Z. M., & Crowe, J. P. (2010). Food-Medication Interactions (16th ed.). Birchrunville, PA: FoodMedication Interactions. Charney, P., & Malone, A. M. (2009). ADA Pocket Guide to Nutrition Assessment (2nd ed.). Chicago, IL: American Dietetic Association. Lee, R. D., & Nieman, D. C. (2010). Nutritional Assessment (5th ed.). New York, NY: McGraw-Hill.