NS480 Unit 8 Crohn's Disease Case Study Example

Two Losses, Kept Apart: A Unit 8 Gastrointestinal Case Study of a Young Man With Crohn's Disease of the Terminal Ileum

[Student Name]

Purdue University Global

NS480: Medical Nutrition Therapy I

Unit 8 Gastrointestinal Case Study

[Instructor Name]

[Date]

The patient and all values are composite; the nutrition guideline for inflammatory bowel disease, the Crohn's disease guideline and the vitamin B12 review cited are real.

Case Presentation

Andre, 27, works as a sound technician and was diagnosed with Crohn's disease of the terminal ileum two years ago. He is in a moderate flare, with four to five loose stools a day, cramping that starts 30 to 60 minutes after most meals, and fatigue. His gastroenterologist has started a biologic medicine and referred him for nutrition care. He has had no surgery.

Anthropometrics: height 180 cm, weight 64 kg, down from 71 kg four months ago, a loss of 7 kg or 9.9 percent. BMI 19.8.

Diet history: Andre has cut back to two small meals a day, mostly white rice, crackers and toast, because larger meals bring on cramping. He avoids vegetables and fruit, which he believes make his symptoms worse, and drinks little milk. He estimates he eats about half of what he ate before the flare.

Labs: hemoglobin 11.9 g/dL, ferritin 18 ng/mL, C-reactive protein raised, vitamin D 17 ng/mL, vitamin B12 within the normal range, albumin 3.3 g/dL.

Loss One: Intake

The first loss is simple arithmetic. Andre eats less because eating hurts. His estimated intake is about 1,300 kcal and 45 g of protein a day, against estimated needs of roughly 2,200 kcal and 77 to 96 g protein. The ESPEN guideline on nutrition in inflammatory bowel disease notes that energy needs are similar to those of healthy people, while protein needs rise during active disease, to between 1.2 and 1.5 g for each kilogram of body weight (Bischoff et al., 2023). At 64 kg, that is 77 to 96 g a day. His deficit in protein is larger, proportionally, than his deficit in energy.

The intake loss explains most of his weight loss. It is also the loss nutrition care can change most directly, by finding foods and patterns he can tolerate.

Loss Two: Absorption

The second loss happens even when he eats. The terminal ileum absorbs vitamin B12 and reabsorbs bile acids. When it is inflamed, bile acids can escape into the colon, causing diarrhea and reducing fat absorption, which in turn reduces absorption of fat-soluble vitamins such as vitamin D. Diarrhea also increases losses of zinc and fluid.

Separating the two losses changes the plan: more food answers the first, while the second needs specific nutrients checked and replaced because eating more will not fully overcome poor absorption.

His low vitamin D fits this mechanism, though limited sun exposure and low milk intake may contribute. His B12 is normal. A review of B12 in inflammatory bowel disease found that Crohn's disease without ileal resection did not clearly raise the risk of deficiency, while resections longer than 30 cm did (Battat et al., 2014). So B12 should be monitored rather than assumed to be low.

His low hemoglobin and ferritin point to iron deficiency. Iron is absorbed mainly in the duodenum, not the ileum, so this deficiency more likely reflects low intake and possible blood loss from inflamed bowel than ileal malabsorption. Inflammation can also raise ferritin, so a ferritin of 18 despite active inflammation suggests his iron stores are genuinely low.

Andre's Beliefs About Food

Andre has built a list of foods he believes cause his flares, mostly from experience in the weeks after diagnosis and from online forums. Some of it is reasonable: high-fat fried meals do seem to worsen his cramping. Some of it has cut out whole food groups, such as all fruit and vegetables, without clear evidence that they trigger his symptoms. During a flare, almost any meal can be followed by cramping, which makes it easy to blame the last thing eaten. The plan respects his experience while testing his list one food at a time once the flare settles, so that his diet can widen again instead of shrinking with every bad day. Keeping a simple symptom diary alongside his food records will help separate real triggers from coincidence.

Nutrition Diagnosis

Inadequate protein-energy intake related to meal-associated cramping during a Crohn's flare, as evidenced by intake of about half of estimated needs and a 9.9 percent weight loss in four months.

A second diagnosis addresses absorption: altered nutrient utilization related to inflamed terminal ileum, as evidenced by low vitamin D and frequent loose stools.

Intervention for Intake

1. Smaller, more frequent meals: five or six a day rather than two, since smaller meals may cause less cramping.

2. Protein at every meal, chosen from foods he tolerates: eggs, fish, chicken, smooth nut butter, tofu and lactose-free yogurt.

3. An oral nutrition supplement once or twice daily to close the gap. The ESPEN guideline supports oral supplements as the first step when diet alone cannot meet needs in active disease (Bischoff et al., 2023).

4. Reintroduce fruit and vegetables in cooked, peeled or blended forms rather than avoiding them entirely. Restrictive diets during a flare can worsen deficits, and a low-residue approach is generally reserved for people with strictures, which Andre's physician has not found.

Intervention for Absorption

1. Vitamin D repletion as directed by his physician, with levels rechecked.

2. Iron status discussed with his gastroenterologist, who may prefer intravenous iron during active inflammation, since oral iron can be poorly tolerated in Crohn's disease.

3. Zinc and fluid: encourage oral fluids with electrolytes on days with more stools.

4. B12 monitored at least yearly.

Coordination With Medical Care

Nutrition care supports, but does not replace, medical treatment of the inflammation. The Crohn's disease guideline emphasizes controlling inflammation as the main goal of treatment (Lichtenstein et al., 2018). As his biologic takes effect, cramping and absorption should both improve, and the nutrition plan will change with them.

Monitoring

1. Weight weekly.

2. Three-day food records at two and six weeks to estimate energy and protein intake.

3. Stool frequency and cramping logged daily.

4. Vitamin D and iron studies rechecked as ordered by his physician.

Evaluation Criteria

Success at six weeks would mean stable or rising weight, intake of at least 80 percent of estimated energy and protein needs, and improving vitamin D and iron values. If weight continues to fall despite supplements, the team may consider enteral nutrition.

Reflection

The most useful step in this case was refusing to treat Andre's weight loss as one problem. Low intake and poor absorption both cause weight and nutrient losses, but they respond to different actions, and a plan that only added calories would have left his vitamin D and iron problems unaddressed.

References

Battat, R., Kopylov, U., Szilagyi, A., Saxena, A., Rosenblatt, D. S., Warner, M., Bessissow, T., Seidman, E., & Bitton, A. (2014). Vitamin B12 deficiency in inflammatory bowel disease: Prevalence, risk factors, evaluation, and management. Inflammatory Bowel Diseases, 20(6), 1120-1128. https://doi.org/10.1097/MIB.0000000000000024

Bischoff, S. C., Bager, P., Escher, J., Forbes, A., Hébuterne, X., Hvas, C. L., Joly, F., Klek, S., Krznaric, Z., Ockenga, J., Schneider, S., Shamir, R., Stardelova, K., Bender, D. V., Wierdsma, N., & Weimann, A. (2023). ESPEN guideline on clinical nutrition in inflammatory bowel disease. Clinical Nutrition, 42(3), 352-379. https://doi.org/10.1016/j.clnu.2022.12.004

Lichtenstein, G. R., Loftus, E. V., Isaacs, K. L., Regueiro, M. D., Gerson, L. B., & Sands, B. E. (2018). ACG clinical guideline: Management of Crohn's disease in adults. American Journal of Gastroenterology, 113(4), 481-517. https://doi.org/10.1038/ajg.2018.27