Inflammatory Bowel Disease: Crohn's Disease & Ulcerative Colitis (Week 4 GI) Flashcards
What are the 2 inflammatory bowel diseases?
- crohns disease
- ulcerative colitis
What is the etiology of IBD?
No known cause or cure for IBD
* Infectious agent–bacteria? virus?
* Auto-immune - body attacks itself
* Psychological – stress induced
* Environment-diet? - Cola, sugar, chewing gum, chocolate, animal protein, dietary fatty acids (ultra processed foods with lots of emulsifiers)
* Genetics
What are some outcomes of malnutrition in IBD?
Energy- protein malnutrition is common in both diseases when disease active; more so in Crohn’s Disease; not as common in UC
* ↑ risk of infections
* ↓ immunocompetence
* ↓ enzyme function (brush border)
* ↑ cost to health care system
* ↓ tolerance to medical treatment
* ↑ morbidity and mortality
* altered fluid and electrolyte balance
therefore preventing & correcting malnutrition is essential
What are some complications of IBD?
- inadequate intake
- decreased absorption
- excessive losses
- ↑ requirements
- drug-nutrient effects
- repaid intestinal transit
What is the incidence of UC?
- 3-6/100,000
- stable incidence
- equal m/f
- bimodal → 15-30 years of age (yoa) and 60-70 yoa
What is the incidence of CD?
- 2-4/100,000
- ↑ incidence
- equal m/f
- bimodal → 15-30 yoa AND 60-70 yoa
- AB has highest incidence in Canada
- Common in Jewish descent in NA
Pathophysiology of UC
More superficial damage
* Mucosal inflammation (associated with ↑ CRP)
* Colon and rectum
* Continuous lesions
* some blood loss on superficial colonocytes
* more internal because of deeper fissures
Pathophysiology of CD
Goes right through inner lumen into blood vessels
* Transmural inflammation
* Any site of GI tract (terminal ileum 70%)
* Skip lesions (Activity index) - based on patients coping mechanism and their perspective so can be subjective
Clinical disease activity, endoscopic inflammation,
and severely active histologic inflammation is associated with ↑ CRP
Complications of IBD
also ulcers
Problem with toxic megacolon?
It is defined as a nonobstructive dilation of the colon, which can be total or segmental and is usually associated with systemic toxicity.
* Rare, but potentially deadly complication of colonic inflammation.
Layers of small intestine
Difference in inflammation between UC vs. CD
- UC: more superficial layers of colonic wall and only appears in colon
- CD: anywhere in the bowel (including oral cavity) and in more than one place in the intestines with depper fissures/damage; increased risk for fistula appearance
Describe a fistula
A fistula is an abnormal connection between two body parts, such as an organ or blood vessel and another structure. This results in drainage into other cavities in the body and can lead to tissue breakdown and severe infection (eg fistula to bladder).
* More common in Crohns
Describe a stricture
is a narrowing of part of the intestine because of scar tissue in its wall. Strictures are more commonly seen in Crohn’s disease than in ulcerative colitis. In Crohn’s disease, 25% of patients have had at least one stricture in their small intestine and 10% have had a stricture in their large intestine.
* Adhesions: when parts of the bowel wall stick together
What factors lead to inadequate intake with malnutrition?
- anorexia
- nausea
- vomiting
- dietary restriction w/o supplementation
What factors lead to decreased malabsorption with malnutrition?
Particularly in small bowel Crohn’s Disease
* ↓ absorptive capacity
* inflammation
* resections
* blind loop syndrome
* strictures
* Fistula
What factors lead to excessive losses with malnutrition?
- diarrhea
- blood (might vommit with upper bowel in Crohns)
- trace elements
- protein losing enteropathy (slough off inner lining with inflammation)
- bile salts
What factors lead to ↑ requirements with malnutrition?
Usually not hyper-metabolic but dont dowregulate
* inflammation
* surgery
* infection
* fever
* repletion of stores
How do corticosteroids effect nutrients?
Corticosteroids (e.g. Prednisone) → immunosuppressent therapy
* increased requirement for protein, vitamin B6, vitamin D, zinc, can result in poor bone heatlh by increasing
* Increase protein turnover and causes insulin resistance so get puffier and water retention of muscles, get bone loss by increase Ca excretion and some people susceptible to mental health problem (psychosis with high dose), can get moon faced (Cushing?) can get electrolyte disturbance.
* Most common used for 15 days in IV fluid NPO
* Used in CD and UC
How do Sulfasalzine (NSAID) effect nutrients?
Folic acid absorption inhibitor
* Need high doses of folate which is usually done TPN at first and the EN
How do cholestyramine effect nutrients?
reduced absorption of fat soluble vitamins
What are critical areas of malnutrition?
- proximal jejunum
- distal ileum <100 cm resection
- distal ileum >100 cm resection
- Ileocecal valve
- ascending colon
problem with proximal jejunum inflammation/ removal
major area of nutrient absorption
problem with distal ileum <100 cm inflammation/ removal
- bile salt wasting
- diarrhea, mild steatorrhea
What is steatorrhea?
excessive amounts of fat in your poop.
* They tend to be looser, smellier and paler in color, like clay. They might float.
problem with distal ileum >100 cm inflammation/ removal
- bile salt depletion
- severe steatorrhea
- fat soluble vitamin deficiency
- hypomagnesemia/ hypocalcemia
- vitamin B12 deficiency
- fluid and electrolyte imbalance
Adjunctive vs. exclusive therapy
adjunctive: combination of therapy
exclusive: using only 1 therapy
Problem with Ileocecal valve inflammation/ removal
- bacterial overgrowth → diarrhea / steatorrhea
- cholerrheic diarrhea
- reduced mucosal contact time
- loss of ileocecal valve ↑ food to colon → reflux
Problem with Ascending colon inflammation/ removal
fluid and electrolyte abnormalities
IBD treatment
Nutritional Therapy
* CD may be treatment therapy
* UC adjunctive or supportive therapy
Drug Therapy for both CD and UC
* anti-inflammatory drugs (such as prednisone)
* antibiotics
* analgesics
Surgical Therapy
* UC/CD: bowel resection with/without ileostomy
* UC: colectomy is curative; typically only do in moderate-severe cases
* CD: in acute exacerbations ± obstructions/adheresions; want to avoid as
NOT curative!
Purpose of nutrition care in IBD?
- To prevent or minimize GI symptoms
- To prevent malnutrition (optimize nutrition status)
- To normalize bowel function as much as possible (try to help them deal with pain)
Diet therapy during acute phase
- Micronutrient supplementation → Individualized
- Fluid intake → adequate to prevent dehydration (diarrhea and blood loss)
- Electrolyte monitoring → supplementation as required
What are some typical approaches to diet therapy?
- Bowel rest
- Exclusive Ng tube feeding
- Crohns Disease exclusion diet
Bowel rest diet therapy
Supportive therapy
* nothing by mouth (NPO)
* TPN for 10 days and treatment with IV medications (corticosteroids) then reintroduce foods
Exclusve Ng tube feeding
Typically 4-8 weeks via nasogastric tubes with clear fluids
* no foods - broths, water, juices without pulp
* ENT formulations may be polymeric, elemental and/or semi-elemental
* Introduction after 4-8 weeks taper off EN feeds and introduction of food
Crohns disease exclusion therapy
New emerging diet therapy for Crohn’s Disease
* Used in Adults; starting to be used in pediatrics.
* Avoidance of emulsifiers or maltodextrins, food additives and can then reintroduce
* May have significant nutritional limitations
* Does not rest Crohns but may help with going into remission
* 3 phases
Phase 1 of Crohns disease exclusion therapy
weeks 1-6 total exclusion of foods
* excluded: dairy, gluten, processed meats, animal fat, canned and packaged foods, coffee, alcohol, emulsifying agents
* included: selected fruits and vegetables, fish , eggs, lean meats
Phase 2 and Crohns disease exclusion therapy
Weeks 7-12 induction phase
Increasing introduction of F/V, small amounts of bread, red meats, and some legumes as per patient tolerance
Phase 3 of Crohns disease exclusion therapy
week 13 onwards - maintenance
