Nature of Crohns Disease - Research Paper Example

? Crohn’s Disease According to the National Institutes of Health, Crohn’s disease is a form of inflammatory bowed disease which usually affects the intestines but may occur anywhere in the digestive system from the mouth to the end of the rectum, where the intestinal wall abnormally thickens. It is usually caused by genes and family history, environmental factors, over-reaction of the body towards normal bacteria in the intestines, and smoking. Nevertheless, the primary cause of this autoimmune disease is unknown, although the main reason why there is a corresponding weight loss in patients diagnosed with Crohn’s disease is the protein-energy malnutrition brought about by the reduced intake of calorie as well as anorexia. Anorexia is caused by cytokines that originate from the inflamed gut (Day et al. 294). Crohn’s disease has several symptoms. The major consequence of digestive problems is nausea, enhanced gastro-colic reflex and abdominal discomfort, and all these also indirectly lead to diminished food intake. Furthermore, there is malabsorption in the intestines. The physical symptoms of the disease include crampy abdominal pain, fever, fatigue, weight loss, loss of appetite, tenesmus, and diarrhea (Day et al. 294). Minor symptoms include skin rashes, vomiting, eye irritation, swelling and pain of the joints, and high temperature (“Crohn’s Disease”). Other symptoms include psychological disturbances which increase in severity as the disease worsens, and even poses as a high risk for developing psychiatric disorders (Assche et al 2010). Basically, the result is reduced food intake, reduced nutrient use, which may ultimat lead to impaired nutrition status in the patient (Vagianos et al. 311). Basically, the solution to the disease is medications, surgery and nutritional intervention. Review of Literature The goal of enteral nutrition as an intervention for patients with Crohn’s disease is to replenish the missing nutrients in the patient’s body as well as to treat the disease itself usually through effecting remission. Usually, patients with Crohn’s disease have inadequate amounts of vitamins E, D, A, and C, as well as the minerals calcium, folate and iron. Moreover, it is characteristic of people with inflammatory bowel disease that they seem well nourished and appear to be so but actually they have micronutrient deficiencies (Vagianos et al. 318). Nutritional therapy is considered a “valid and effective” treatment in Crohn’s disease. Among the advantages of this intervention is to induce remission and control of inflammatory changes, to heal the mucosa, to promote growth and overall status in terms of nutrition, and to avoid other forms of medical therapies. Nutritional therapy indeed has direct mucosal anti-inflammatory effects as well as it alters intestinal microflora, both for the benefit of the patient with Crohn’s disease (Day et al. 293). The technical term used for the nutritional intervention for Crohn’s disease is Exclusive Enteral Nutrition, or EEN, and this refers to an “enteral formula, either elemental or polymeric, which is given exclusively instead of normal diet as a distinct therapy” (Day et al. 295-296). EEN began in Europe even in the 1970s because of its rumored benefits on patients suffering from any of the inflammatory bowel diseases like severe colitis and gut inflammation (Day et al. 296). One benefit of EEN is that it can help maintain remission and it can delay the need for further therapy such as the use of corticosteroids. Moreover, EEN also have long-term benefits which include not only the absence of a relapse after the establishment of remission and the delay of the need for further medication but also improved weight, greater mucosal improvements, and greater complete healing (Day et al. 300-303). Moreover, EEN can exert numerous anti-inflammatory benefits as well as bowel rest, nutritional improvements, boosting of immunity and alteration of intestinal microflora (Day et al. 300-303). One more benefit is that there is also improved growth among patients undergoing EEN (Dziechciarz et al. 804). Before EEN is administered as a form of intervention in the treatment of Crohn’s disease, nutritional assessment is important as the very first step in ensuring a successful nutrition management program for the patient. Moreover, nutrition assessment begins with the identification of factors that alter the degree of nutrient intake of patients suffering from Crohn’s disease. Since Crohn’s disease is characterized by nutrition abnormalities resulting from decreased food intake, malabsorption, and medications, it therefore follows that a number of factors must be considered before EEN should be administered. These factors include a decreased intake of nutrients, the occurrence of nausea, vomiting, abdominal pain, and diarrhea, the use of restrictive diets, the side effects of medications, the presence of oral aphthous ulcerations, the increase in the need for vitamins and minerals, the overgrowth of bacteria, the loss of blood, the occurrence of malabsorption, and the suppression of appetite as well as changes in taste. These factors may then be determined through a physical exam, a nutritional history, objective laboratory parameters, as well as clinical judgment. Moreover, there is also subjective global assessment, or SGA, which is one useful tool for screening patients with Crohn’s disease or any other IBD (Eiden 33-34). Nutritional assessment for Crohn’s disease patients is rigid. One way to do it is through the measurement of height, weight, mid-upper arm circumference or MUAC, tricep skin fold or TSF, mid-arm muscle circumference of MAMC, mid-arm muscle area or MAMA, and mid-am fat area or MAFA. In the case of height, it is measured using a wall-mounted stadiometer using a standardized scale that measured the nearest 0.1 cm. Body weight was measured in such a way that the participant used only minimum clothing using an electronic scale that contained a digital readout with an accuracy of 0.01 kg. The necessary data for body mass index, or BMI, was then calculated using height and weight. The mid-upper arm circumference was measured using a scale that had an accuracy of 0.1 cm using a non-stretchable tape. The triceps skinfold thickness was measured with the use of Harpendien calipers. Moreover, all the measurements were taken using the non-dominant arm. Data on MUAC, TSF, MAMC, MAFA and MAMA were then used to compare with the standard values that the reference population had. From these, the ideal body weight, or IBW, is calculated. Later on, considering all the values that have been derived from the calculations – %IBW, BMI, %TSF, %MUAC, %MAMC – if any three were abnormal, the patient was classified either malnourished or not (Benjamin et al. 196). Moreover, in addition to body mass index, serum albumin level is also another one of the “most predictive” determinants of malnutrition (Mijac et al.). Aside from the aforementioned factors that should be assessed in a patient with Crohn’s disease, there are still various biochemical indices that should be taken into consideration in order to determine the patient’s nutrition status. Among these are the patient’s complete blood count, total protein, phosphate, calcium, 25-hydroxy vitamin D, vitamin B12, carotene, zince and ferritin levels, which are all expected to be lower than standard levels (Vagianos et al. 312). It is expected that patients with Crohn’s disease or any inflammatory bowel disease would also have a lower hemoglobin level (314). Furthermore, as Crohn’s disease may extend up to 20 years, this particular duration is characteristic of those with lower serum carotene levels (315). Lastly, a significant number of patients with Crohn’s disease develop anemia or iron deficiency at around 40% (317). These aforementioned micronutrient deficiencies in the patient with Crohn’s disease may actually not manifest in the gross physical appearance but may only be noticeable as laboratory results. Thus, those with Crohn’s disease may really appear healthy until one sees the results of their laboratory tests on their micronutrient levels. Moreover, the patient’s resting energy expenditure, or REE, was also taken. The resting energy expenditure is the amount of energy expended during rest or inactivity. The data for this is taken during a follow-up as it is compared with total caloric intake. Moreover, the subjects are not allowed to consume any food or drink at least two hours before REE is analyzed “to avoid the transient thermic effect of intermittent food on the REE” (Vagianos et al. 312). The recent dietary intake of the patient is also crucial to determining the type of EEN that must be used as an intervention in his case. Care should be taken to ensure that every meal that the patient takes must be measured, including midmorning and evening snacks. The types of foods as well as their respective quantities must be measured. Other information that should be taken includes the types and amount of fat or oil that the patient has used as a cooking medium, as well as the types of macronutrients – protein, energy, carbohydrates and fats – taken in by the patient recently. Moreover, the nutritionist should also try to find out whether there have been any food restrictions or prescribed special dietary changes and recommendations that were made by the patient recently. Furthermore, the patient’s physical activity factor must also be determined. A recommended scale for determining physical activity factor is 1.2 for bed-ridden patients, 1.3 for ambulatory patients, 1.2 for sedentary workers and 1.3 for moderate workers (Benjamin et al. 196). Three types of recommended EEN formulas for patients with Crohn’s disease include elemental enteral formula, or formulations of amino acids; semielemental or oligomeric enteral formula, or formulations of amino acids as well as oligopeptides; and polymeric formula, or whole protein (Dziechciarz et al. 2007). Basically, the nutritional formula for patients with Crohn’s disease consists of energy, carbohydrates and fat components but may differ in the source of nitrogen, for this is usually intact in polymeric formulas while hydrolyzed in elemental ones. Nevertheless, the form of nitrogen sources – whether hydrolyzed or polymeric – is “irrelevant to [the enteral nutrition’s] therapeutic effectiveness” (Yamamoto et al.). Although in one study, remission was successful in more patients who had elemental enteral nutrition (80%) compared to those who had enteral polymeric nutrition (55%), the conclusions still say that there were no significant differences between the two types of enteral nutrition (Verma et al.). A few examples of branded enteral nutrition products include Osmolite and Promote, manufactured by Ross Laboratory and priced at $7.20 and $7.70 per 1000 Kcal respectively, and which are both polymeric. Examples of elemental forms include Criticare HN and Modulen IBD, manufactured by Mead Johnson and Nestle respectively, and priced at $27 and $8 per 1000 Kcal. Two oligomeric formulas, Peptamen and Subdue, are manufactured by Nestle and Mead Johnson respectively, and priced at $25.06 and $19.79 per 1000 Kcal respectively (Eiden 48). Inside the patient’s body, EEN directs anti-inflammatory effects, causes nutritional improvements, as well as alters intestinal microflora. EEN may actually prompt the observed beneficial effects that it has on the intestinal microflora. This results in mucosal responses and a corresponding reduction in the secretion of epithelial antibacterial proteins, as a way to modulate epithelial responses, for it is these epithelial responses that somehow increase inflammation. Moreover, the epithelial apical surface of the intestinal mucosa interacts directly with the contents of the lumen, as a result, and this is a main contributor to innate immune responses. This also activates other related immune responses (Day et al. 302-304). Discussion The importance of conducting a nutritional assessment for patients suffering from Crohn’s disease is emphasized by the study of Benjamin et al. in 2008 and earlier by Eiden in 2003. The purpose of the nutritional assessment is not only to determine the current state of disease but also to choose which particular therapy is most suitable for the patient – whether it is surgery, medication or nutritional intervention. Moreover, if it is nutritional intervention, then the assessment is expected to determine whether it is elemental, oligomeric or polymeric enteral nutrition that is necessary. The fact that the patient’s medical history should be included in the preliminary assessment is extremely essential for he might end up developing allergies towards particular food supplements, as gleaned from the ideas of Eiden in 2003. Moreover, the rather extremely meticulous procedure of determining the patient’s body mass index is essential in order to be able to measure improvement later on after the course of the nutritional intervention. Assessing the patient’s height, weight, MUAC, MAMC, MAMA, and MAFA may in fact be tedious to the nutritionist or medical professional. Nevertheless, the determination of the patient’s body mass index is necessary for determining later on whether the patient is indeed malnourished or not. However, although the body mass index is extremely reliable, it is a fact that some patients with Crohn’s disease actually look healthy and this may translate as appearing to have the right body mass index despite the actual micronutrient deficiencies (Vagianos et al. 318). There is therefore a need for an internal assessment tool, and this is the serum albumin level (Mijac et al.). A significant decrease in the levels of serum albumin naturally corresponds to an incidence of Crohn’s disease. In fact, according to Cabral et al., “The serum albumin levels correlated inversely with the disease activity [and that] hypoalbulminemia was 100% sensitive for detection of disease activity.” Without gauging the serum albumin content of the patient, it is therefore very likely that an error in diagnosis will be committed since Crohn’s disease or any inflammatory bowel disease is not just a matter of body mass index but primarily a matter of internal deficiency in nutrition. Moreover, other biochemical markers of Crohn’s disease should also be considered as well before treatment is to be conducted. Crohn’s disease may coincide with anemia and other vitamin and mineral deficiencies (Vagianos et al. 312-317). Although there is no particular rule that Crohn’s disease must really have these characteristics in terms of micronutrient levels, one should somehow use the clue from previous laboratory studies in order to ascertain the occurrence of the disease. Moreover, the various nutritional deficiencies may also be essential in determining the proper type of nutritional intervention for the patient. The recommended nutritional intervention for patients with Crohn’s disease may be elemental, oligomeric, or polymeric formula. Although they have basically the same content, it is in their type of protein that they differ. These formulas are usually sold by famous pharmaceutical complanies like Mead Johnson. Moreover, although there are no known significant differences among the three types of enteral formulas. However, studies seem to have a higher percentage of recovery from elemental formulas compared to oligomeric and polymeric types. Hydrolyzed protein, therefore, which is characteristic of elemental formulas, may have a more efficient way of eliciting anti-inflammatory effects and nutritional improvements in the patient with Crohn’s disease. Conclusion In any case, there should be further studies that should be conducted in order to find out which of the three types of enteral formulas is the most efficient among these three. There should also be further studies to determine whether the alleged efficiency of the elemental formula also works for other inflammatory bowel diseases aside from Crohn’s disease. Moreover, there is very little evidence on the criteria used to determine which particular formula should be used for which type of patient with Crohn’s disease. Should children take in an elemental formula and should adults subsist on polymeric formulas? There should be a better system for determining these criteria and that they should be better defined. The use of nutritional care in the management and treatment of Crohn’s disease is indeed a better, less expensive and less harmful approach compared to medications and surgery. Patients with Crohn’s disease should therefore be thankful for the existence of this nutritional intervention. However, the rigorous nutritional assessment process may possibly exhaust these patients as well as the lack of definite criteria for the use of elemental, oligomeric or polymeric formulas. Nevertheless, nutritional intervention for Crohn’s disease patients is definitely a very promising form of management and treatment of the disease. Top of Form Bottom of Form Works Cited Assche, Gert Van, Axel Dignass, Walter Reinisch, C. Janneke van der Woude, Andreas Sturm, Marine De Vos, and Mario Guslandi. “The second European evidence-based Consensus on the diagnosis and management of Crohn’s disease: Special situations.” Journal of Crohn’s and Colitis 4.1 (2010): 63-101. Print. Benjamin, Jaya, Govind K. Makharia, Kalaivani M., and Yogendra K. Joshi. “Nutritional status of patients with Crohn’s disease.” Indian Journal of Gastroenterology, 27.5 (2008): 195-200. Print. Cabral, V. L., L. De Carvalho, and S. J. Miszputen. “Importance of serum albumin values in nutritional assessment and inflammatory activity in patients with Crohn’s disease.” Arq. Gastroenterology 38.2 (2001): 104-108. Print. “Crohn’s Disease.” National Institutes of Health. 2012. Web. 20 Mar. 2013. . Day, A. S., K. E. Whitten, M. Sidler, and D. A. Lemberg. “Systematic review: nutritional therapy in paediatric Crohn’s disease.” Alimentary Pharmacology & Therapeutics 27 (2008): 293-307. Print. Dziechciarz, P., A. Horvath, R. Shamir, and H. Szajewska. “Meta-analysis: enteral nutrition in active Crohn’s disease in children.” Alimentary Pharmacology and Therapeutics 26 (2007): 795-806. Print. Eiden, Kelly Anne. “Nutritional Considerations in Inflammatory Bowel Disease.” Nutrition Issues in Gastroenterology 5 (2003): 33-54. Print. Mijac, D. D., G. L. Jankovic, J. Jorga, and M. N. Krstic. “Nutritional status in patients with active inflammatory bowel disease: prevalence of malnutrition ad methods for routine nutritional assessment.” [Abstract]. European Journal of Internal Medicine 21.4 (2010): 315-319. Print. Vagianos, Kathy, Savita Bector, Joseph McConnell, and Charles N. Bernstein. “Nutritional Assessmentof Patients with Inflammatory Bowel Disease.” Journal of Parenteral and Enteral Nutrition 31.4 (2007): 311-319. Print. Verma, S., S. Brown, B. Kirkwood, and M. H. Giaffer. “Polymeric versus elemental diet as primary treatment in active Crohn’s disease: a randomized, double-blind trial.” [Abstract]. American Journal of Gastroenterology 95.3 (2000): 735-739. Print. Yamamoto, T., M. Nakahigashi, S. Umegae, and K. Matsumoto. “Enteral nutrition for the maintenance of remission in Crohn’s disease: a systematic review.” [Abstract]. European Journal of Gastroenterology and Hepatology 22 (2010): 1-8. Print. Read More