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

Question 1

What are the 2 inflammatory bowel diseases?

Answer 1

• crohns disease
• ulcerative colitis

Question 2

What is the etiology of IBD?

Answer 2

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

Question 3

What are some outcomes of malnutrition in IBD?

Answer 3

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

Question 4

What are some complications of IBD?

Answer 4

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

Question 5

What is the incidence of UC?

Answer 5

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

Question 6

What is the incidence of CD?

Answer 6

• 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

Question 7

Pathophysiology of UC

Answer 7

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

Question 8

Pathophysiology of CD

Answer 8

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

Question 9

Complications of IBD

Answer 9

also ulcers

Question 10

Problem with toxic megacolon?

Answer 10

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.

Question 11

Layers of small intestine

Answer 11

Question 12

Difference in inflammation between UC vs. CD

Answer 12

• 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

Question 13

Describe a fistula

Answer 13

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

Question 14

Describe a stricture

Answer 14

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

Question 15

What factors lead to inadequate intake with malnutrition?

Answer 15

• anorexia
• nausea
• vomiting
• dietary restriction w/o supplementation

Question 16

What factors lead to decreased malabsorption with malnutrition?

Answer 16

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

Question 17

What factors lead to excessive losses with malnutrition?

Answer 17

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

Question 18

What factors lead to ↑ requirements with malnutrition?

Answer 18

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

Question 19

How do corticosteroids effect nutrients?

Answer 19

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

Question 20

How do Sulfasalzine (NSAID) effect nutrients?

Answer 20

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

Question 21

How do cholestyramine effect nutrients?

Answer 21

reduced absorption of fat soluble vitamins

Question 22

What are critical areas of malnutrition?

Answer 22

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

Question 23

problem with proximal jejunum inflammation/ removal

Answer 23

major area of nutrient absorption

Question 24

problem with distal ileum <100 cm inflammation/ removal

Answer 24

• bile salt wasting
• diarrhea, mild steatorrhea

Question 25

What is steatorrhea?

Answer 25

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

Question 26

problem with distal ileum >100 cm inflammation/ removal

Answer 26

* bile salt depletion * severe steatorrhea * fat soluble vitamin deficiency * hypomagnesemia/ hypocalcemia * vitamin B12 deficiency * fluid and electrolyte imbalance

Question 27

Adjunctive vs. exclusive therapy

Answer 27

adjunctive: combination of therapy exclusive: using only 1 therapy

Question 28

Problem with Ileocecal valve inflammation/ removal

Answer 28

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

Question 29

Problem with Ascending colon inflammation/ removal

Answer 29

fluid and electrolyte abnormalities

Question 30

IBD treatment

Answer 30

**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!

Question 31

Purpose of nutrition care in IBD?

Answer 31

* 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)

Question 32

Diet therapy during acute phase

Answer 32

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

Question 33

What are some typical approaches to diet therapy?

Answer 33

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

Question 34

Bowel rest diet therapy

Answer 34

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

Question 35

Exclusve Ng tube feeding

Answer 35

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

Question 36

Crohns disease exclusion therapy

Answer 36

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

Question 37

Phase 1 of Crohns disease exclusion therapy

Answer 37

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

Question 38

Phase 2 and Crohns disease exclusion therapy

Answer 38

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

Question 39

Phase 3 of Crohns disease exclusion therapy

Answer 39

week 13 onwards - maintenance