Case Study C: Crohn’s Disease
Mr. P.T., age 19, has had Crohn disease, affecting the ileum and part of the jejunum, for 5 years and has had numerous exacerbations. Several members of his extended family have a history of Crohn disease. The purpose to give the pathophysiology of Crohn’s disease, recognize possible triggers that will exacerbate the disease and discuss nutritional deficits with Crohn’s disease.
1. Crohn’s disease, one of the two illnesses that are categorized as inflammatory bowel disease or called IBD. It is characterized by inflammation of the digestive tract, usually occurring in the terminal ileum, part of the small intestines, or in the colon, but it can occur anywhere in the GI tract (Hubert, VanMeter, 2018). The cause of Crohn’s disease is unknown, yet there is correlation noted with genetic and immunological impacts on the gastrointestinal tract where the body is unable to distinguish between self-antigens from foreign bodies (Feld, Glick, Cifu, 2019; Hubert, VanMeter, 2018). Crohn’s disease often presents itself subtly and insidious with the symptoms varying, depending on the location, the extent, and the severity of the involved tissues (Marcil, Levy, Amre, Bitton, Guilhon De Araújo, Szilagy, Seidman, 2019). The occurrence of the disease is chronic and reoccurring (Marcil et al. 2019). Inflammation related to Crohn’s disease manifests itself in sections called skip sections where there are affected segments of tissue followed by normal segments of tissue without inflammation (Hubert et al. 2018). Episodes of inflammation with Crohn’s disease affect the mucosal and submucosal layers and develop into shallow ulcers. As the illness advances, the ulcers join together forming fissures. If the inflammation continues to progress, the inflammation and fibrosis will reach the transmural layer causing the affected section of the intestinal wall to be rigid and thick (Feld et al. 2019; Hubert et. al 2018). Stenosis is common and these changes cause narrowing of the lumen making it easier for total obstruction of the GI tract.
2. Exacerbation of Crohn’s disease can be caused by environmental triggers and stressors (Ta-Chiang, Kern, VanDussen, Shanshan, Kaiko, Wilen, Rajala, Caruso, Holtzman, Feng, McGovern, Nunez, Head, Stappenbeck, Liu, Xiong, Gao, McGovern, 2018). Stress is a leading factor in episodes of Crohn’s due to an increase in blood flow to the GI tract causing increased diarrhea and cramping. Smoking should be avoided as it is noted individuals who smoke require surgery more frequently than nonsmokers (Ta-Chiang et al. 2018 ). Medications such as aspirin, ibuprofen, and antibiotics are hard on the stomach lining or change the bacterial flora allowing Crohn’s to be exacerbated, it is suggested for minimal use of these medications. Finally, dietary intake affects a patients’ Crohn’s process and their wellbeing (Laudisi, Stolfi, Monteleone, 2019). Food triggers vary from case to case but usually foods that increase gas, diarrhea, and hard to process food leads to intestinal inflammation and exacerbation of Crohn’s disease (Feld et al. 2018). By identifying and avoiding possible triggers, one can reduce inflammation caused by Crohn’s disease.
4. Individuals who are diagnosed with Crohn’s disease are at risk for malnutrition due to the intestinal tracts’ inability to absorb nutrients (Wessels, Rink, 2020). A major micronutrient that will be deficient is B12, this is due to the terminal ileum being inflamed and inhibiting the absorption of the vitamin (Laudisini et al 2019). The recommended replacement for B12 deficiency is for a monthly IM of B12 1000 mcg. Other micronutrients that will be deficient are calcium, vitamin D, folate, iron, magnesium, zinc, and pyridoxine. The recommendation is that patients who have Crohn’s disease ingest a chewable or liquid form of a multivitamin. Calories will be diminished as the patient has a hard time absorbing macronutrients. Protein supplements may be needed due to medication use such as steroids and prolonged diarrhea. As advanced health care providers, there is a five-step screening tool assist with malnutrition which is called the MUST (Keetarut, Zacharopoulou-Otapasidou, Bloom, Majumdar, Patel, 2017) assisting providers to develop a care plan. Crohn’s patients require close monitoring for appropriate nutritional intake.
Feld, L., Glick, L. R., & Cifu, A. S. (2019). Diagnosis and Management of Crohn Disease. Jama, 321(18), 1822. doi: 10.1001/jama.2019.3684
Hubert, R. J., & VanMeter, K. (2018). Gould’s pathophysiology for the health professions: Elsevier.
Keetarut, K., Zacharopoulou-Otapasidou, S., Bloom, S., Majumdar, A., & Patel, P. S. (2017). An evaluation of the feasibility and validity of a patient-administered malnutrition universal screening tool (‘MUST’) compared to healthcare professional screening in an inflammatory bowel disease (IBD) outpatient clinic. Journal of Human Nutrition and Dietetics, 30(6), 737–745. doi: 10.1111/jhn.12481
Laudisi, Stolfi, & Monteleone. (2019). Impact of Food Additives on Gut Homeostasis. Nutrients, 11(10), 2334. doi: 10.3390/nu11102334
Marcil, V., Levy, E., Amre, D., Bitton, A., Ana Maria Guilhon De Araújo Sant’Anna, Szilagy, A., … Seidman, E. G. (2019). Erratum: A Cross-Sectional Study on Malnutrition in Inflammatory Bowel Disease: Is There a Difference Based on Pediatric or Adult Age Grouping? Inflammatory Bowel Diseases. doi: 10.1093/ibd/izz275
Sturdik, I., Krajcovicova, A., Jalali, Y., Adamcova, M., Tkacik, M., Sekac, J. Hlavaty, T. (2019, November 30). Pathophysiology and risk factors for cholelithiasis in patients with Crohn’s disease. Retrieved March 8, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/31842581
Ta-Chiang Liu, Kern, J. T., VanDussen, K. L., Shanshan Xiong, Kaiko, G. E., Wilen, C. B., Rajala, M. W., Caruso, R., Holtzman, M. J., Feng Gao, McGovern, D. P. B., Nunez, G., Head, R. D., Stappenbeck, T. S., Liu, T.-C., Xiong, S., Gao, F., & McGovern, D. P. (2018). Interaction between smoking and ATG16L1T300A triggers Paneth cell defects in Crohn’s disease. Journal of Clinical Investigation, 128(11), 5110–5122. https://doi.org/10.1172/JCI120453
Wessels, I., & Rink, L. (2020). Micronutrients in autoimmune diseases: possible therapeutic benefits of zinc and vitamin D. The Journal of Nutritional Biochemistry, 77, 108240. doi: 10.1016/j.jnutbio.2019.108240