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Answer to #1
UC and CD are very similar, but can be distinguished from one another by the following:
Symptoms
Complications
Antibody testing
Imaging and biopsy results
Crohn's disease Ulcerative colitis
Symptoms Blood &/or mucus in stool
Abdominal pain & cramping
Fever
Wt loss
Chronic diarrhea
Anorexia
Malnutrition
Delayed growth in adolescents Bloody diarrhea with mucus
Abdominal &/or rectal pain
Fever
Wt loss
Possibly constipation & rectal spasm
Arthritis
Dermatological changes
Ocular manifestations
Complications Malabsorption
Malnutrition
Abdominal fistulas & abscesses
Intestinal obstruction
Bacterial overgrowth (blind loop syndrome)
Gallstones
Perianal disease
Neoplasia
Urinary tract infections
Kidney stones
Thromboembolic complications
Affects any part of the GI tract (from mouth to anus) and may have a skipping pattern Severe bleeding
Toxic colitis
Toxic megacolon
Strictures
Perforation
Colonic structures
Dysplasia
Carcinoma
Intolerance to immunosuppression
Affects the colon and rectum only (continuous)
Diagnosis Clinical presentation CDAI score
Abdominal ultrasound
MRI
CT
Antiglycan antibodies (ASCA/ANCA)
Calprotectin, lactoferrin, & polymorphonuclear neutrophil elastase Abdominal ultrasound
MRI
CT
Antiglycan antibodies (ASCA/ANCA)
Calprotectin, lactoferrin, & polymorphonuclear neutrophil elastase
Answer to #2
Hyperglycemia has been shown to correlate with poor outcomes in the ICU patient. It has been shown to lead to increased length of stay and higher risk of in-hospital mortality. Also, in patients with known DM before admission, it has been shown to increase the risk for infection and shock. For our patient, the hyperglycemia was treated using an insulin drip protocol, which is a commonly used therapy in critically ill patients. Tight blood glucose control (80-110 mg/dL) does not confer advantages in these patients. Both Society of Critical Care Medicine (SCCM) and ASPEN recommends a goal of 110 to 150 mg/dL while the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists recommends a goal of 140-180 mg/dL as a reasonable goal for these patients.
Answer to #3
When a patient is receiving nutrition support, it is important to monitor: physical assessment (signs of fluid and nutrient excess or deficiency), functional status (mobility, sedation), vital signs, actual nutrient intake (oral, enteral, and parenteral) in comparison to nutrition prescription, weight and weight changes, pertinent labs (blood glucose, triglycerides, inflammatory markers, BUN, liver function enzymes, electrolytes), medications administered (propofol, SSI), and changes in gastrointestinal function (bowel sounds, I/O, stool output). Additionally, the RD should ensure that the head of bed is at a 30o-45o angle (for EN) and tube patency is maintained.
Monitor wound healing and the progress of his open abdominal wound closure. This can confirm (or not) the adequacy of the patient's nutrient intake. Nitrogen balance can be helpful to measure the adequacy of nutrient intake as well, even though this can be altered with the abdominal wounds and metabolic stress.
Answer to #4
Inflammatory bowel disease (IBD) is a chronic relapsing inflammatory condition involving the gastrointestinal tract; the term IBD encompasses the two specific diagnoses of Crohn's disease and ulcerative colitis (UC). IBD is thought to involve the activation of T cells (by macrophages) to produce a T H1 immune response (cytokine production) that causes a vicious cycle of chronic inflammation. The mucosal damage from the abnormal immune response can allow the translocation of luminal contents past the tight junctions. This can allow the body to produce antigens to these leaked in contents. . The etiology of IBD is still unclear, but it is believed that various environmental factors may be involved as triggers for the inflammatory response of the disease; genetics also play an important role in the etiology of the disease. Certain genes are linked to the dysregulation of the gastrointestinal immune response and microbiome and therefore certain individuals are more susceptible than others to develop IBD. IBD has been found to be more prevalent among individuals of Caucasian and Ashkenazi Jewish descent. However, because all genetically susceptible individuals do not develop IBD, and because of the speed at which IBD incidence has increased in certain regions of the world, genetics cannot be the sole factor in the etiology of IBD. Proposed theories regarding the environmental factors associated with IBD involve the hygiene hypothesis, Helicobacter pylori, family size and birth order, urban environment, etc. Smoking, oral contraceptives, appendectomy, diet, breastfeeding, and nonsteroidal anti-inflammatory drugs (NSAIDs).
Answer to #5
Alicia Clarke (Nutrition consult for IBS)
7-10-12
A: 42 YOWF Dx: irritable bowel syndrome-Diarrhea (D); PMH: history of constipation and diarrhea, obesity, GERD, and hypothyroidism
Meds: Omeprazole 50 mg twice daily; Levothroxine 25 mcg; vitamin D 600 IU; 800 mg calcium; Lomotil prn. Elavil (25 mg daily), Metamucil (1 T in 8 oz. of liquid twice daily)
Skin: warm, dry
Abdomen: hyperactive bowel sounds x4; no organomegaly or masses - lower abdominal tenderness.
Labs: glu 115, Chol 201, Tg 171, HDL 42, HbA1C 6.1, Urinalysis: WNL
Height: 5' 5 (65in.), Weight: 191 lbs. BMI: 32 (obese), IBW 125 +/- 10, 153 IBW
Estimated energy requirements: 1250 -1420 kcal (22-25 kcal/kg IBW to facilitate weight loss)
Estimated protein requirements: 46-57 g per day
Diet Hx: diet reveals many fermentable oligosaccharides, disaccharides, monosaccharides, artificial sweeteners, and sugar alcohols are consumed (FODMAP assessment analysis). Snacks are high in fat as evidenced by cookies, cake, and ice cream. Often consumption of gas-producing foods including: asparagus, kidney beans, lentils, fruit juice, dried fruit, artificial sweeteners, and fructose, which may contribute to IBS symptoms. Daily high fiber sources include wheat, dried fruit, kidney beans, and lentils.
D: Nutrition-related knowledge deficit related to FODMAP food consumption as evidenced by FODMAP assessment with frequent consumption of asparagus, sugar alcohols, high-sugar foods, and lentils.
I: Goal: Identify food triggers that make symptoms worse and alleviate symptoms.
pt. will focus on elimination diet and re-introduction over 6-8 week trial.
pt. will be educated on the FODMAP foods to identify which foods may contribute to symptoms.
pt. will consider adding probiotics such as cheese, kefir, or yogurt to diet.
pt. may consider continuing weight reduction to improve overall health.
M/E: pt. will keep a food diary for six weeks to identify food patterns. Pt. should note when symptoms occur to identify food triggers. Pt. should note episodes of diarrhea.
Symptoms will be monitored as pt. eliminates FODMAP foods from diet over a period of time.
Answer to #6
There is mixed evidence as to whether acupuncture and hypnotherapy are effective complementary therapies for IBS patients. Some patients report feeling better while it does not work for others. Providing guidance on evaluating information is an important aspect of nutrition education.
The role of the RDN is to determine the nutritional intervention for IBS. This puts an emphasis on treating IBS by identifying certain trigger foods that may be associated with its symptoms.
The RDN could refer the patient to a specialist in these alternative therapies, but since RDNs only share information that is evidence-based, these forms of treatment may be out of standards of practice for the RDN.
Answer to #7
1 . Goal: Maintain nitrogen balance by meeting patient's protein needs
Intervention: Increase protein intake in conjunction with increased EN tolerance with a high-protein enteral formula
2 . Goal: Decrease parenteral nutrition regimen in conjunction with increased EN delivery to promote normal GI function
Intervention: Consult with physician about the risks with continued TPN and the importance of EN delivery as the main energy and protein source and to promote wound healing of anastomotic leak/abdominal surgeries; EN promotes gut motility; wean PN appropriately with pharmacy and physician recommendations
3 . Goal: RQ value 0.8-0.9 and proper composition of nutrition support for his altered GI tract
Intervention: If continuing propofol, change PN to 2-in-1 solution without lipids
Increase rate of TPN to 150 mL/hr with elimination of lipids to provide 2600 kcal from TPN and 924 kcal from propofol for a total of 3525 kcal. Continue trickle tube feeds of 5 mL/hr to provide an additional 180 kcal and advance rate slowly as tolerated.
4 . Goal: Increase enteral nutrition with patient tolerance
Intervention: Modify distribution and type of feeding by continuing both PN and EN to meet nutritional needs; advance EN of Pivot 1.5 via J-tube by 10 mL/hr q 6-8 hours or as tolerated to goal rate of 75 mL/hr with continued propofol use to provide 1800 mL, 2700 kcal, 168 grams protein, and 1431 mL fluid (35 kcal/kg IBW, 2.3 grams protein/kg IBW); adjust rate based on energy and protein needs as metabolic cart measurements change with clinical course; once >60 of energy needs are met enterally, discontinue parenteral nutrition
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