Medical Nutrition Therapy in

Crohns Disease Patients

UNIVERSITY OF MARYLAND, COLLEGE PARK
DIETETIC INTERNSHIP PROGRAM
ANASTASIA MACZKO
MAY 6, 2015

Objectives
Define and differentiate the types of IBD
Identify the Medical Nutrition Therapy associated

with Crohns Disease patients

Discuss the implications of findings to the Dietetic

Practice

Inflammatory Bowel Disease

O IBD involves chronic inflammation of all or part of the

digestive tract
Crohns Disease

Ulcerative Colitis

Inflammation may occur anywhere

along the digestive tract (damage to
large/small intestine)

Large intestine (damage to large

intestine and rectum)

Inflammation may occur in patches

Continuous inflammation

Ulcers deeper into bowel wall

Ulcers remain in inner lining

Abdominal pain, GI bleed,

malabsorption, weight loss, diarrhea,
vomiting, stomach ulcers

Abdominal pain, bloody diarrhea,

dehydration, loss of appetite,
malabsorption, rectal bleeding, weight
loss, urgent bowel movement

Crohns Disease
Etiology unknown

Hereditary? Diet? Stress? Environment?

Combination of clinical judgment, lab values, endoscopy/CT
scans

Treatment variable

Altered diet
Bowel resection

70% of CD patients require surgery

30% of patients who have surgery will experience S/S in 3 years
60% of patients who have surgery will experience S/S in 10 years

Medication suppress immune system

Alternative Therapies
Nutrition Supplements

Zinc

Folic Acid

B12

Vitamin D

Calcium

Omega-3 Fatty Acids

Probiotics

B-acetyl glucosamine

Acupuncture
Herbal Medications

Slippery elm

Marshmallow

Turmeric

Cats claw

Homeopathy

Mercurius

Podophyllum

Veratrum album

Dietary Interventions
Increased risk of Malnutrition

S/S: decreased appetite, nausea, abdominal pain, altered taste

buds, decreased absorption related to intestinal inflammation, need
for increased energy/protein needs

60-75% of CD patients

Goal = maximize oral intake to prevent malnutrition and

dehydration
Varies

Low-fiber/residue or low-fat diet

Bowel rest (CLD)

Bowel resection enteral/parenteral nutrition

Nutrition Assessment

Meet Patient X
47-year-old Caucasian male
Signs/Symptoms x 1 week PTA

Abdominal pain

Poor appetite

Persistent cough

Postnasal drip

Fever

Chills

PCP started patient on Cipro and Flagyl

CT scan revealed pockets of abscess inflammation
Admitted October 2, 2014

Patient History
220-lbs, 60 BMI=29

Weight remains stable at 220-lbs x 5 years

124% IBW

Medications

Ciprofloxacin, Fluticasone Nasal, Metronidazole, Protonix, Prednisone

No past medical history

Surgical history Age 17, ileoascending colectomy
No allergies
Married w/ no children
Active Job
History of smoking (quit 2 yrs ago)
Social drinking on weekend (6-10 beers)

Nutrition Diagnosis

Diagnosis
NC-1.4: Altered GI function related to compromised

function of GI tract as evidenced by Crohns disease

flare up and bowel inflammation via abdominal CT
scan.
NI-5.3: Inadequate protein, energy intake related to
restricted po intake as evidenced by

current clear liquid diet order not meeting patients energy needs.
(10/3/14)
current clear liquid diet and PSS not meeting patients energy
needs. (10/6/14)
current NPO diet order for bowel rest 2/2 Crohns Disease and PSS
not meeting patients energy needs. (10/8/14)

Nutrition Intervention

Energy & Nutrient Needs

Source
Facility Standards
EAL
Online Nutrition
Care Manual

Kcal
Requirements
2,187-2,417 kcals
(Mifflin St Jeor)
2,187-2,417 kcals
(Mifflin St Jeor)

Protein
Requirements
100 g protein (1.0
g/kg)
n/a

2,500 kcals (25

kcal/kg)

100-150 g protein
(1.0-1.5 g/kg)

Fluid
Requirements
1,296-2,495 mL
(20-25 mL/kg)
2,187-2,417 mL
(Adolph Method 1
mL/kcal)
2,187-2,417 mL
(Adolph Method 1
mL/kcal)

Dietary Regimen
24-hr diet recall

Diet

Modifications Intake

10/03/2014 Clear Liquid

Diet

------

100%

10/04/2014 Clear Liquid

Diet
10/09/2014 NPO

------

100%

------

------

Nutrition
Intake
Supplements
Ensure Plus
100%
(3x/day)
PSS, Ensures
discontinued
TPN, PSS
discontinued

-----------

Monitoring & Evaluation

Discharged on October 11, 2014
Home-TPN

IV Cipro, IV Flagyl, Prednisone, Protonix, Fluctinase

Cycled 24-hours prior to discharge

Return to facility x 2-4 weeks for CT scan per MD
Continue to follow-up with MD every 6 months

Nutritional Implications to the Dietetic Practice

Every patient is different!
RDs play crucial role in identifying trigger foods

and examining 24-hr recall

Discuss with patient herbal-supplement interaction
Determining appropriate diet (i.e. soft, CLD, bowel
rest) and making recommendations for advancement
Coordinating with MD to discuss nutrition support
More research is needed

Probiotics? Trickle feed? Enteral vs. Parenteral

Thank You!

What are your questions??

References
Mahan KL, Escott-Stump S, Raymond JL.

Krauses food and nutrition care process. 13th ed. St. Louis, MO: Elsevier; 2012.

Print.
Donnellan CF, Yann LH, Lal S. Nutritional management of Crohns disease. Therapeutic Advances in
Gastroenterology 2013;6(3):231-242. doi:10.1177/1756283X13477715.
Forbes A. Nutrition in inflammatory bowel disease. Journ of Parenteral and Enteral Nutrition. 2011:35(5):571-578. Print.
American Dietetic Association. Nutrition Care Manual. Crohns Disease and Ulcerative Colitis: Background Information.
http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=19449&ncm_heading=Nutrition%20
Care&ncm_content_id=92009#NutritionSupport
. Accessed November 16, 2014.
Romagnani P, Annunziato F, Baccari MC, Parronchi P. T cells and cytokines in Crohns disease. Curr Opin Immunolog.
1997;9(6):793-9. http://www.ncbi.nlm.nih.gov/pubmed/9492980
Brand S. Crohns disease: Th1, Th17 or both? The change of a paradigm: new immunological and genetic insights implicate
Th17 cells in the pathogenesis of Crohns disease. Gut. 2009;58(8):1152-67. doi: 10.1136/gut.2008.163667.
Hendrickson BA, Gokhale R, Cho JH. Clinical aspects and pathophysiology of inflammatory bowel disease. Clin Microbial
Rev. 2002;15: 79-94. http://cmr.asm.org/content/15/1/79.full
University of Maryland Medical Center. Crohns disease: Complementary and Alternative Therapies.
http://umm.edu/health/medical/altmed/condition/crohns-disease
Manual of Clinical Dietetics, 6th ed. American Dietetic Association, Chapter 1, Nutrition Assessments of Adults. 2000, p.
33. http://www.andeal.org/topic.cfm?menu=2820&cat=3217
Charney P, Malone AM. Nutrition Assessment. 2nd ed. Chicago, IL: American Dietetic Association; 2009.
http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=19449
Eiden K. Nutritional considerations in inflammatory bowel disease. Pract Gastroenterol. 2003; 33-50.
http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=19449