Nutritional Management of Diverticulitis with Abscess Colon Resection

Nutritional Management of Diverticulitis with Abscess & Colon Resection Jessica Lacontora ARAMARK Dietetic Internship Southern Ocean Medical Center March 15, 2013

Case Report Presentation Contents o o o Disease Description Evidence-Based Nutrition Recommendations Case Presentation Nutrition Care Process (NCP): ADIME Conclusion

Disease Description o Diverticulosis -presence of herniations in the mucosal layer of the colon through muscle layer of the bowel n n o Risk factors n n o 1)Meckel’s diverticulum- found near the ileocecal valve & are present at birth 2)Developed with advancing age- more common History of constipation High intake of red meat Obesity Low physical activity Complications: diverticular bleeding and diverticulitis n Diverticulitis- inflammation of a diverticulum.

Disease Description continued o Symptoms n n n o Abdominal pain of the left lower quadrant Fever Nausea and Vomiting Elevated white blood cells CT scans Inflammation cause: n n n Perforation abscess formation Peritonitis Obstruction acute bleeding Sepsis o Severity n n o Mild -inflammation Deadly peritonitis caused by perforation. Surgical intervention n n high morbidity & mortality rates patients present with co -morbidities

Disease Description continued o Common Comorbidities n Ulcerative colitis n Tumor or colon cancer n Obesity n Ischemic colitis n Irritable bowel syndrome (IBS) n Crohns disease n Angiodyplasia o Aging Complications n n n Neuropathy Reduced gastric mobility Diabetes Kidney disorders Cardiopulmonary This patient presented with coronary artery disease, hypoalbumenia, gout, dyslipidemia, benign prostate hypertrophy, arterial fibulation, hypertension, random hypotension (meds), & chronic kidney disease.

Disease Description continued o Rate of Occurrence n One of the most common conditions in America n One of the highest reasons for outpatient visits and inpatient admittance n Economic burden n This disease has increased among the under 40 population as a result of obesity and the western diet o appendicitis n 50% of people over 60 years old have diverticula with 10 -25% developing complications such as diverticulitis n Inpatient hospitalization rates increased by 26% from 1998 to 2005.

Disease Description continued o Fiber n n n Fiber increases stool bulk in the intestine Muscular pressure on intestinal walls rather then on the contents, which, form pockets or diverticula at weak points Clinical trials have found that a high-fiber diet may reduce symptoms and have a protective role against future complications Many forms of fiber and fiber supplements Need more research

Evidence Based Nutrition Recommendations o o o The Academy of Nutrition & Dietetics Diverticulum n Nothing by mouth (NPO) with bowel rest until bleeding & diarrhea resolve n Begin oral intake with clear liquids n Nutritional supplement with protein, energy, vitamins, & minerals as needed n Poor nutritional status, or anemia- slowly begin low-fiber nutrition therapy n After- high-fiber diet & adequate fluid eudcation Diverticulitis n High-fiber nutrition therapy of 6 to 10 g + (20 g to 35 g/day) n Add fiber to diet gradually to ensure tolerance n Emphasize sources of insoluble fiber n Supplement if dietary intake is insufficient n Probiotic and prebiotic n Ensure adequate fluid Restriction of nuts, seeds, & corn is no longer recommended

Evidence Based Nutrition Recommendations o o According to the American Society for Parenteral and Enteral Nutrition (ASPEN) Enteral nutrition (EN) first Protein-calorie malnutrition & EN not feasible use parenteral nutrition (PN) as soon as possible following adequate resuscitation. Antioxidant vitamins and trace minerals Mild underfeeding initially at 80%

Evidence Based Nutrition Recommendations A systematic review of high fiber dietary therapy in diverticular disease Unlu et. al. o No study could demonstrate that fiber therapy can prevent the reoccurrence of diverticulitis n Multiple randomized demonstrated mixed results A reduction in pain symptoms? Reduction in constipation? Use of methylcellulose – study small and not specific Metamucil showed the largest reduction in symptoms n Lactulose vs bran tablets - no difference in benefit n n o (p<0. 025) Lack of clear evidence for a high fiber diet in treatment of diverticular disease.

Evidence Based Nutrition Recommendations Obesity increases the risks of diverticulitis and diverticular bleeding Strate et. al. o Data from the Health Professional follow-up study o Identified 801 incidences of diverticular disease in 730, 446 people o High BMI (p=0. 07), waist to hip ratio and waist circumference were more likely to be sedentary, eat more fat and red meat and use analgesics o Positive association with obesity for both diverticulitis and diverticular bleeding (p=0. 17) o For obese patients with diverticular disease, weight loss should be considered as part of the Nutritional Care Plan

Evidence Based Nutrition Recommendations Current indications and role of surgery in the management of sigmoid diverticulitis Dr. Luca Stocchi o o o o o Reviewed of data regarding surgical management Antibiotics - used as the first step in treating uncomplicated diverticulitis Complicated diverticular disease often requires surgery Laparoscopic surgery is increasingly accepted as the best surgical approach Timing of surgery in relation to the diverticular attack has been subject to controversy due to stoma formation. Current census wait till the 3 rd or 4 th Patients who underwent surgery for uncomplicated diverticulitis has declined to 17. 9 to 13. 7% from 1991 -2005 (p=0. 0001). Must approach each case differently as each patient will have varying comorbidities and compilations. Limited by use of retrospective studies, data < 2005.

Case Presentation o o o January 25, 2013 - 82 year old male presented to the outpatient GI office with abdominal pain for 1 week & rectal bleeding 2 days prior to admission Sent to ER -> CT scan revealed diverticulitis with abscess Past Medical Dx: higher risk for complications of bowel resection n n Obesity – increased risk of diverticular disease Arterial fibrillation Hypertension with episodes of hypotension (meds) Iron deficiency anemia Chronic kidney disease with baseline creatinine around 1. 5. Coronary artery disease Hypoalbuminemia Gout Dyslipidemia Benign prostatic hypertrophy Vitamin D deficiency

NCP: o ADIME Client History (CH-2. 1) n n n n o. While March 2012 -Fall- nasal fracture, hand contusion October 2012 - UTI Eye glasses & hearing impaired Well the patient walks daily & drinks alcohol occasionally His past medical history previous slide Recent surgical intervention: o central venous line placed o sigmoid partial colon resection with total splenectomy o Cysto bilateral stent placed Wife and adult children that are very supportive administering medical nutrition therapy (MNT) in compliance with the Academy of Nutrition and Dietetics, as well as, ARAMARK standards, the Nutrition Care Process was used to document patient care, as outlined by the International Dietetics and Nutrition Terminology Reference Manual (IDNT).

NCP: o ADIME Food/Nutrition Related History (FH-1. 1. 1) n n n n n During the majority of his stay the patient has been NPO for GI complications and surgical procedures Advanced to a soft diet for 3 days 50 -75% The patient was placed on TPN once the gut was deemed unavailable Wife reports good eater usually No known food allergies No problems with chewing or swallowing prior to admission Developed dysphaga after being vented for an extended period of time No supplement prior to admission Prior to his TPN he was willing to start Ensure plus and/or Ensure clear with each meal Good attitude and strong desire to go home

Prescribed Medications Medication Dose Reason Side Effect Digoxin (Lanoxin) . 25 mg QOD Antiarrthymic N/V diarrhea, wt loss Albuterol 3 m. L mini neb Q 10 pm Broncodilator N/V tachycardia Fluconazole 200 mg Antifungal headache, liver Epoetin 20000 units RBC production Elevated BP Tigecycline 50 mg q 12 hr antibiotic N/V Nystatain Topical 1 xdaily antifungal None Metoprolol 5 mg Beta blocker GI distress Protonix 40 mg Antigerd Diarrhea Diltizem 125 mg Antihypertensive Edema Heparin 15 m. L/hr anticoagulant GI-bleed Dilaudid . 5 -1 mg/hr for pain opoid Constipation Reglan 10 mg as needed Gastroparisis Nausea/Vomiting Acetaminophen 1000 mg q 12 hr >100 F fever Increased ALT Ativan 1 mg Agitation Fatigue Zofran 4 mg q 6 hr as needed Nausea/Vomiting Constipation Sodium chloride 1000 m. L @ 250/hr IV fluids n/a

NCP: o ADIME Nutrition-Focused Physical Findings (PD-1. 1. 5) n n n n n Week before –abdominal pain with reduced intake No significant weight loss noted Prior to admission -well nourished with good oral health He presented with tenderness to the lower right quadrant of his abdomen Appetite varied from poor to fair He is motivated to eat with the concept of going home Edematous -signs of muscle and fast wasting Developed severe dysphaga Swallowing ability improved over 3 days & his intake on March 15 th, 2013 was 50% of his pureed diet.

NCP: o ADIME Anthropometric Measurements (AD-1. 1) n n n n 67 inches 238 to 214 # - fluctuation Edema which partially responsible for weight changes. Current- 216 lbs, BMI 33, Obese I Usual body weight 235# Ideal body weight (IBW) 163 # Current weight is 132% of IBW Anthropometric Data Height Weight IBW BMI 5’ 7” 216 # or 98 kg 148 10%= 133 -163 33 -obese BMI 25=163 # Nutrient Needs REE Protein 98 kg x 20 kcal/kg = 1960 kcal 98 kg x 25 kcal/kg = 2450 kcal 1960 -2450 kcal/day 98 kg x 1. 0 g/kg = 98 g 98 kg x 1. 3 g/kg = 127 g 98 -127 g/day

NCP: o ADIME Biochemical Data, Medical Tests and Procedures n n n n n CT scan of the abdomen for obstruction or abscess GI - surgical intervention Swallow study (BD-1. 4. 23) 1 and 3 days post extubation Metabolic panel (BD-1. 8. 2) Acid base balance (AD-1. 1. 1) CBC (BD-1. 10) PTT, Catheter tip culture, blood culture and fluid drain culture were ordered for fungal VRE and yeast infection suspicion Glucose (BD-1. 5. 2) steroid medications Mineral levels (BD-1. 2. 5 -11)-adjustintravenous fluids (IVF)

NCP: o ADIME Nutrient Needs n Energy requirements (CS-1. 1. 1) were 1960 -2450 kcal (20 -25 kcal/kg) Energy requirements were calculated using 20 -25 kcal/kg of current body weight in order to promote weight maintenance without over feeding or increasing vent dependence. n Protein (CS-2. 2. 1) requirements were 98 -127 g (11. 3 g/kg) Since the patient was under stress and at risk for pressure ulcer wounds, his nutrient requirements for protein were elevated. n Fluid requirements (CS-3. 1. 1) were 2000 ml/day. n The patient also received a varying amount of fat calories from Propofol increasing his caloric intake while vented.

Lab Values Lab Measurement Value Normal Value Rationale WBC 13. 0 H 4. 1 – 10. 9 K/UL Infection (sepsis), Abscess, & Stress Glucose 108 -152 H 70 – 100 mg/d. L Elevated – Stress, steroids Calcium 7. 5 L 8. 5 -10. 1 mg/d. L IVF electrolyte balance Chloride 122 H 98 -107 mmol/L IVF electrolyte balance Sodium 148 w/ edema 136 – 148 mmol/L Fluid retention, IVF, malabsorption, & medications BUN 71 HH 7 – 18 mg/d. L protein catabolism, renal failure GFR 51 > 57 Renal insufficiency Creatinine 1. 83 H 0. 8 – 1. 3 mg/d. L renal dysfunction & infection Bilirubin 2. 0 H 0 -1. 0 mg/d. L liver damage & malnutrition Pre Albumin 8 L 18 -38 mg/d. L Short term protein stores Albumin 2. 0 3. 4 – 5 g/d. L Malnutrition, short-term protein and energy deficiency, acute inflammation, fluid retention Triglycerides 91 < 150 mg/d. L Monitored when on PN AST/SGOT 51 H 15 -37 IU/L Produced from cell death, renal disease, hepatic disease, trauma

NCP: o ARAMARK Nutrition Status Classification n n o ADIME 15 nutrition care points = Status 4 -Severely compromised o 3 points for nutrition hx (poor appetite-50% of needs for >2 weeks) o 4 points for feeding modality (TPN/PPN and NPO >4 days) o 0 priority points for unintentional wt loss (hard to classify with edema) o 0 points for weight status as he was obese when admitted o 4 points for serum albumin ( 1. 1 -1. 9 g/d. L) o 4 points for diagnosis/condition (malnutrition, sepsis) Follow up should be scheduled in 1 -4 days Diagnosis-Related Group (DRG) n n Not used at Southern Ocean Medical Center Tool to diagnose malnutrition Increased reimbursement from Medicare Other Protein Calorie Malnutrition (PCM) with an inadequate intake for 3 days and an albumin value of <3. 5 g/d. L.

NCP: A o DIME NCP: Nutrition Diagnosis n Upon initial assessment the patient, presented with multiple GI related problems. Interventions and recommendations were based on the primary nutritional diagnosis. The MD ended TPN prior to the pt being able to consume >50% of needs orally. Domai n Problem/Nutrition Diagnosis Etiology Intake (NI-5. 3) Inadequate protein energy intake related to Intake (NI-2. 1) Inadequate oral intake related to Decreased ability to consume sufficient energy inability to consume sufficient energy Signs/Symptoms as evide nced by Decreased appetite from abdominal pain, NPO status 4 days. as evide nced by change in appetite, estimate of 10% intake of needs, dysphaga

NCP: ADIME o o NCP: Interventions n PTA - Antibiotic regimen n ER - CT scan n After admission- cysto bilateral stent placement, a partial sigmoid colon with low anterior resection and low pelvic colorectal anastomosis with total splenectomy, central venous line using ultrasound guidance n Propofol in varying amounts to maintain TASS -2 while vented Enteral and Parenteral Nutrition: Parenteral Nutrition/IV Fluids - Formula/solution (ND-2. 2. 1) - Initial MD parenteral nutrition order for TPN included 72 g protein, 276 g dextrose and 250 m. L 20% fat emulsion. Recommended increase 72 g (. 75 g/kg) to 116 g (1. 2 g/kg) protein. Will provide 1902 kcal (20 kcal/kg) n Goal-maintain lean body mass & support the immune system n TPN discontinued immediately upon extubation- speech pathologist/swallow evaluation n 4 days 50% or less intake- no nutritional support despite recommendations Nutrition Education Content – Purpose of the nutrition education (E-1. 1). Provided education on diverticular diet to prevent future inflammation and obstruction. Medical Food Supplements – Commercial beverage (ND-3. 1. 1). Commercial beverage Ensure Plus, 8 oz BID with meals to provide an additional 700 kcals and 26 g of protein daily and Ensure Clear BID to provide 400 kcal and 14 g protein. Goal for intervention was to promote wound healing, maintain lean body mass and support immune system

NCP: ADIME o o Nutrition Care Process: Monitoring and Evaluation n High nutritional risk follow-up 3 to 5 days. n Oral intake was monitored when diet order present. Parenteral nutrition orders and tolerance were monitored with each follow-up. Food and Nutrition-Related History n Food and Nutrient Intake o Energy intake - Total energy intake (FH-1. 1) Meet needs o Protein intake - Total protein (FH-1. 5. 2. 1) Meet needs n Food and Nutrient Administrationo Parenteral nutrition intake – Formula/solution (FH- 2. 1. 4. 2). Evaluated for total energy and protein intake. MD upped to 100 g from n Medication and Herbal Supplement Use o Prescription medications were monitored including Propofol due to its addition of calories from fat. n Knowledge/Beliefs/Attitudes o Food and nutrition knowledge – Area and level of knowledge (FH-4. 1. 1) o Beliefs and attitudes- Food preferences (FH-4. 2. 12) o During periods of PO intake the patients preferences were noted to promote optimal intake (Greek Yogurt)

NCP: ADIME o Anthropometric Measurements n o Body composition – Weight (AD-1. 1. 2) monitored daily via bed scale The patient’s weight was not a reliable predictor of malnutrition as he developed edema. Our goal was to maintain his body weight. Biochemical Data, Medical Tests and Procedures n n Lipid profile- Triglycerides (TG) (BD-1. 7. 7) monitored while on TPN and Propofol to avoid further cardiovascular disease progression and complications. Goal to keep TG under 250 mg/d. L Protein profile- Albumin (BD-1. 1). Monitored daily to evaluate effectiveness of nutritional therapy and state of malnutrition. Recommendations for discharge n n High fiber diet, continued oral beverage supplement use, and monitor weight Swallow improved but fatigue causes early satiety limiting intake RN is gradually educating the patient and family on colostomy care Continue to follow up 3 -5 days or as needed per MD or RN request.

Conclusion o o o Diagnosis is common and difficult to manage resulting in a high reoccurrence rate with complications. = economical burden Uncomplicated cases can often avoid surgical intervention with bowel rest and antibiotics. Preexisting medical conditions make recovery from a bowel resection a challenge ASPEN guidelines for PN in a CC patient should be utilized throughout MNT PN began should be used when gut is deemed unavailable & the patient is stable Monitor energy & protein intake, weight, wounds and labs each follow up session. Risk factors - constipation, high intake of red meat, obesity & low physical activity. Progressive disease-most prevalent in the elderly population Increasing in the under 40 population-processed foods. Opinions vary on the high fiber diet. More research needs to be conducted on high fiber diet and fiber supplementation for complications and prevention. Intervention is key - Nutritional education on a healthy diet high in fruits, and vegetables should be provided at all ages especially for those with a history of constipation related to low fiber intake.

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