Nutritional Management of Diverticulitis with Abscess

1
Nutritional Management of Diverticulitis with
Abscess Colon Resection

• Jessica Lacontora
• ARAMARK Dietetic Internship
• Southern Ocean Medical Center
• March 15, 2013

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Case Report Presentation Contents

• Disease Description
• Evidence-Based Nutrition Recommendations
• Case Presentation
• Nutrition Care Process (NCP) ADIME
• Conclusion

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Disease Description

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

4
Disease Description continued

• Symptoms
• Abdominal pain of the left lower quadrant
• Fever
• Nausea and Vomiting
• Elevated white blood cells
• CT scans
• Inflammation can cause
• Perforation
• abscess formation
• Peritonitis
• Obstruction
• acute bleeding
• Sepsis

• Severity
• Mild -inflammation
• Deadly peritonitis caused by perforation.
• Surgical intervention
• high morbidity mortality rates
• patients present with co-morbidities

5
Disease Description continued

• Common Comorbidities
• Ulcerative colitis
• Tumor or colon cancer
• Obesity
• Ischemic colitis
• Irritable bowel syndrome (IBS)
• Crohns disease
• Angiodyplasia

• Aging Complications
• 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.

6
Disease Description continued

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

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Disease Description continued

• Fiber
• 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

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Evidence Based Nutrition Recommendations

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

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Evidence Based Nutrition Recommendations

• 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

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Evidence Based Nutrition Recommendations

• A systematic review of high fiber dietary therapy
  in diverticular disease Unlu et. al.
• No study could demonstrate that fiber therapy can
  prevent the reoccurrence of diverticulitis
• 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 (plt0.025)
• Lactulose vs bran tablets - no difference in
  benefit
• Lack of clear evidence for a high fiber diet in
  treatment of diverticular disease.

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Evidence Based Nutrition Recommendations

• Obesity increases the risks of diverticulitis and
  diverticular bleeding Strate et. al.
• Data from the Health Professional follow-up study
• Identified 801 incidences of diverticular disease
  in 730,446 people
• High BMI (p0.07), waist to hip ratio and waist
  circumference were more likely to be sedentary,
  eat more fat and red meat and use analgesics
• Positive association with obesity for both
  diverticulitis and diverticular bleeding (p0.17)
• For obese patients with diverticular disease,
  weight loss should be considered as part of the
  Nutritional Care Plan

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Evidence Based Nutrition Recommendations

• Current indications and role of surgery in the
  management of sigmoid diverticulitis Dr. Luca
  Stocchi
• 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 3rd or 4th
• Patients who underwent surgery for uncomplicated
  diverticulitis has declined to 17.9 to 13.7 from
  1991-2005 (p0.0001).
• Must approach each case differently as each
  patient will have varying comorbidities and
  compilations.
• Limited by use of retrospective studies, data lt
  2005.

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Case Presentation

• 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 -gt CT scan revealed diverticulitis
  with abscess
• Past Medical Dx higher risk for complications of
  bowel resection
• 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

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NCP ADIME

• Client History (CH-2.1)
• 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
• central venous line placed
• sigmoid partial colon resection with total
  splenectomy
• Cysto bilateral stent placed
• Wife and adult children that are very supportive

• While 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).

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NCP ADIME

• Food/Nutrition Related History (FH-1.1.1)
• 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

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Prescribed Medications
Medication Dose Reason Side Effect
Digoxin (Lanoxin) .25 mg QOD Antiarrthymic N/V diarrhea, wt loss
Albuterol 3 mL mini neb Q 10pm Broncodilator N/V tachycardia
Fluconazole 200mg Antifungal headache, liver
Epoetin 20000 units RBC production Elevated BP
Tigecycline 50mg q 12hr antibiotic N/V
Nystatain Topical 1xdaily antifungal None
Metoprolol 5mg Beta blocker GI distress
Protonix 40mg Antigerd Diarrhea
Diltizem 125mg Antihypertensive Edema
Heparin 15mL/hr anticoagulant GI-bleed
Dilaudid .5-1 mg/hr for pain opoid Constipation
Reglan 10mg as needed Gastroparisis Nausea/Vomiting
Acetaminophen 1000mg q12 hr gt100 F fever Increased ALT
Ativan 1mg Agitation Fatigue
Zofran 4mg q 6hr as needed Nausea/Vomiting Constipation
Sodium chloride 1000mL _at_ 250/hr IV fluids n/a
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NCP ADIME

• Nutrition-Focused Physical Findings (PD-1.1.5)
• 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 15th, 2013 was 50 of his pureed
  diet.

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NCP ADIME

• Anthropometric Measurements (AD-1.1)
• 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 Anthropometric Data Anthropometric Data Anthropometric Data Anthropometric Data
Height Weight IBW IBW BMI
57 216 or 98 kg 148 ? 10 133-163 148 ? 10 133-163 33-obese BMI 25163
Nutrient Needs Nutrient Needs Nutrient Needs Nutrient Needs Nutrient Needs
REE REE REE Protein Protein
98 kg x 20 kcal/kg 1960 kcal 98 kg x 25 kcal/kg 2450 kcal 1960-2450 kcal/day 98 kg x 20 kcal/kg 1960 kcal 98 kg x 25 kcal/kg 2450 kcal 1960-2450 kcal/day 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 98 kg x 1.0 g/kg 98 g 98 kg x 1.3 g/kg 127 g 98-127 g/day
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NCP ADIME

• Biochemical Data, Medical Tests and Procedures
• 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)

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NCP ADIME

• Nutrient Needs
• 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.
• Protein (CS-2.2.1) requirements were 98-127 g
  (1-1.3g/kg) Since the patient was under stress
  and at risk for pressure ulcer wounds, his
  nutrient requirements for protein were elevated.
• Fluid requirements (CS-3.1.1) were 2000 ml/day.
• The patient also received a varying amount of fat
  calories from Propofol increasing his caloric
  intake while vented.

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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/dL Elevated Stress, steroids
Calcium 7.5 L 8.5-10.1 mg/dL 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/dL protein catabolism, renal failure
GFR 51 gt 57 Renal insufficiency
Creatinine 1.83 H 0.8 1.3 mg/dL renal dysfunction infection
Bilirubin 2.0 H 0-1.0 mg/dL liver damage malnutrition
Pre Albumin 8 L 18-38 mg/dL Short term protein stores
Albumin 2.0 3.4 5 g/dL Malnutrition, short-term protein and energy deficiency, acute inflammation, fluid retention
Triglycerides 91 lt 150mg/dL Monitored when on PN
AST/SGOT 51 H 15-37 IU/L Produced from cell death, renal disease, hepatic disease, trauma
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NCP ADIME

• ARAMARK Nutrition Status Classification
• 15 nutrition care points Status 4 -Severely
  compromised
• 3 points for nutrition hx (poor appetite-50 of
  needs for gt2 weeks)
• 4 points for feeding modality (TPN/PPN and NPO gt4
  days)
• 0 priority points for unintentional wt loss (hard
  to classify with edema)
• 0 points for weight status as he was obese when
  admitted
• 4 points for serum albumin ( 1.1-1.9 g/dL)
• 4 points for diagnosis/condition (malnutrition,
  sepsis)
• Follow up should be scheduled in 1-4 days
• Diagnosis-Related Group (DRG)
• 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 lt3.5 g/dL.

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NCP ADIME

• NCP Nutrition Diagnosis
• 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 gt50 of needs
  orally.

Domain Problem/Nutrition Diagnosis Etiology Signs/Symptoms
Intake (NI-5.3) Inadequate protein energy intake related to Decreased ability to consume sufficient energy as evidenced by Decreased appetite from abdominal pain, NPO status 4 days.
Intake (NI-2.1) Inadequate oral intake related to inability to consume sufficient energy as evidenced by change in appetite, estimate of 10 intake of needs, dysphaga
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NCP ADIME

• NCP Interventions
• PTA - Antibiotic regimen
• ER - CT scan
• 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
• 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 72g protein, 276g dextrose
  and 250mL 20 fat emulsion. Recommended increase
  72g (.75g/kg) to 116g (1.2 g/kg) protein. Will
  provide 1902 kcal (20 kcal/kg)
• Goal-maintain lean body mass support the immune
  system
• TPN discontinued immediately upon extubation-
  speech pathologist/swallow evaluation
• 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 26g of protein daily and Ensure Clear BID to
  provide 400 kcal and 14g protein. Goal for
  intervention was to promote wound healing,
  maintain lean body mass and support immune system

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NCP ADIME

• Nutrition Care Process Monitoring and Evaluation
• High nutritional risk follow-up 3 to 5 days.
• Oral intake was monitored when diet order
  present. Parenteral nutrition orders and
  tolerance were monitored with each follow-up.
• Food and Nutrition-Related History
• Food and Nutrient Intake
• Energy intake - Total energy intake (FH-1.1.1.1)
  Meet needs
• Protein intake - Total protein (FH-1.5.2.1) Meet
  needs
• Food and Nutrient Administration-
• Parenteral nutrition intake Formula/solution
  (FH- 2.1.4.2). Evaluated for total energy and
  protein intake. MD upped to 100g from
• Medication and Herbal Supplement Use
• Prescription medications were monitored including
  Propofol due to its addition of calories from
  fat.
• Knowledge/Beliefs/Attitudes
• Food and nutrition knowledge Area and level of
  knowledge (FH-4.1.1)
• Beliefs and attitudes- Food preferences
  (FH-4.2.12)
• During periods of PO intake the patients
  preferences were noted to promote optimal intake
  (Greek Yogurt)

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NCP ADIME

• Anthropometric Measurements
• Body composition Weight (AD-1.1.2) monitored
  daily via bed scale The patients 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
• 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 250mg/dL
• Protein profile- Albumin (BD-1.11.1). Monitored
  daily to evaluate effectiveness of nutritional
  therapy and state of malnutrition.
• Recommendations for discharge
• 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.

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Conclusion

• 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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References

• Academy of Nutrition and Dietetics. Pocket Guide
  for International Dietetics Nutritional
  Terminology (IDNT) Reference Manual 3rd edition.
  Chicago IL, 2011.
• Academy of Nutrition and Dietetics Evidence
  Analysis Library. Critical Illness Nutrition
  Practice Guidelines. A.N.D. Evidence Analysis
  Library website. Available at lthttp//www.adaevid
  encelibrary.com/topic.cfm?cat3016gt Accessed
  February 20, 2013
• ARAMARK Healthcare. Nutrition Assessment
  Nutrition status classification worksheet.
  Patient Food Services Policies and Procedures,
  Volume IV Revised 3/10/10.
• Gearhart SL et. al. Common Diseases of the Colon
  and Anorectum and Mesenteric Vascular
  Insufficiency. Harrisons principles of Internal
  Medicine. 16th ed. Columbus, OH McGraw-Hill
  2005. Available from http//www.accessmedicine.co
  m/resourceToc.aspx?resourceID4part12. Accessed
  February 11, 2013.
• Mahan LK, Escott-Stump S. Krauses Food
  Nutrition Therapy. 13th ed. St. Louis, MO
  Saunders Elsevier 2013.
• Diverticulosis and Diverticulitis. HHS National
  Digestive Diseases Information Clearinghouse
  (NDDIC). Available atlthttp//digestive.niddk.nih.
  gov/ddiseases/pubs/diverticulosis/index.aspxgt
  Accessed February 21, 2013
• Malnutrition Codes and Characteristics/Sentinel
  Markers. Academy of Nutrition and Dietetics Web
  site. Available atlthttp//www.eatright.org/Member
  s/content.aspx?id6442451284termsDRGgtAccessed
  February 21, 2013.
• Martindale RG, McClave SA, Vanek VW, et al.
  Guidelines for the provision and assessment of
  nutrition support therapy in the adult critically
  ill patient Society of Critical Care Medicine
  and American Society for Parenteral and Enteral
  Nutrition executive summary. Crit Care Med
  2009371757-61
• MD Guidelines. Diverticulitis and diverticulosis
  of the colon Comorbid conditions. 2012 Reed
  Group. Available at http//www.mdguidelines.com/d
  iverticulosis-and-diverticulitis-of-colon/comorbid
  -conditions. Accessed March 10, 2013.
• Pronsky ZM. Food-Medication Interactions, 16th
  ed. Birchrunville, PA Food-Medication
  Interactions 2010.
• Stocchi, Luca. Current indications and role of
  surgery in the management of sigmoid
  diverticulitis. World of Gastroenterology 2010
  16(7) 804-817. Accessed February 9, 2013.
• Strate et. al. Obesity increases the risks of
  diverticulitis and diverticular bleeding.
  Gasteroenterology. 2009 Jan 136 (1) 115-122.
  Accessed February 9, 2013.
• Unlu, Cagdas et.al. A systematic review of
  high-fiber dietary therapy in diverticular
  disease. Int J Colorectal Disease. 2012
  27419-427. Accessed February 9, 2013.
• Weizman, AV GC Nguyen. Diverticular disease
  Epidemiology and management. Can J Gastroenteral
  2011 25(7) 385-389. Accessed February 9, 2013.

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• Questions?