1. Ulcerative Colitis
Brittney Hudson

2. Patient Profile KV 18 y.o. male Just moved to Provo, Utah
Mother, father, 3 brothers
Plays football

3. Medical History
Ear tubes

4. Disease Progression Bloody diarrhea x 3 months
June 2011 – times/day
Fatigue
Decreased appetite
Lost pounds

5. Diagnosis
Colonoscopy – July 2011
Ulcerative Colitis

6. Inflammatory Bowel Disease
Autoimmune, chronic inflammatory condition of the gastrointestinal tract
Inflammatory Bowel Disease
Ulcerative Colitis
Crohn’s

7. Etiology
Immune System
GI System
Genetics
Environmental Factors

8. Pathogenesis Intestinal flora, diet, etc. Inflammatory response
Body can’t suppress immune system
GI tissue damage occurs

9. Signs and Symptoms Abdominal pain Diarrhea Nausea Vomiting Osteopenia
Dermatitis
Hepatobiliary complications

10. Disease effect on Nutrition
Weight loss
Electrolyte imbalances
Anemia
Malabsorption
Food allergies or aversions
Fear of eating
Self-imposed dietary restrictions

11. General Treatment Recommendations
Induce and maintain remission of disease
Corticosteroids
Anti-inflammatory agents
Immunosuppressive agents
Colectomy
Ileostomy

12. Beginning Treatments Prednisone Constantly changing doses
Unresolving symptoms

13. Anti-inflammatory and
Drugs/Medications
Medication
Purpose
Prenidsone
Anti-inflammatory and
Immunosuppressive
Methotrexate
Remicade
Zofran
Nausea

14. Side Effects of Prednisone
Weight gain
Acne
Hyperlipidemia
Hypertension
Osteopenia
Joint pain

15. Procedures
Colectomy with ileostomy placement on September 25, 2012

16. Diet before Colectomy Poor Didn’t feel like eating
Elemental formula – Neocate Jr

17. Diet after Colectomy TPN and clear liquids – small bowel obstruction
Lost 25 pounds
Taken off TPN due to hepatitis – October 18, 2012
ALT U/L ( U/L is normal)
AST U/L (15-45 U/L is normal).

18. UVRMC Admitted on October 25, 2012 Dehydration
Weight Loss and Malnutrition
Intractable nausea

19. Malnutrition
When nutritional reserves are depleted or nutrient intake is inadequate to meet the body’s daily metabolic needs.

20. Signs and Symptoms
Weight loss
Protein wasting
Fatigue

21. Refeeding Syndrome
When patients are moderately or severely malnourished
Tissue growth
Not enough electrolytes
Fluid overload

22. KV’s Treatments NJ tube feeding was started Ate sparingly
Ileostomy takedown
NJ tube feeding started again
KV pulled it out
TF replaced
KV vomited it out
TPN started
Psychiatric Counseling

23. Drugs/Medications Medication Purpose Prenidsone Anti-inflammatory and
Immunosuppressive
Cyproheptatdine (Periactin)
Appetite stimulator
Zofran
Nausea
Calcium
Supplementation
Magnesium “
Potassium
Sodium
Zinc
Multivitamin

24. Nutrition Assessment

25. Food/Nutrition Related History
Unremarkable before diagnosis
After diagnosis: poor appetite, anxiety
Diet
Start
Clear Liquid
11/5
Regular
11/4
Full Liquid
11/3
11/1
NPO
10/31
10/29
10/28
10/27
10/26
10/25

26. Food/Nutrition Related History
Diet
Start
3 L standard TPN with 20% lipids 2 times per week
11/6
Peptamen AF 10 mL/hr
11/3
Peptamen AF 50 mL/hr
10/28
Peptamen AF 35 mL/hr
10/27

27. Anthropometrics
Height: 5’8”

28. Biochemical Data

29. Biochemical Data

30. Biochemical Data

31. Biochemical Data

32. Nutrition Focused Physical Findings
Attentive and cooperative
Respiratory and cardiovascular systems normal
Abdomen was soft, non-tender, active bowel sounds
No rashes or legions
OK muscle tone

33. Comparative Standards
Calories
Protein
Fluid
Kcals
kcals/kg gm
gm/kg mL
mL/kg
Based On
1775 – 2130
25-30
1.2 – 1.5
2840 40
Actual Body Weight (71 kg)

34. Nutrition Diagnosis
Inadequate oral intake related to nausea/vomiting/dehydration as evidenced by weight loss of 30 pounds the past two months.

35. Nutrition Intervention
Problem
Inadequate oral intake related to nausea/vomiting/dehydration as evidenced by weight loss of 30 pounds the past two months.
Long-Term Goal
Increase oral intake to the point where the patient will be able to consume enough to meet estimated needs without the use of PN or EN.
Short-Term Goal
Have patient consume 10-15% of calories through oral intake and gradually increase to keep the gut stimulated.

36. Specific Intervention and Client Objectives
1. Intervention: Food and/or Nutrient Delivery
a. Patient switched between a clear liquid, full liquid and regular select diet throughout his hospital stay depending on his tolerance. A select diet means he was able to call down and order food when he felt like it.
Objective: Patient will call down and order something from room service everyday.

37. Specific Intervention and Client Objectives
2. Intervention: Nutrition Education
a. Review nutrition relationship to his disease
Objective: Patient will be able to explain the effect his disease and health status has on his nutritional status.
b. Recommended modifications
Objective: Patient will be able to explain how to best increase his oral intake (i.e. eat one thing and see how his body reacts so he can figure out if any certain foods cause a bigger problem for him than others).

38. Nutrition Diagnosis
Altered GI function related to ulcerative colitis and colectomy as evidenced by need for TPN and/or EN.

39. Nutrition Intervention
Problem
Altered GI function related to ulcerative colitis and colectomy as evidenced by need for TPN and/or EN.
Long-Term Goal
Discontinue TPN and/or EN as soon as patient is able to consume most of his estimated calories by mouth.
Short-Term Goal
Provide enough calories and protein through TPN and/or EN to meet his estimated needs while avoiding refeeding syndrome.

40. Specific Intervention and Client Objectives
1. Intervention: Food and/or Nutrient Delivery
a. Patient was started on Peptamen AF after being admitted to UVRMC.
Objective: Patient will receive adequate calories and protein to meet his needs and not have any issues with the feeding tube.
Objective: Will be infused at 50% (35mL/hr) of needs on Day 1, 75% (50 mL/hr) of needs on Day 2 and 100% (70 mL/hr) of needs on Day 3. Target infusion rate of Peptamen AF at 70 mL/hr will provide 1660 mL, 2015 kcals, 126 g protein and 1344 mL free fluid which meets his needs.

41. Specific Intervention and Client Objectives
b. Patient was started on TPN after his feeding tube was dislodged because of vomiting.
Objective: Patient will be able to tolerate TPN better than EN.
Objective: Standard TPN will be infused 2.5 L/day and 20% lipids 2 times/week providing 2060 kcal and 100 g protein which will meet KV’s estimated needs.

42. Specific Intervention and Client Objectives
2. Intervention: Nutrition Education
a. Purpose of the nutrition education
Objective: Patient will be able to explain the purpose of enteral nutrition and parenteral nutrition and the role it will play in his recovery.
b. Survival Information
Objective: Patient will be able to explain how he will be able to wean off of EN and/or TPN (i.e. tolerance to oral intake and adequate oral intake). He will also explain his role in the process (i.e. being willing to try foods and not being anxious about it).

43. Nutrition Monitoring and Evaluation
PO intake
Refeeding syndrome
Tolerance of EN and TPN

44. Appropriateness of Care
Pretty appropriate
Multiple doctors
Back and forth
Difference of opinions
Dietitian not consulted each time
TPN not lowered when LFTs started increasing

45. Discharge
To home on TPN

46. References
(1) American Dietetic Association. Nutrition Care Manual.
(2) Mahan LK, Escott-Stump S. Krause’s Food and Nutrition Therapy. 12th ed. St. Louis: Saunders Elsevier; 2008.
(3) Mayo Clinic. Prednisone and other corticosteroids.
(4) Medline Plus. Methotrexate.
(5) Web MD. Drugs &Medications. Remicade+IV.aspx?drugid=16554&drugname=Remicade+IV
(6) Pagana KD, Pagana TJ. Mosby’s Manual of Diagnostic and Laboratory Tests. 4th ed. St. Louis: Mosby Elsevier; 2010.
(7) Periactin Side Effects.
(8) Utah Valley Regional Medical Center Standards of Care
(9) The American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. Chicago: American Dietetic Association; 2011.