ULCERATIVE COLITIS
Ulcers in the colon & rectum. Starting in rectum & works up |
Periods of inflammation & remission |
S/S: cannot store contents, cannot distinguish between gas & solids, fatigue, low energy, small stools |
Montreal classification |
E1: Ulcerative proctitis (distal to the rectosigmoid junction) |
E2: left sided UC (distal to the splenic flexure) |
E3: Extensive UC (proximal to the splenic flexure) |
Causes (both)
not known exactly - genetics, smoking, abnormal immune system, bacteria, environemntal triggers, low fibre |
Risk factors (both)
genetics |
smoking |
infections |
antibiotics |
dysregulated immune response |
Diagnosis (both)
Exclude infections and gastrotroenterities |
Stool test – feacal calprotein (measures inflammation) |
Endoscopy, colonoscoty, sigmoidoscopy, CT/MRI |
Biopsies UC vs DC |
Biochem
↓ RBC |
↑ WBC |
↑ CRP |
UC – ↑ pANCA |
CD - ↑ ASCA |
Medications
Aminosalicylates (Sulfasalazine, Mesalazine) (UC ONLY) |
Long-term to maintain remission in mild-to-moderate UC. Nausea, ↓ appetite, diarrhoea, folate deficiency |
Corticosteroids (Prednisolone, Prednisone, budesonide) |
Reduce inflammation quickly; short term. ↑d appetite, weight gain, fluid retention, bone loss -> Ca & Vit D supps |
Antibiotics (Metronidazole, ciprofloxacin) |
Nausea, ↓ appetite, diarrhoea, ↓ Vit K |
Immunomodulators (azathioprine (Imuran), mercaptopurine(Purinethol), thioguanine (Lanvis) |
supress the immune system. Up to 3 months to work |
Biologics (infliximab (Remicade), adalimumab (Humira), vedolizumab (Entyvio)) |
Target specific inflammation pathways for moderate-severe-IBD. Fatigue, weight changes, ↑d infection risk, altered gut absorption |
Methotrexate |
↓ growth of cells and suppress the immune system. Causes low folate levels. Nausea, ↓ appetite, liver toxicity |
Steroids |
Reduce inflammation. Stimulates appetite. Swelling, weight gain, hair growth and acne. Often need Ca & Vit D supps. |
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CROHN’S DISEASE
Chronic inflammation - affect Entire GIT – commonly end of S.I (ilium) & start of L.I |
immune system upregulated – not able to turn itself off again |
Characteristics: Fat wrapping around bowel. Muscle hypertrophy. Fissures (small tears). Strictures (narrowing of part of the intestine because of scar tissue). Fistulas (opening, connection forms between two organs/skin) |
S/S: Abdominal pain, diarrhoea, weight loss, loss of appetite, anal skin tags, stunted growth (children), mouth ulcers, blood in stools |
CROHN’S DISEASE
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Montreal classification |
Age of diagnosis |
A1 <16 yr |
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A2 17-40 yr |
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A3 >40 years |
Location |
L1 ileal |
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L2 colonic |
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L3 ileocolonic |
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L4 isolated upper disease |
Behaviour |
B1 non-stricturing, non-penetrating |
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B2 stricturing |
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B3 penetrating |
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P perianal disease |
Nut Reqs
E: 125-145kj/kg (active), 100-125 kj/kg (remission) |
P: 1.2-1.5kj/kg (active), 0.8-1g/kg (remission) |
Intervention
Remission = varied healthy diet |
No evidence to restrict fibre unless strictures or an obstruction |
ONS/EN if indicated |
Screen for malnutrition |
CROHNS ONLY DURING FLARE - Exclusive Enteral Nutrition (EEN): nutritionally complete formula as sole source of nutrition – no food, but water allowed (6-8 weeks) |
PAEDS CHRONS ONLY - Crohn’s Disease Exclusion Diet (CDED) + partial enteral nutrition (PEN). Reduces dairy, wheat, animal fat, emulsifiers, pre-packaged foods, alcohol, coffee, artificial sweeteners |
Consider
Strictures, avoid “stringy” = avoid – celery, pineapple, organs, mangoes, gristly meats |
Dairy products – transient lactose intolerance during flares |
Patients mental health – draining, painful condition |
PN – if ileus, ischemia, high output fistula |
Example PESS
Chronic disease or condition related malnutrition (NC-4.1.2) |
Guidelines & References
Bishoff et al. ESPEN practical guideline: Clinical nutrition in inflammatory bowel disease |
Forbes et al. ESPEN guideline: Clinical nutrition in inflammatory bowel disease |
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