Ulcerative Colitis &

Total AbdominalColectomy/End

Ileostomy Cori Glazer

Northwestern HospitalChicago, Illinois

Morrison Dietetic InternFebruary 15, 2018

Acknowledgement

ThankyoutoallmypreceptorsforbeingsopatientwithmeandgivingtheirtimeandenergytoansweranyquestionsIhavethroughouttheinternship,Itrulyappreciateyourtime.

AbigthankyouinparticulartoEmilyTurnertohelpmefindthispatientandbeingsosupportive throughouttheprocess.

OverviewPatientProfileonAdmissionBackgroundResearch/NutritionalImplications– UlcerativeColitis– Totalabdominalcolectomy– Ileostomy

NutritionCareProcess– Assessment– Diagnosis– Interventions– Monitoring&Evaluation

Conclusions

PatientProfile• NHisa57y/oM

• PtwasdiagnosedwithUlcerativeColitisin2005.Sincethen,hehasbeentomultipledoctorsandhastriedmanymedications.

• Ptstartedtakingprednisone40mgdailyon12/14/17.Symptomspersistedandworsenedwith20BM/dayandassociatedwith8lbweightlossPTA.

• AfterafewdaysoftrailIVsteroidsandnoimprovements,thepthadatotalabdominalcolectomy,endileostomy,andimplantationofrectalstumpon1/17/18.

Background Research1,2,3,4,5

Ulcerative ColitisUlcer:spotsinthelargeintestinemucosawheretissueiserodedawayandhasopensoresinthemembrane

Colitis:inflammationofthecolon(largeintestine)

Etiology:• Geneticpredispositionand

autoimmunearethoughttobetheorigin

• Withrecentresearch,ithasbeenseenthatdietandstressaresecondarycausesofUC

UCflareiswhenanewdamagehasoccurredinthelargeintestinewall

Anatomy & Physiology of the Large Intestine1

Majorfunctions:• Asiteforreabsorptionofwater,electrolytes,and

somenutrients– VitaminK,Biotin,Sodium,Chloride,Potassium,

Short-chainfattyacids• Siteforformationandstorageoffeces

• Asmanyas400differentspeciesofbacterialivewithinthecolon• Theyprovidefermentationoffiber,

resistantstarch,andsugaralcohols.

BackgroundResearch6,7LaparoscopicTotalAbdominalColectomy

BackgroundResearch6,7LaparoscopicTotalAbdominalColectomy

Background Research1

Ileostomy• Removalofthecolonandrectum.Theendoftheileumissurgically

attachedtothestoma– Stoma:surgicallycreatedartificialopeningintotheabdomen

• Theindividualwillthenhaveapouchwherethefecesandotherwasteproductsarecollected

• Stooloutputwithanileostomyismuchmoreliquid

Nutritional Implications1,8,9

• Goalsfornutritiontherapy:– Decreaseriskofobstruction

– Maintainnormalfluidandelectrolytebalance

– Reduceexcessivefecaloutput

– Minimizegas• Inordertoreduceodorandinflationofthepouch

Patient Profile• NHisa57y/oM

• AdmittedforexperiencingUCflares(steroiddependent),abdominalcramping,increasedBMfrequency,andbloodydiarrheafor6weeksPTA.

• Colonoscopy(1/16)showedmoderate-severeUlcerativecolitis,despiteIVsteroidtreatmentinthehospital

• Totalabdominalcolectomy,endileostomy,andsubcutaneousimplantationofrectalstump(1/17).

• MedicalHistory:UlcerativeColitis,C.diff,hypothyroidism

NutritionTimeline

1/09:Admitted

1/16:Pthadarescreenduetobeing7thdayadmission

1/19:PtwasassessedduetoaBradenscale<12duetopoornutritionandactivity.

1/17Ptreceivedsurgery

1/23&1/30:Follow-up

2/8:Follow-upwithNutritionEducation

Totalabdominalcolectomy,endileostomy,andrectal

stump.

NutritionalHistoryandAnthropometricsMeasurements

ØHeight:73in(185.4cm,6’1")ØAdmitWeight:222#(100.9kg)ØBMI:29.5(overweight)ØIBW:83.4kg(120%)

FirstNutritionAssessment(1/19)POD#1endabdominalcolectomy/endileostomy

• Significantevents/Issues– ThedaybeforeCODEwascalledbecausethepatientwasfoundpulseless.

– PtwasthenreturnedtoSICUincriticalconditionduetohemorrhagicshock.Pthadseverelacticacidosis,acutekidneyinjury,andstartedContinuousVeno—VenousHemodialysis(CVVH),andwasintubated

NutritionIntervention(1/19)PESstatement:Inadequateenergyintaker/talterationinGIstructure/functionasevidencebyweightlossPTA,severeepisodesofdiarrhea/day,anddxofulcerativecolitis.

EstimatedProteinneeds:100-167g(1.2-2.0g/kgIBW)REE:2108kcals(PennStateEquation,2003b)

NutritionOrder:NPO(day4).

Labsofnote:BUN:26,Cr:2.28,glucose:91-268over24hours

Labmonitoring:Recommendclosemonitoringofphosphorous,potassium,andmagnesium(atleastdaily)d/triskforrefeedingsyndrome.

Monitoring/Evaluation:MonitorGIfunction,labvalues,medications,skinintegrity,weighttrends

Follow-update:1/23/18

ImportanteventsbetweenthenextFollow-Up

• Ptwasstartingtofeelwell• Ptwasextubated1/22andswitchedtoanasalcannula• PtwasonCVVHandswitchtoHemodialysis(HD)on1/22• Hewaspassingsmallamountsofclotsandairintheileostomy

bag• Showinggoodsignsofimprovement

NutritionFollow-Up(1/23)

• Diethistory:– PTApt wasnotfollowinganyparticulardiet– Perpt report,helost8lbsassociatedwith20BMs/dayandpoorPOintake

• Ptreportedtotolerateclearliquidsbuthasapoorappetiteduetorecentsurgery.

• Deniesabdominalpain/nausea/vomitingrelatedtofoodintake

NutritionIntervention(1/23)PESstatement:Inadequateenergyintaker/talterationinGIstructure/functionasevidencebyweightlossPTA,severeepisodesofdiarrhea/day,anddxofulcerativecolitis.-remainsofconcern.

NewPESstatement:Moderatemalnutritioninthecontextofacuteillness,relatedtoalterationinGItractstructure/function,asevidencedbyenergyintake<75%ofestimatedrequirementsx>7daysand4%weightlossin1month.

Dietorder:ClearLiquids

Ileostomyoutput(1/22):50mL(1/21):170mL

Labsofnote:BUN:41,Cr:3.88,glucose:132

EER:2480-2580(25-26kcals/kgadmit),119-139g(1.2-1.4g/kgadmit),fluidsperMD

– Changedbecausept nolongerisintubated

Labmonitoring:RecommendclosemonitoringofPhos,K+,andMg(atleastdaily)d/triskforrefeedingsyndrome

Monitoring/Evaluation:Monitorfoodandnutrientintake,POtolerance,weight,labs,skinintegrity,e'lytes,ostomyoutput

Goals:ToleratePOintakeandnofurtherdrywt loss

TPNrecommendations:Ifptisunabletotoleratedietadvancement,considernutritionsupportserviceconsultandinitiationofTPN.Ptismalnourishedandwithoutadequatenutritionforx8days.

ImportantEvents• 1/24:Theptwasunabletotolerateclearliquidsduetonausea/emesisthatoccurred– TPNwasstarted(1/24)

• 1/26:OnCVVH.NGThelpedn/vthroughoutthefewdays.Onnasalcannula.

• 1/28:stoppedCVVHandstartedHD.NGTremovedlaterthatday.

• 1/29CTscanthatfoundgascystsofthebowelwallandtheywereconcernedforischemicsmallbowel– TPNwasheldd/tpatientfebrileat101.7Fthatmorning–awaitbloodculturestobenegative>48hoursperprotocol

Follow-Up(1/30):NutritionInterventionPESstatement:• Moderatemalnutritioninthecontextofacute

illness,relatedtoalterationinGItractstructure/function,asevidencedbyenergyintake<75%ofestimatedrequirementsx>7daysand4%weightlossin1month(remainsofconcern).

• Wt Hx:Admitwt (1/9):222lb (100.9kg)Updatedwt (1/24):231lb (105kg)– Weightchangeslikely2/2fluidshifts

• EstimatedNutritionalNeeds:Calories:2085-2502kcals(25-30kcal/kgIBW)Protein:100-125g(1.2-1.5g/kgIBW)Fluid:perMD– Changedrequirementsduefluidshifts

• Labsofnote- BUN:70,Cr:8.51

• Meds:PPI,ZofranPRN,HumaLOG PRN

Dietorder:NPOforbowelrest.ResumePNassoonasmedicallyableandcontinueuntilGItractfunctionalorPOintake/tolerance.

Goals:ToresumePNandtoadvancedietassoonasmedicallyable.

Monitor/Evaluate:MonitorGIfunction,labvalues,medications,skinintegrity,ostomyoutput,andweight.

NutritionEducation:Willf/uforileostomyandrenaldietguidelineseducation,whenappropriate.

SignificantEvents• 1/31:restartTPN,bloodculturesnegative• 2/01:Pthasgoodostomyoutput

– Meetingestimatedkcalandproteinneeds.Bloodsugaracceptable.K+,Mg,CaandPhossupplementationwereadequate.

• 2/2:IRvascularcatheterplacedforcontinuedHD.• 2/4:Ptwasfoundtohaveanewlineassociatedwithdeep

veinthrombosisintherightcommonfemoralvein.– Ptstartedwarfarin

• 2/5-2/6:TPNcontinues,clearliquidsallowed.• 2/7:Fullliquidsinthemorning.PtadvancedtoGIsoftlater

intheday.Overnight,thept experiencedemesisx2.

NutritionEducation2/8EndIleostomy

• Asaptrecoversfromsurgery,followalowfiberdiet.• Forthefirst6weeks:

– choosecookedorprocessedfruits/vegetables,refined(white)grains,anddairyastolerated

Topreventblockage:1) Eatslowlyandchewfoodthoroughlytoprevent

blockage2) Avoidskins/fibrousrawfruits&vegetables

Toreducegas/preventodor:1) Avoiddrinkingstraws2) Avoidcarbonated

beverages3) Limitfruit&vegetable

skins

Topreventdiarrhea/helpthickenstool:1) Avoidspicy,fried,andgreasyfoods2) Avoidsweetenersandfoodshighinsugar3) Limitcaffeineandalcohol4) Onceabletoincorporatefibertomeals,thatwill

helpprovidebulktostoolandslowmovementthroughintestine

Otherimportanttips:1)Small,frequentmeals2)Somefoodmaychangethecoloroftheoutput3)Eatthelargestmealduringthemiddleofthedaytoavoidhighostomyoutputatnight4)Donotskipmeals

LowFiberDietforIleostomyPatients10,11,12,13,14,15

FoodGroup FoodstoChoose FoodstoAvoidDairyProducts lowfatmilk,cheese(creamcheese,small

amountsofBrie,sourcream) plainyogurtCheesewithseeds/nut,yogurtwithseeds/nuts/fruitskins

Proteins Groundorwell-cooked tenderbeef,ham,veal,pork,orpoultry,eggs/eggwhites,fish,sardines,hummus,liver,smoothpeanutbutter,tofu

Toughfibrousmeats, chunkypeanutbutter,driedpeasandlentils,soybeans,kidneybeans,blackbeans,veggieburger,shellfish,delimeatswithwholespices,soybeans,almonds,peanuts, cashews,walnuts,pumpkinseeds, organmeats,chickenliver,beefliver, oysters, crayfish

Breads,Starches White, rye,grahambreads,sweetrolls,pretzels,creamofwheat,drycerealsfromcorn,rice,oats,refinedwheat,oatmeal,potatoeswithoutskins,whiterice,cornorflourtortillas,grahamcrackers,crackers,pitabread,pancakes,potatochips

Breads/rolls/crackers withaddedbran,seeds,nuts,orcoconut,wholegraincereals,“highfiber”cereals,wholewheatpasta,potatoskins,brownrice,popcorn,quinoa, branmuffin, raisinbran, wheatgerm,potatoeswithskins

Vegetables Asparagustips,beets,broccolitips,carrots,peeledeggplants,pureedvegetableswintersquash,pumpkin,avocado,

Allrawvegetables,bakedbeans,kale, Brusselsprout,cabbage,cauliflower,greenpeppers,collardgreens, onions,corn,cucumber,sweetpotatoes,greenbeans,spinach, chickpeas,broccoli,mushroomslentils,turnipgreens,tomatoes, zucchini,SwissChard,artichokes

**ProteinsaretypicallyhighinPhosphorusandPotassium,somakesureyouareonlyeating2-3ozpermeal/snack

LowFiberDietforIleostomyPatients1,11,12,13,14,15

FoodGroup FoodstoChoose FoodstoAvoidFruit Cookedandcanned: applesauce,peaches,pears,

mango,pureedfruits,fruitcocktail,mandarinoranges,bananas

Apples,apricots,berries,grapefruit,grapes,freshpeaches,freshpears,pineapple,driedfruit, coconut,cranberryproducts, cranberry juice,prune juice, oranges,melons,nectarines,cantaloupe,kiwi,pomegranate

FatsandOils Margarine, butter,cream,oliveoil,vegetableoilspreads,plainsaladdressingsmadefromallowedfoods

Soybean oil,canolaoil

Desserts,Sweets Low sugaricecream,popsicles,pudding,honey,chocolatesyrup,cookies,sherbet,piesfromallowedfruits,hardcandy,marshmallows,gelatin

Dessertsorcandythatcontainnuts,coconut,dried fruits,jam,preserves,ormarmaladewithseeds

Other Broth,cream/pureed/homemadesoups madefromallowedfoods,mustard,alternativeyogurts,ricemilk,almondmilk,spicesandherbs

Soupsmadefromvegetablesnotallowed, pizzamadewithnotallowedvegetables,hotchocolate,greentea,seeds,olives,coconutwater,molasses

NutritionEducationSixweeksaftersurgery

• Afterstarting6weekspost-op,itisrecommendedtoaddonenewfoodeveryfewdays.Startwithfoodsthatthepatientwasabletoeatwithoutproblemsbeforesurgery

• Slowlyaddfiberfoodsbackintoyourmealstoallowyourbodytogetusedtothem– Itisbesttokeepalistoffoodsthatcausethesesymptoms.Ifacertain

foodcausessymptoms,avoiditfor2to3weeks.Then,tryitagaininsmallamountstoseehowhisbodyreactstothefood.

– Trailanderror(andsmallamountsofit)todetermineifyouareabletohandlethem

Hydration11

• Pt’s withanileostomylosemorebodyfluids,andatagreaterriskofdehydration.

• Spreadoutaminimumof8-10cupsofwaterperday

• Avoidhigh-sugardrinks,alcohol,andcaffeine• Nocarbonation• IncludedrinksthatrehydratethebodywithaddedelectrolytessinceyouarelosingPhos,Na,andK+

HYDRATIONP t ’ s w i t h a n i l e o s t o m y l o s e m o r e b o d y f l u i d s , a n d a r e a t a g r e a t e r r i s k o f d e h y d r a t i o n .

11

S p r e a d o u t a m i n i m u m o f 8 - 1 0 c u p s o f w a t e r p e r d a y

A v o i d h i g h - s u g a r d r i n k s , a l c o h o l , a n d c a f f e i n e  

N o c a r b o n a t i o n  

I n c l u d e d r i n k s t h a t r e h y d r a t e t h e b o d y w i t h a d d e d e l e c t r o l y t e s s i n c e y o u a r e l o s i n g P h o s , N a , a n d K +  

OstomyOutputTrends1

NormalIleostomyOutputRange:<1,200mL(or1.2liters/day)

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400

600

800

1000

1200

Ileostomyou

tput(m

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Discharge?• Theplanisforthept tobeonwarfarinforatleast3monthsthenitwillbedecidedifitisstillneeded

• ContinueHDMWF• AfterdischargeatNorthwesternthept willbegoingtoaninpatientacuterehabduetoshowinglimitationsofdailylivingtaskswithoccupationaltherapy

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14) Woolf, I. L., & Babior, B. M. (1972). Vitamin K and warfarin. The American Journal of Medicine, 53(3), 261-267. doi:10.1016/0002-9343(72)90167-2

15) Cohen, A. B., Lee, D., Long, M. D., Kappelman, M. D., Martin, C. F., Sandler, R. S., & Lewis, J. D. (2012). Dietary Patterns and Self-Reported Associations of Diet with Symptoms of Inflammatory Bowel Disease. Digestive Diseases and Sciences, 58(5), 1322-1328. doi:10.1007/s10620-012-2373-3

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Questions?