What is Crohn’s disease characterized by? What is the major player?
dysfunctional regulatory T cells, which normally control proinflammatory cytokine release. If activated antigen presenting cells and lymphocytes are allowed to overly secrete proinflammatory cytokines, then tissue damage may result from prolonged inflammation
TNF alpha
What is the difference between ulcerative colitis and corhn’s?
Ulcerative is a full section of the colon whereas crohn’s is varias small sections
UC: ulcerations lead to toxic megacolon, thin, ulcerated colon
Crohn’s: fistulas, strictures, obstruction
How can IBD be diagnosed?
- symptoms
- upper GI series
- plain xRays
- upper GI endoscopy
- ultrasound
- MRI
- colonoscopy
How can a patient prepare for a colonoscopy (4 steps)?
- obtain a bowel preparation solution at least 2 days before the test
- clear liquids all day before the test. From 6-8pm drink 2L of any PEG-based solution
- 4h before appointment drink remaining 2L of the PEG-based solution and finish 2h before the test
- stop drinking all liquids including water 2h before the test
What are the clinical manifestations of IBD?
- abdominal pain
- febrile, tachycardic
- CRP elevated
- WBC elevated
- weight loss
What are the characteristics/symptoms of small intestinal Crohn’s?
- obstructive in nature
- pain with eating
- palpitation causes pain in lower right quadrant
- anorexia and diarrhea
- malabsorption (lactose intolerance)
- ileocolonic disease
What are the characteristics of colonic Crohn’s?
- similar to UC but with:
- diarrhea often contains blood -> hematochezia)
- pain prior to defecation
- perianal skin tags
- deep anal fissures
- perianal fistula
What are the systemic and extraintestinal manifestations?
- fever
- weight loss
- arthritis
- oral ulcers and skin lesions
- urinary tract disease
- enhanced oxalate absorption (kidney stones)
- altered body composition
What are the 4 stages of Crohn’s disease?
- Mild-moderate
- ambulatory
- able to tolerate oral intake without dehydration
- toxicity (fevers)
- abdominal tenderness
- painful mass
- obstruction
>10% weight loss - Moderate-severe
- failure to respond to treatment for mild-moderate disease or
- those with more major symptoms of fevers
- significant weight loss
- abdominal pain or tenderness
- intermittent nausea or vomiting
- significant anemia - Severe-fulminant
- persisting symptoms in spite of steroid Rx or
- those presenting with high fever, persistent vomiting
- evidence intestinal obstruction
- rebound tenderness
- cachexia
- evidence of abscess - Remission
- asymptomatic
- without inflammation sequelae and
- includes those who have responded to acute medical intervention or surgical resection without gross evidence or residual disease
What are the 4 tests of absorption?
- xylose test - low excretion = malabsorption
- 72h fecal test - >6g = malabsorption
- lactose breath - 50g of lactose and hydrogen in breath is measured
- low excretion of B12 = deficiency
What are the 5 main feeding issues?
- long-term steroid use = calcium and vit D deficiency
- insufficient intake/anorexia = PEM
- medications to treat IBD = folate deficiency
- SBS/intestinal losses = Mg, Zc, fluid and electrolyte deficiencies
- Blood losses in IBD = iron deficiency
What is necessary in the low oxalate diet?
- 3-4L water/d
- low fat
- vit C supplements NOT recommended
What is the most common CAM?
probiotics
What meds contribute to folate deficiency and what does it cause?
sulfasalazine and methotrexate
- contributes to anemia
What medication contributes to calcium and vitamin D deficiency?
glucocorticoids (prednisone)
What is the nutritional management for IBD?
Fluids: 1ml/kcal E: 25-30kcal/kg or more Pro: 1-1.5g/kg High minerals and vitamins normal fiber complex carb no need to limit lactose fat as tolerated ca and vit D supplements if needed (if on glucosteroids)
What is done in active IBD according to the Nutrition Care Manual?
nutrition support (EN > PN)
progress to low-fat, low-fiber, high protein, small frequent meals
give vit D, B12, zinc, calcium, magnesium, folate, iron
What is done in remission IBD according to the Nutrition Care Manual?
maximize E and Pro intake for maintenance or gain of weight
Avoid high oxalate
Increase antioxidant intake
Consider supplementation with O3 and glutamine
Use pro+prebiotics
