1. Ulcerative Colitis Mini Case Study Krista Blackwell Sodexo Mid-Atlantic Dietetic Internship January 6, 2014

2. Overview I. Ulcerative Colitis II. MNT in IBD III. Case Study I. History and Physical II. Medication and Labs III. Assessment IV. Diagnoses V. Goals and Intervention VI. Monitoring and Evaluation VII. Education IV. Article Review V. Resources

3. Ulcerative Colitis A form of IBD that effects the colon and rectum Causes: Genetic, environment, and “irritant” Inflammatory and abnormal immune response Dx made with sigmoidoscopy

4. Side Effects Diarrhea Fever Weight loss Anemia Food intolerances Malnutrition GI and/or rectal bleed Growth failure Protein losses Electrolyte disturbances Dehydration Anorexia Malabsorption Altered GI transit Increased secretions

5. Healthy Colon vs. Ulcerative Colitis

6. MNT in IBD Goals: Reduce inflammation, alleviate symptoms, correct dehydration and nutritional deficiencies Individualized treatment Acute phase/ flare up: Low-fiber Remission: High protein (1.0-1.5 g/kg), nutrient-dense diet, 2 quarts of water daily

7. MNT in IBD Avoid: Diarrhea-causing foods, extreme temperatures, carbonated beverages, alcohol, caffeine, spicy foods, lactose Small frequent meals, eat slowly and chew well MVI with minerals: Thiamine, Vit E, iron, zinc, Ca, K, folic acid

8. Case Study: History and Physical CP is a 26 year old female PMHx: Dx with ulcerative colitis in 2011 CP reported having multiple episodes of bloody diarrhea Distended abdomen and abdominal cramping NKA

9. Chief Complaint Nov. 2 nd : CP presented with bloody bowel movements and fatigue, was put under observation and given Solu-Medrol and prednisone and d/c Nov. 3 Nov. 6 th : CP vomited her first dose of prednisone Nov. 9 th : Early this morning, CP had one bloody BM an hour and presented to the ED and was admitted to SGAH for further evaluation and monitoring

10. Medical Diagnoses Ulcerative Colitis (Dx in 2011) Rectal bleeding Hemorrhage of the anus and rectum Hypokalemia Anemia

11. Social History CP is a 26 year-old Caucasian female Lives at home in Rockville, MD with her parents Manager at GAP Works long hours Limited access to food

12. Home Medications

13. Hospital Medications

14. Anthropometric Data Ht: 157cm (62”) Wt 11/9/13: 46.5 kg (102.3lb) Wt 11/3/13: 53.6 kg (118lb) UBW: 50kg (110lb) IBW: 50 kg (110lb) %IBW: 93% % wt change: 5% wt loss over 1 week BMI: 18.86

15. Laboratory Data

16. Nutrition Assessment Diet Order: Clear Liquid Intake: Fair Risk Level: Moderate Reason for visit: Diet Education Summary of visit 8lb wt loss since last hospital admission on 11/3 Pt’s nausea subsided, able to consume clear liquid diet and the doctor will be advancing her to full liquids Tries to drink adequate fluids, usually about 3-4 bottles of water a day No BM since hospital admission Provided pt with diet education for ulcerative colitis/ inflammatory bowel disease

17. Nutrition Prescription Estimated Energy Needs: 1388-1500kcal (MSJ 1.2-1.3) Estimated Protein Needs: 38-47g (0.8-1.0 g/kg) Estimated Fluid Needs: 1500 mL (1mL/kcal) Micronutrient Needs: MVI with minerals

18. Nutrition Diagnoses Nutrition Diagnoses I: Involuntary weight loss R/T ulcerative colitis AEB 5% wt loss over 1 week Diagnoses II: Food and nutrition-related knowledge deficit R/T lack of prior exposure to nutrition-related information AEB no formal prior education while experiencing acute colitis symptoms

19. Goals Pt consume adequate energy intake: At least 75% of meals within the next 3-4 days. Pt maintain current weight and prevent further weight loss Patient to demonstrate knowledge of diet guidelines through menu selections prior to discharge

20. Interventions Nutrition Education: Provided pt with information about a low fiber diet for the next few weeks and how to slowly reincorporate fiber into the diet Food and Nutrition Delivery/ Meals and Snacks: As tolerated and as medically feasible, suggest advancing to a low fiber diet MVI with minerals

21. Monitoring and Evaluation Monitor po intake Monitor pt’s wt trends RD to monitor understanding of information presented

22. Discharge Summary Discharged Nov. 13 Diagnoses: Ulcerative Colitis flare Rectal bleeding secondary to ulcerative colitis flare: Diarrhea and rectal bleed resolved Anemia, which is stable Acute dehydration Hypokalemia, which is resolved Discharge medications: Prednisone and protonix Pt to follow up with GI doctor in 2 days

23. Nutrition Care in Adult IBD Nutrition Assessment Identifying deficiencies and malnourished pts Goals Diet in IBD Common Deficiencies: Fe, Zinc, Mg, Vit B12, Folate, Vit D and Ca Omega 3s Enteral and Parenteral Nutrition Nutrition Issues in Gastroenterology, June 2012 Authors: Amar S. Naik and Nanda Venu

24. Remission Induction and Maintenance Effect of Probiotics on Ulcerative Colitis: A meta-analysis Aim: To evaluate the induction of remission and maintenance effects of Probiotics for UC 13 randomized controlled trials from MEDLINE, EMBASE, Coch rane Controlled Trials Register Evaluates probiotic’s curative effects for treating UC based on existing random control trials World Journal of Gastroenterology, April 2010 Authors: Li-Xuan Sang, Bing Chang, Wen-Liang Zhang, Xiao-Mei Wu, Xiao-Hang Li, Min Jiang

25. Remission Induction and Maintenance Effect of Probiotics on Ulcerative Colitis: A meta-analysis Results: Further research is needed including variations of bacterial species, applied dosage, treatment timing, and course of treatment Results were not consistent

26. Resources Mahan, K.., Escott-Stump, S, Raymond, J. Krause’s Food and the Nutrition Care Process. 3 rd ed. Elsevier Saunders. 2012 Width, Mary; Reinhard, Tonia. The Clinical Dietitian’s Essential Pocket Guide. Lippincott Williams & Wilkins. 2009. Naik, Amar S., Venu, Nanda. “Nutrition Care in Adult Inflammatory Bowel Disease.” Nutrition Issues in Gastroenterology, series #106. June 2012. Sang, Li-Xuan., Chang, Bing., Zhang, Wen-Liang., Wu, Xiao- Mei., Li, Xiao-Hang., Jiang, Min. “Remission induction and maintenance effect of probiotics on ulcerative colitis: A meta-analysis”. World Journal of Gastroenterology. April 2010.

27. Thank you!