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NUTR 468 Clinical > Inflammatory Bowel Disease: Crohn's Disease & Ulcerative Colitis (Week 4 GI) > Flashcards

Inflammatory Bowel Disease: Crohn's Disease & Ulcerative Colitis (Week 4 GI) Flashcards

1
Q

What are the 2 inflammatory bowel diseases?

A
  • crohns disease
  • ulcerative colitis
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2
Q

What is the etiology of IBD?

A

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

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3
Q

What are some outcomes of malnutrition in IBD?

A

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

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4
Q

What are some complications of IBD?

A
  • inadequate intake
  • decreased absorption
  • excessive losses
  • ↑ requirements
  • drug-nutrient effects
  • repaid intestinal transit
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5
Q

What is the incidence of UC?

A
  • 3-6/100,000
  • stable incidence
  • equal m/f
  • bimodal → 15-30 years of age (yoa) and 60-70 yoa
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6
Q

What is the incidence of CD?

A
  • 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
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7
Q

Pathophysiology of UC

A

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

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8
Q

Pathophysiology of CD

A

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

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9
Q

Complications of IBD

A

also ulcers

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10
Q

Problem with toxic megacolon?

A

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.

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11
Q

Layers of small intestine

A
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12
Q

Difference in inflammation between UC vs. CD

A
  • 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
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13
Q

Describe a fistula

A

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

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14
Q

Describe a stricture

A

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

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15
Q

What factors lead to inadequate intake with malnutrition?

A
  • anorexia
  • nausea
  • vomiting
  • dietary restriction w/o supplementation
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16
Q

What factors lead to decreased malabsorption with malnutrition?

A

Particularly in small bowel Crohn’s Disease
* ↓ absorptive capacity
* inflammation
* resections
* blind loop syndrome
* strictures
* Fistula

17
Q

What factors lead to excessive losses with malnutrition?

A
  • diarrhea
  • blood (might vommit with upper bowel in Crohns)
  • trace elements
  • protein losing enteropathy (slough off inner lining with inflammation)
  • bile salts
18
Q

What factors lead to ↑ requirements with malnutrition?

A

Usually not hyper-metabolic but dont dowregulate
* inflammation
* surgery
* infection
* fever
* repletion of stores

19
Q

How do corticosteroids effect nutrients?

A

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

20
Q

How do Sulfasalzine (NSAID) effect nutrients?

A

Folic acid absorption inhibitor
* Need high doses of folate which is usually done TPN at first and the EN

21
Q

How do cholestyramine effect nutrients?

A

reduced absorption of fat soluble vitamins

22
Q

What are critical areas of malnutrition?

A
  • proximal jejunum
  • distal ileum <100 cm resection
  • distal ileum >100 cm resection
  • Ileocecal valve
  • ascending colon
23
Q

problem with proximal jejunum inflammation/ removal

A

major area of nutrient absorption

24
Q

problem with distal ileum <100 cm inflammation/ removal

A
  • bile salt wasting
  • diarrhea, mild steatorrhea
25
Q

What is steatorrhea?

A

excessive amounts of fat in your poop.
* They tend to be looser, smellier and paler in color, like clay. They might float.

26
Q

problem with distal ileum >100 cm inflammation/ removal

A
  • bile salt depletion
  • severe steatorrhea
  • fat soluble vitamin deficiency
  • hypomagnesemia/ hypocalcemia
  • vitamin B12 deficiency
  • fluid and electrolyte imbalance
27
Q

Adjunctive vs. exclusive therapy

A

adjunctive: combination of therapy
exclusive: using only 1 therapy

28
Q

Problem with Ileocecal valve inflammation/ removal

A
  • bacterial overgrowth → diarrhea / steatorrhea
  • cholerrheic diarrhea
  • reduced mucosal contact time
  • loss of ileocecal valve ↑ food to colon → reflux
29
Q

Problem with Ascending colon inflammation/ removal

A

fluid and electrolyte abnormalities

30
Q

IBD treatment

A

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!

31
Q

Purpose of nutrition care in IBD?

A
  • 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)
32
Q

Diet therapy during acute phase

A
  • Micronutrient supplementation → Individualized
  • Fluid intake → adequate to prevent dehydration (diarrhea and blood loss)
  • Electrolyte monitoring → supplementation as required
33
Q

What are some typical approaches to diet therapy?

A
  1. Bowel rest
  2. Exclusive Ng tube feeding
  3. Crohns Disease exclusion diet
34
Q

Bowel rest diet therapy

A

Supportive therapy
* nothing by mouth (NPO)
* TPN for 10 days and treatment with IV medications (corticosteroids) then reintroduce foods

35
Q

Exclusve Ng tube feeding

A

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

36
Q

Crohns disease exclusion therapy

A

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

37
Q

Phase 1 of Crohns disease exclusion therapy

A

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

38
Q

Phase 2 and Crohns disease exclusion therapy

A

Weeks 7-12 induction phase
Increasing introduction of F/V, small amounts of bread, red meats, and some legumes as per patient tolerance

39
Q

Phase 3 of Crohns disease exclusion therapy

A

week 13 onwards - maintenance

NUTR 468 Clinical (34 decks)

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