Ulcerative Colitis and Malnutrition

SCH Case Study

Kaitlyn Dickson, MS
Sea Mar CHC Dietetic Intern
Objectives
To introduce Ulcerative Colitis (UC) and review
etiology, incidence, history and symptoms
To address both medical and nutritional
therapies related to UC
To discuss a complicated pediatric patient with
UC and malnutrition, his treatment course,
nutrition support, and potential surgical
options

http://www.livestrong.com/article/471678-diet-after-small-bowel-obstruction/
 Inflammatory Bowel Disease
A chronic inflammatory condition of the GI tract, defined by periods of relapse and remission 5
Crohns Disease 5

Affects any portion of the GI tract

Affects all layers of bowel wall
Can present intermittently

Ulcerative Colitis 2

Mucosal inflammation limited to the colon

Affects only the lining of the colon

Indeterminant Colitis 5

Involves clinical findings representative of

http://www.superfoodsam.com/ulcerative-colitis/
both CD and UC
 Incidence, History and Pathophysiology
Incidence
Pathophysiology5

Currently unknown but

250,000 US children are
suspected to be a
currently living with UC1
multidimensional combination
of:
60-80% of pediatric cases
are extensive3
Genetics
Increased Immune
20-30% of pediatric cases
response
require a colectomy3
Environment

Mulder D, Noble A, et al. A tale of two diseases: The history of inflammatory bowel
disease. J Crohns and Colitis (2013), http://dx.doi.org/10.1016/j.crohns.2013.09.009.
 Flare Symptoms and Symptom Management
Clinical Symptoms5
Goal of Care: Manage inflammation
Abdominal pain and symptoms to achieve remission.
Diarrhea
Managed with medical treatment.
Blood in stool
Frequent stooling Diet may be modified to relieve
Night stooling symptoms during a flare:
Abnormal labs
GI intolerance GI1 or GI2 DIet Order
Anorexia Decrease high fat
Malnutrition Decrease fiber
Weight loss Decrease excess sugar
Growth failure Decrease lactose
MNT: 1-Day GI2 Sample Menu
Breakfast: Scrambled eggs, english
muffin, applesauce

Snack: Yogurt with canned peaches (no

sugar added)

Lunch: Turkey sandwich on white bread,

chicken noodle soup, cooked carrots,
mandarin orange

Snack: Crackers with smooth peanut

butter

Dinner: Roasted chicken, white rice with

butter, cooked zucchini http://www.livestrong.com/article/471678-diet-after-small-bowel-obstruction/
 6
Specific Carbohydrate Diet (SCD)
Research has provided evidence that pediatric patients with mild to moderate
Ulcerative Colitis may benefit from dietary therapy as primary intervention

2016 SCH study demonstrated:

Improvements in clinical markers and labs

Shift in fecal microbiota

Limitations:

Small sample size

Diet compliance
Subject bias

http://vaaft.com/diet-in-fistula-specific-carbohydrate-diet/
 UC Flare Medical and Nutritional Therapy
Non-immunosuppressive therapy1 Malnutrition diagnosis may indicate
nutrition intervention:
1. 5-aminosalicylic acids
1. Diet liberalization
2. Antibiotics
2. Oral nutrition supplement
3. Enteral nutrition
Immunosuppressive therapy1 4. Parenteral nutrition

1. Corticosteroids
2. Immunomodulators

Biologics1

1. Anti-TNF alpha therapies

Surgery
https://www.bsna.co.uk/pages/about-specialist-nutrition/parenteral-nutrition
 4
PUCAI: Pediatric Ulcerative Colitis Activity Index
Good discriminant and predictive
validity tool in acute severe colitis
1-2 minutes to complete
Very responsive to change
Used with labs to guide care
Range: 1-85
Goal for discharge <35
Proceed with same therapy 35-45
Surgery is considered >65
Malnutrition Diagnosis related to BMI z-score
A BMI z-score or standard deviation score expresses the anthropometric value as a number of standard deviations
below or above the reference mean or median value, or 50th percentile for age

Mild: z-score <-1

Moderate: z-score <-2

Severe: z-score <-3

1. World Health Organization. Global Database on Child Growth and Malnutrition. http://www.who.int/nutgrowthdb/about/introduction/en/index5.html.
Case Study: Ulcerative Colitis and Malnutrition
Introducing Case Study Patient EP

17 year old young man (caucasian)

Sophomore in high school
Enjoys track and basketball

Admitted to SCH emergency department on

3/26/17 with severe UC flare and dehydration.

Symptoms: profuse stool output, bloody

stool, abdominal pain and decreased appetite
and oral intake.
Severe malnutrition diagnosis as evidence
by BMI z-score less than -2, 12% weight loss in
6 months, and severe muscle and fat wasting
 Disease and Nutrition History Weight History
Previously healthy young man October 2016
August 2016 67 kg
Symptoms began December 2016
September 2016 60 kg
Visit to Emergency Department 10% weight loss in less than 2
Treated with 5 days prednisone and referred to months
Gastroenterology March 2017
October 2016 58.5 kg upon admission to ED at
Presented in SCH Outpatient GI clinic in SCH
Elevated inflammatory markers 12.7% weight loss in less than 6
Endoscopy: pancolitis, normal upper GI months
December 2016 NFPE
Follow-up in SCH Outpatient GI in Severe fat wasting
Diagnosed with Acute Moderate Malnutrition Severe muscle wasting
March 26, 2017 Mid-Upper Arm
Follow-up in SCH Outpatient GI in Circumference: 194 mm
<<5th% (Frisancho)
 Anthropometrics Initial Labs
Admit Height: 185.4 cm LAB Refere Wk Abnormal Lab
Admit Weight: 58.5 kg nce 1 Indication

BMI: 17.2 CRP <=0.8 22.5 Increases with

Ideal Body Weight: 73 kg mg/dl H Inflammation

Percent Ideal Body Weight: 80% ESR 0-15 30 Increases with

mm/hr H Inflammation
Usual Body Weight: 67 kg
Percent Usual Body Weight: 91%
HGB 13-16 14.9 Decreases with

Estimated Requirements
g/dL GI bleed

HCT 37-49 45.2 Decreases with

% Gi bleed
Calories: BMR (1600) x 1.8-2 = 3000-3200
Albu 3.8-5.4 3.1 Decreases with
kcals/day min g/dl GI losses
Protein: 2 g/kg/d = 116 g/day
PUCAI <35 70 Increases with
Fluid: 2600 ml/day for maintenance clinical sx
Progress: Week 1-2
LAB Refere Wk Wk Abnormal Lab
3/29: First Remicade infusion nce 1 2 Indication

CRP <=0.8 22.5 21.3 Increases with

4/1: Began Methotrexate with mg/dl H H Inflammation
folate therapy ESR 0-15 30 --- Increases with
mm/hr H Inflammation
4/4: Second Remicade infusion
HGB 13-16 14.9 10.8 Decreases with
Symptoms and labs remained g/dL L GI bleed

refractory HCT 37-49 45.2 33.5 Decreases with

5% wt loss since admission % L Gi bleed
Poor PO intake Albu 3.8-5.4 --- 3.1 Decreases with
min g/dl L GI losses

PUCAI <35 70 70 Increases with

clinical sx
Progress: Week 3 Dietary Recall
Breakfast: Blueberry cereal with
4/7-11: Quadruple antibiotic therapy
lactose-free milk, cinnamon raisin bagel
Symptoms remained refractory with cream cheese

4/11: Surgery consult Lunch: Grilled cheese sandwich, tomato

soup
4/11: TPN initiated
Snack: Goldfish crackers
Advanced to 71% kcals EEN (2140 kcals)
Weight began to trend up, achieved admit weight
on 4/16 Dinner: Potato chowder with peas, 5
pieces of vegetarian sushi
4/12: Began IV methylprednisolone
(7 day treatment) Oral Intake Provides: 1843 kcals, 71g pro
TPN Provides: 2139 kcals, 117 g pro
Increased appetite, increased PO intake Total Nutrition: 3,982 kcal, 178 g pro
PUCAI was stable, improved CRP
Progress: Week 4
LAB Refere Wk Wk Wk Wk Abnormal Lab
4/16: Vedolizumab infusion nce 1 2 3 4 Indication
Range
4/16: Methylprednisolone
CRP <=0.8 22.5 21.3 1.9 5.6 Increases with
extended to 10 days mg/dl H H H H Inflammation

ESR 0-15 30 --- --- 16 Increases with

Symptoms remained refractory mm/hr H H Inflammation
Weight began to trend down
Surgery to be reconsidered HGB 13-16 14.9 10.8 9.6 10.5 Decreases with
g/dL L L L GI bleed

4/20: TPN advanced HCT 37-49 45.2 33.5 30.2 34.1 Decreases with
% L L L Gi bleed

100% EER (3098 kcals) Albu 3.8-5.4 --- 3.1 --- --- Decreases with
min g/dl L GI losses
PUCA <35 70 70 60 70 Increases with
I clinical sx
 Progress Week 5
LAB Refere Wk Wk Wk Wk Wk Abnormal Lab
nce 1 2 3 4 5 Indication
Weight continued to trend down Range
TPN advanced to 110% EER to
provide 3412 kcals CRP <=0.8
mg/dl
22.5 21.3 1.9
H H H
5.6
H
17.6
H
Increases with
Inflammation
Hypophosphatemia, hyperglycemia
ESR 0-15 30 --- --- 16 --- Increases with
PO intake decreased mm/hr H H Inflammation
Worsening abdominal pain
HGB 13-16 14.9 10.8 9.6 10.5 --- Decreases with
PUCAIs in 80s g/dL L L L GI bleed
Surgery scheduled HCT 37-49 45.2 33.5 30.2 34.1 27.8 Decreases with
% L L L L Gi bleed

Albu 3.8-5.4 --- 3.1 --- --- 2.2 Decreases with

min g/dl L L GI losses
PUCAI <35 70 70 65 70 >80 Increases with
clinical sx
Surgery
Proctocolectomy with ileal pouch-anal anastomosis
Total Proctocolectomy with ileostomy

https://www.trustedtherapies.com/articles/52-surgery-for-ulcerative-colitis https://www.pinterest.com/hhholland/0-the-j-pouch-life/
Conclusions
Ulcerative colitis manifest differently in each patient
Requires catered medical therapy and nutrition plan
Goal of care during a flare is to manage inflammation to achieve
remission
Nutrition can help manage symptoms
During remission the disease is managed by maintenance medications
and a healthy, balanced diet
Colectomy is offered with refractory disease
Curative
Complications can occur
 Time for a Fun Activity!
Write a TPN order (macronutrients only) for EP using the SCH Pediatric (1 year and older)
Parenteral Nutrition (PN) Order

Reference Weight: 57.6 kg

Calories Need: BMR (1600) x 1.8-2 = 3000-3200 kcals/day
Protein Needs: 2 g/kg/d = 116 g/day
Maintenance Fluid Needs: 2600 ml/day

Hint: Start with 5.5 g Dextrose and 1 g Lipids

How many total calories does the TPN provide?

What percent of his EER does this order provide?
References
1. Bradley G, Oliva-Hemker M. Pediatric ulcerative colitis:current treatment approaches including role of
infliximab. Biologics: Targets and Therapy 2012;6: 125-134.

2. Mulder D, Noble A, et al. A tale of two diseases: The history of inflammatory bowel disease. J Crohns and Colitis
(2013), http://dx.doi.org/10.1016/j.crohns.2013.09.009.

3. Turner D, Levine A, et al. Management of Pediatric Ulcerative Colitis: Joint and ESPGHAN Evidence-based
Consensus Guidelines. JPGN 2012;55: 340-361.

4. Seattle Childrens Hospital, Wahbeh G, Esmaili S, et al. Inflammatory Bowel Disease-Ulcerative Colitis Medical
Management. 2012 June. Available from:
www.seattlechildrenshospital.org/pdf/IBD-ulcerativecolitis-medical-management-pathway.pdf.

5. Seattle Childrens Hospital, Williamson N. Clinical Practice Guidelines on Inflammatory Bowel Disease. 2013.

6. Suskand D, MD, Cohen S, MD, et al. Clinical and Fecal Microbial Changes With Diet Therapy in Active
Inflammatory Bowel Disease. J Clin Gastroenterol 2016: 00;00.

7. World Health Organization. Global Database on Child Growth and Malnutrition.

http://www.who.int/nutgrowthdb/about/introduction/en/index5.html. Accessed: April 29, 2017.