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Monday, January 7, 2013

Crohn's Disease

SAlam.. Harini ada sorg patient datang outpatient utk Crohn's disease.. dia kata ada problem kat small intestine.. ape yg aku nk bgtau ni jgn diambil secra formal lak.. malas la nk taip formal2 ..cukupla kt tempat kje.hehe..
 Pening fikir diet ape yg paling sesuai utk pesakit ni.. berat hilang dari 53kg-49 kg in 1 month.. sOOo... fikir punya fikir.. hmm... i sugest supplement Nutren Optimum untuk dia dulu.. nanti kena review balik pasal sakit ni.. secara general leh baca sini ek ;) 

Nutritional assessment

The nutritional problems of patients with Crohn's disease can be divided into those that concern macronutrients (protein, energy) and those that concern micronutrients (vitamins, minerals and electrolytes). The easiest and most useful way to assess the protein and energy status of patients is with the subjective global assessment (SGA), which is a qualitative assessment of the severity of a patient's malnutrition based on the history of gastrointestinal symptoms, sustained inadequate food intake, weight loss and poor functional status, coupled with a physical examination focused on the identification of muscle wasting, fat loss and edema.3,4 In the history-taking, recent and continuing weight loss, poor dietary intake and the persistence of conditions that propagate these are assigned the greatest importance. From this assessment, a judgement can be made as to whether nutrient assimilation has been restricted because of decreased food intake, maldigestion or malabsorption, whether any effects of malnutrition on organ function and body composition have occurred and whether the patient's disease process influences nutrient requirements. Most important is a history of recent and continuing weight loss, poor dietary intake and the continuous presence of conditions that limit food intake. The aim of SGA is to categorize a patient as being (A) well-nourished, (B) moderately malnourished or (C) severely malnourished. Baker and colleagues3 and Detsky and colleagues4 found that the use of SGA in evaluating hospital inpatients gives reproducible results with better than 80% agreement when 2 independent observers assessed the same patient.
For example, a person with a 10% weight loss from her usual body weight over the previous 8 months, but who has recently regained weight and has good functional status and no loss of muscle or fat, would fall into the SGA A category. However, Ms. C's condition would be classified as SGA B, because she has an acute exacerbation of Crohn's disease with 10% weight loss within the previous 2 weeks, while ingesting mostly liquids to avoid gastrointestinal discomfort. She is ambulatory, but off work, and has slight loss of subcutaneous tissue (reduced buccal fat pad and loose skinfolds over the arms). Whereas, if the patient had minimal food intake for 3 months, 15% weight loss and continuing weight loss, marked muscle weakness and fatigue, lacked subcutaneous tissue, and had hollow temples, deltoid muscle wasting and mild pitting edema, her condition would be classified as SGA C. More details about SGA and the assessment of protein–energy malnutrition are given in an earlier paper in this series by L. John Hoffer.5
Micronutrient (vitamin and mineral) deficiencies are very common in Crohn's disease, and especially common in patients who are in SGA classes B and C. These deficiencies require hematologic and biochemical assessment (Table 1).
Anemia is common, and when it is not caused by chronic disease, it is most often the result of iron deficiency. The diagnosis of iron deficiency can be a problem. Microcytosis occurs with iron deficiency but is also seen with other conditions such as thalassemia. Raised iron binding capacity with reduced serum iron is an index of deficiency. However, low serum iron levels can occur with chronic illness. Low ferritin levels are diagnostic of iron deficiency but, because ferritin is an acute phase reactant, when inflammation is present, a low normal serum ferritin concentration does not exclude iron deficiency. It may be necessary to observe the effect of a trial of iron therapy or to evaluate bone marrow iron. Patients with ileal resection commonly require parenteral vitamin B12, because the vitamin B12–intrinsic factor complex is absorbed only in the terminal ileum. Folate supplementation is also frequently required, because patients have poor dietary intake.
Metabolic bone disease also commonly occurs in patients with Crohn's disease and is usually the result of dietary calcium and vitamin D deficiencies or malabsorption. Serum calcium is typically normal, being maintained in the normal range by secondary hyperparathyroidism, at the cost of loss of calcium from the skeleton. Serum phosphate levels are depressed. Metabolic bone disease is assessed by a bone density scan with dual energy x-ray absorptiometry. Overt vitamin D deficiency disease may occur; patients often present with bone pain and mild myopathy.

Management of nutritional problems

Protein–energy malnutrition
Decisions about the dietary rehabilitation of malnourished patients with Crohn's disease require a review of the patient's gastrointestinal investigations: What is the extent of the disease? Is there intestinal obstruction? Is there a significantly short bowel? From this information, a decision should be made to determine whether the patient can eat a normal or modified oral diet. If so, a dietitian should be consulted to prescribe suitable protein and energy intakes and to modify the diet to account for food intolerances or allergies and adjust vegetable and fruit intake for bowel obstruction. It is generally believed that fruit and vegetables may not pass through strictures and may cause a bolus obstruction behind a stricture. Hence, patients with symptoms suggestive of mild or partial bowel obstruction, consisting of severe abdominal pain associated with vomiting and the inability to pass stools or flatus, should avoid the intake of raw fruit and vegetables. In general, intestinal obstruction due to vegetable matter often occurs in patients who have had gastric surgery,6 but this has also been seen in patients with an intact bowel,7 including those with Crohn's disease.8 On the other hand, in controlled trials fibre made of fine particles, such as bran in unrefined cereal, is tolerated quite well.9
The target protein–energy intake should be 126–146 kJ/kg per day, with 1.5–1.7 g/kg of protein per day. However, patients with a short bowel (such as those who have had a previous bowel resection for obstructions) and malabsorption should increase both their protein and energy intake to compensate for the reduced absorption.
Fluid and electrolyte deficiencies
These usually occur in patients with a short bowel. This is best treated by using an oral rehydration solution (ORS), which was first described by Harrison as a treatment for infantile diarrhea.10 Since then the composition has evolved so that the composition for adults should approximate the following: glucose 90 mmol/L, sodium chloride 45 mmol/L, sodium citrate 45 mmol/L and potassium chloride 20 mmol/L. The sodium concentration must be at least 90 mmol/L.11 Sports drinks designed to replace losses due to sweating, such as Gatorade, are often prescribed as a substitute for ORS. This is inappropriate, because these drinks contain a very low concentration of sodium, are rich in soluble carbohydrates and have high osmolality, characteristics that may even increase the volume and frequency of diarrhea.
Iron deficiency
Iron deficiency is treated with iron supplements, such as ferrous sulfate or gluconate starting with doses of 300 mg once a day and increasing to 300 mg 3 times a day, but patients with inflammatory bowel disease often do not tolerate oral iron. In addition, there is some evidence that iron in the colon increases oxidative stress and may exacerbate inflammation.12 For these reasons, it is sometimes necessary to administer iron by intravenous infusion or intramuscular injection.12 Even if oral iron is tolerated, the degree of deficiency may be such that ferritin levels do not rise and the hemoglobin level remains low. Under these circumstances, after suitable observation for about a month showing no change in hemoglobin, parenteral iron should be given.
Other mineral deficiencies
Magnesium deficiency is common in Crohn's disease, especially in patients who have had an intestinal resection. The best treatment consists of oral supplements with magnesium heptogluconate (Magnesium-Rougier) or magnesium pyroglutamate (Mag 2). The other salts of magnesium will cause more diarrhea. The total dose of elemental magnesium required to ensure normal serum magnesium varies between 5 and 20 mmol/day. To avoid causing diarrhea with magnesium supplements, I recommend that the total dose be mixed in the ORS and sipped throughout the day, ice cold and flavoured with non–sugar-containing agents.
Although difficult to diagnose biochemically, zinc deficiency occurs in patients with inflammatory diarrhea owing to considerable losses in the stools.13 All patients with Crohn's disease who have significant diarrhea, passing more than 300 g of stool per day, should receive zinc supplements for as long as their diarrhea continues. Zinc deficiency can be treated by the administration of zinc gluconate, 20–40 mg/day.
Calcium supplements usually consist of calcium carbonate, providing 1000–1500 mg of elemental calcium per day in divided doses.
Vitamin deficiencies
Adequate folic acid nutrition is important in light of recent data indicating that folate supplementation may provide protection against colon cancer.14Patients with Crohn's disease should routinely take folic acid, 1 mg/day. Owing to the high prevalence of biochemical vitamin deficiency even in patients with inactive disease, supplementation with thiamine, riboflavin, pyridoxine, niacin and ascorbate should be recommended using a standard decavitamin preparation. The treatment of vitamin D deficiency depends on the cause. If it is the result of malabsorption, large doses (2000–4000 IU/day), or even calcitriol (0.25–0.5 μ/day), may be necessary.

Larat ke baca?? hahaha.. xlarat nk baca tapi bagus untuk ilmu pngetahuan.. nnti xdela terkial2 kalau ada pateitn cmni dtg lg.. tgu folow up bulan 3 :p

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