Inflammatory Bowel Disease Case Study

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Inflammatory Bowel Disease Case Study

• Rachel Lees
• Specialist Dietitian, HEFT

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Aims

• To consider a Patients experience of IBD
• To gain an appreciation of the complexities of
  IBD how this can impact on Dietetic input
• To reflect on the need to be flexible, there are
  often no absolutes with Dietetic Treatment!
• To remember we need to deliver Patient centred
  care

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Patient Profile

• NR, a female Asian patient born in 1976
• Diagnosed with Crohns Disease in 1999
• ß Thalassemia trait
• Vegetarian
• Avoids milk on cereal
• Height 1.60m, usual weight around 60kg

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History 1

• OP between Nov 02 Dec 04
• Weight 58.6kg, stable
• Crohns active
• Eating small vegetarian meals regularly /-
  Fortisip 1 per day
• Anaemic, started on Iron. Discussed good sources
  of Iron in a Vegetarian Diet
• Advised to have a Colectomy, decided to delay
  this
• Drug Rx Methotrexate, Prednisilone, Calcichew D3
  Forte

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History 2

• Jan 2005
• Admitted 20/1 with L sided abdominal pain
  vomiting. Weight 55kg
• Diagnosis of Crohns Colitis /- Perforation or
  Abcess
• Recommenced on supplements
• Theatre 30/1 for subtotal colectomy Ileostomy.
  No evidence of small bowel Crohns seen in
  theatre

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History 3

• 7/2/2005
• Faecal peritonitis sepsis
• Albumin 10, Mg 0.9
• Re-laparotomy, abdominal drains
• ITU for Ventilation
• NG feeding commenced with Nutrison Protein Plus
• Complex Entero Cutaneous Fistulae Diagnosed

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History 4

• 10/2/05
• Still on NG feed. Aspirates rising
• Feed coming up through Abdo drain
• 2 x small occipital infarcts seen on CT
• Commenced TPN, stopped NG feed, NG tube for
  drainage

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History 5

• 16/2/05
• HDU
• TPN 13.5g N 1800 total Kcals sips of water
• Requiring Insulin
• Problems keeping K within normal limits
• 2/3/05 9/4/2005
• Tubogram shows continued leak
• CRP ?183
• No output from fistula or drains
• Pus draining from abdominal wounds
• Started on free fluids but debate clear free v
  free!!!

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History 6

• 16/3/05 29/3/05
• Pyrexial, TPN stopped line removed
• Weight 45.6 kg
• Stoma acting
• ?fistula drain output
• Pyrexia precludes placement of TPN line
• IVI Therapy

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History 7

• 1/4/05 11/4/05
• Trial of using complete supplements to meet
  nutritional requirements
• Small amount of food introduced, reluctant to eat
• Fistula output ? again
• Became dehydrated needed Gelofusin
• Abdo pain
• USS ill defined collections around liver right
  upper quandrant ? Food stopped

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History 7

• 15/4/05 5/5/05
• CT dilated loops of small ?obstruction, ? Active
  Crohns
• Restarted Enteral Feeding
• Ileostomy contrast shows no obstruction for
  diet fluids
• Reluctant to eat as ?pain, fistula stoma output
  , encouraged low fibre diet Fortisip Forceval
• Discharged 5/5/05 on supplements

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History 8

• 11/5/05-10/05
• Weight 49 53kg
• Several short readmissions
• Small amounts of diet 4-5 Fortisip daily
• Fistula still draining
• Seen by St Marks for opinion.

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History 9

• 10/05 - present
• Regular OP appointments with surgeons
  gastroenterologists
• Course of Infliximab commenced Oct 2006
• Regular dressing reviews by Colorectal nurses
• Mucous fistula Ileostomy
• Wound dehiscence entero-cutaneous fistula
  improving

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Update 1

• Not an untypical experience
• After initial recommendation for surgery managed
  3 years of comparative good health
• Stormy post op period left NR very anxious about
  eating, heavy reliance on supplements
• Another course of Infliximab June 2006 (previous
  2002) Budesonide 6MP

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Update 2

• Still having drainage from fistula 2 years on,
  Team Specialist centre reluctant to perform
  further surgery unless essential
• Less frail, anaemic but weight stable at 57kg
  gradually eating more.
• Continues on Fortisip Forceval
• Encouraged to increase oral intake to build up
  tolerance

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Discussion

• Many changes to Nutritional intervention
  throughout acute phase
• Would have preferred to give Parenteral Nutrition
  for longer but sepsis intervened
• Surgeons needed to respond rapid fluctuations in
  her condition
• ? Benefit of using Elemental formula
• Patient very low in mood tearful for most of
  this period
• Minimal mobilisation

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Conclusion

• No happy ending! But still improving
• Continues to need regular monitoring by surgeons,
  gastroenterologists Dietitian
• Fear of food diminishing
• Altered body image as abdomen is scarred and has
  stoma wound management bags
• Nutritional status sub optimal without
  supplementation