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Complications of
Ulcerative Colitis
Leah WendlandSodexo Mid-Atlantic Intern
February 1st 2013
Objectives
Be able to identify intestinal complications of UC
Be able to identify an extraintestinal complication of UC
Identify a potential treatment of UC and potential side effects of this treatment
Ulcerative Colitis (UC)“Approximately 10% of ulcerative colitis (UC) patients
require a colectomy within 10years of diagnosis”
Ulcerative Colitis (UC)a type of inflammatory bowel disease (IBD) that affects the lining of the large intestine (colon) and rectum
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Intestinal Complications of UC
Malnutrition/Malabsorption Bleeding
anemia
Intestinal Infections Colorectal cancers Colectomy
Extraintestional Complications
Arthritis Diminished bone health Liver and Gall Bladder disorders
primary sclerosing cholangitis (PSC) cirrhosis
Thromboembolism Kidney stones
Treatments for UC
Diet/Nutrition Medication
Aminosalicylates Corticosteroids Immunosuppressants
Surgery
Long term effects of UC medication
Corticosteroids (prednisolone, methylprednisolone) Weight gain, excessive facial hair, HTN,
Hyperglycemia, osteoporosis/weakened bonesAnti-inflammatory
Aminosalicylates (mesalamine, balsalazide) nausea, vomiting, diarrhea, heartburn and headache
Anti-inflammatory
Immunosuppresents (Azasan, Imuran) Increased risk of infection/opportunistic infections
Anti-inflammatory
Nutrition Therapy for UC
Low- fiber diet during flare up High-fiber diet while in remission Possible lactose, gluten or wheat
intolerance Modify diet to fit needs of individual pt
No nuts, seeds, skins, popcorn etc.
AS 47 y/o F
Admitted 12/14 to post acute care/rehab floor
Patient admitted to this floor for PT 2° deconditioning
Antibiotic therapy
PMH
Ulcerative Colitis s/p colectomy 2°
severe colitis HTN GERD Recurrent renal stones Arthritis Appendectomy
Ulcerative Colitis Diagnosis 1996
16 years w/o major complications
Medical Diagnosis
S/P total colectomy with end ileostomy c/b rupture of Hartmann’s stump With perihepatic and intra-abdominal
abscesses Requiring antibiotic therapy
Deconditioning
Colectomy with End Ileostomy
Hartmann’s Stump
Location of Abscesses
Social History
Single Lives alone Has 2 grown children No reported drug or tobacco use
Nutrition AssessmentAnthropometric
Ht: 5’2” (156cm) Wt: 193# (87.6kg) Adj Wt: 130# (59kg) BMI: 34
Subjective/Objective
Pt consuming >75% meals
Stage 2 wound on buttock
Surgical wound on abdomen (healing)
Intra-abdominal abcesses
Nutrition Related Medication
Multivitamin Hydrochlorothiazide Folic Acid Ranitidine Zofran
Labs
Lab Value Range 12/15 12/19Sodium 136-145mEq/L 138 136Potassium 3.5-5.5mEq/L 3.6 3.6BUN 8-18mg/dL <5 L <5 LCreatinine .6-1.2 mg/dL .8 .8BG 70-110mg/dL 79 79Calcium 9-11mg/dL 7.8 L 7.8 LMagnesium 1.8-3mg/dL 2 2Phosphorous 2.3-4.7mg/dL 4.4 4.4WBC 4.8-11.8 11.7 12.5 H
Nutrition DxIncreased Nutrient Needs r/t wound healing a/e/b Stage 2 wound on buttock and surgical
abdominal wound
Unintentional Wt. Loss r/t medical course with low intake and increased needs a/e/b pt
reporting ~20# wt loss in <1month
Diet and Estimated Needs
Regular Diet >75% intake first visit
Ensure Complete TID
Caloric Needs: 30-35kcal/kg 30-35x adj BW59kg=
1770-2065kcal
Protein Needs: 1.3-1.5g/kg 1.3-1.5gx adj BW
59kg= 77-89g
Intervention and M/E
Nutrition Intervention: Rec Ensure Complete
TID Continue multivitamin,
folic acid
Monitoring and Evaluation PO/Supplement intake:
pt to meet ≥75% estimated needs
Weight: Pt to maintain weight +/- 3% in one month
Lab Values: monitor nutrition related lab values WNL
Follow Up
12/19: *my first contact Reported N/V Provided new diagnosis Altered GI function r/t colectomy and recent
hospital course a/e/b Pt reporting N/V, hx ileostomy and colectomy
Medications added Warfarin
Provided ileostomy nutrition education as well as Vit K/ warfarin education
Evaluation of Compliance
AS was actively engaged in education Asked questions Provided feedback on supplement and food Pt appeared to be motivated
Lab Values F/ULab Value Range 12/21 12/27 12/31 1/4 1/10Sodium 136-145mEq/L 139 140 141 140 140Potassium 3.5-5.5mEq/L 2.9 L 3.1 L 3.5 L 3.5
L4.4
BUN 8-18mg/dL <5 L <5 L <5 L <5 L
<5 L
Creatinine .6-1.2 mg/dL .7 .8 .7 .7 .7BG 70-110mg/dL 84 67 84 73 78Calcium 9-11mg/dL 7.3 L 7.6 L 7 L 7.4
L8.0 L
Magnesium 1.8-3mg/dL 1.9 1.6 L 1.7 L 1.8 1.9
Phosphorus 2.3-4.7mg/dL 3.0 3.0 n/a 3.0 n/a
WBC 4.8-11.8 9.5 9.2 9.2 10.9
11H
Date GI distress
PO New Medications
Change to care plan
Education Provided
12/21 No complaints
>50% KCL none Encouraged intake
12/27 N/V <50% none Consider appetite stimulant
Food preferences obtained
12/31 N/V <50% 2.5mg MarinolMagnesium
none Encouraged intake
Follow Up Chart
Follow Up Chart cont.Date
GI distress
PO New Medications
Change to care plan
Education Provided
1/4 Nausea <50%
none Discontinue ensureAdd resource breeze TID, arginaid BID, glutasolve 1x daily
Encouraged intake
1/9 N/V <50%
none MD to place NGT. Discontinue modulars
Encouraged intake, NGT for nocturnal feeds
1/10 N/V <50%
5mg Marinol BID
Attempt NGT again
Educated on importance of NGT
Hospital Course
Updates
References http://www.caet.ca/caet-english/education-ileostomy-guide.htm
http://www.askdrmakkar.com/ulcerativecolitis.htm
Forbes, A., Goldesgeyme, E., & Paulon, E. Nutrition in inflammatory bowel disease. Journal of Parenteral and Enteral Nutrition, 2011; 35(5), 571-580.
Peppercorn, M. Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults. UpToDate,2011
Ma, C., Crespin, M., Proulx, M., DeSilva, S., Hubbard, J., & Hubbard, J. Postoperative complications following colectomy for ulcerative colitis: a validation study. BMC Gastroenterology,2012;
Comorbidity in inflammatory bowel disease (San Roman,Munoz ,2011)
Ardizzone, S., Puttini, P. S., Cassinotti, A., & Porro, G. B. Extraintestinal manifestations of inflammatory bowel disease. Digestive and Liver Disease, 2008; S253-S259.
Herrera, J. Hepatobiliary complications of inflammatory bowel disease. Practical Gastroenterology,2006
Nguyen, G. C., & Sam, J. Rising prevalence of venous thromboembolism and its impact on mortality among hospitalized inflammatory bowel disease patients. American Journal of Gastroenterology, 2008; 2272-2280.
References cont. Warner, B. Short and long term complications of colectomy. Journal of
Pediatric Gastroenterology and Nutrition, 2009; 48(2), S72-S74. Loftus, E. V., Friedman, H. S., Delgado, D. J., & Sandborn, W. J. Colectomy
subtypes, follow-up surgical procedures, post surgical complications, and medical charges among ulcerative colitis patients with private health insurance in the united states. Inflammatory Bowel Disease, 2009; 15(4), 566-575.
Tappenden, K. Quest for excellence: inspiration from the illeum. Journal of Parenteral and Enteral Nutrition, 2010; 34(6), 716-722.
Camden, J., & Carucci, L. Internal illiac pseudoaneurysm rupture attributed to perforated hartmann's pouch diagnosed on ct. Open Journal of Radiology, 2012; 52-54.
Xue, H., Sufit, A., & Wischmeyer, P. E. Glutamine therapy improves outcome of in vitro and in vivo experimental colitis models. Journal of Parenteral and Enteral Nutrition,2011; 35(2), 188-197.
Questions?Thank you!!