ULCERATIVE COLITIS WITH HEMORRHOIDS
ULCERATIVE COLITIS WITHHEMORRHOIDSSHWETA D. KAMBLIR.D. INTERN
ULCERATIVE COLITIS Inflammatory bowel disease (IBD) encompasses both ulcerative colitis (UC) and Crohn’s disease (CD). Ulcerative colitis affects the colon and rectum and typically involves only the innermost lining ormucosa, manifesting as continuous areas of inflammation and ulceration. The different types of ulcerative colitis are classified according to the location and the extent ofinflammation.UlcerativeProctitisPan-ulcerative (total)ColitisProctosigmoiditisLeft-sided Colitis
SYMPTOMS OF PAN-ULCERATIVE COLITIS: Abdominal pain and cramps Diarrhea with blood, mucus and/or pus Tenesmus - feeling the need to pass stools despite bowel being empty Fatigue Weight loss Fever
Hemorrhoids are ruptured blood vessels located near the anal sphincter. These vascular structure under any normal condition act as cushions that facilitate stool control. They become pathological or piles when swollen or inflamed. At this point the condition is technicallyknown as hemorrhoidal disease.Internal HemorrhoidExternal Hemorrhoid
Internal hemorrhoids are further graded based on their appearance and degree of prolapse, known asGoligher’s classification.
Hemorrhoidectomy (Operative management) Excisional hemorrhoidectomy is the most effective treatment for hemorrhoids with the lowestrate of recurrence compared to other methods. In clinical practice, the third-degree or fourth-degree internal hemorrhoids are the main indicationfor hemorrhoidectomy.
PATIENT PROFILE Name: Mrs. XYZ Addictions: None Age: 53 years Dietary pattern: Jain (no onion, no garlic) Gender: Female SGA Score: A Community: Gujrati (Jain) Date of Admission: 7/12/2016 State: Maharashtra Date of Discharge: 12/12/2016 Residential area: Urban Length of hospital stay: 6 days Economic Status: Upper middle class
ANTHROPOMETRIC Body mass index (BMI)20.28 Kg/m2Ideal Body Weight (IBW)52kg
CLINICAL ASSESSMENT Present Complaints: k/c/o Ulcerative colitis on medications. Pain in the abdomen, loose stools;now admitted with c/o bleeding with swelling protruding out of the anal canal since last 15 days. Past Medical History: k/c/o Ulcerative Colitis. Past s/o Hysterectomy done 27 years back. Colonoscopy done on 22/11/2016 which indicated pan ulcerative colitis with grade 3 internal andexternal hemorrhoids. Operative details: Hemorrhoidectomy with excision of anal skin tags and lateral analsphincterotomy.Final Medical Diagnosis: HEMORRHOIDS WITH FISSURE.
BIOCHEMICAL ASSESSMENTa. Blood ERENCE RANGEWBC7.077.097.08Hemoglobin11.211.211.54-1010 3/uL11.5-16g/dLPlatelets359359360140-440 10 03.5-5.1mmol/LChloride10810610098-107 mmol/LFasting Blood sugar99--65-165mg/dLSerum Creatinine0.70.70.70.7-1.2mg/dL
b. Other 988220110/7097%11/12/201610:00am987520110/7098%
MEDICATIONS DURING HOSPITAL STAY
MEDICATIONDOSAGEMECHANISM OF ACTIONMEDICATIONS Works by Inhibiting the growth of microorganism andTab. Orni OTab. Nexpro 40 mg1-0-11-0-1killing the infection causing bacteria.SIDE EFFECTSLoss Of Appetite For Food, Dizziness,DiarrheaNausea, Headache, Abdominal pain,Works by lowering the acid production in the stomach. Constipation, Diarrhoea, FlatulenceAn oral solution which works by drawing water into the Dehydration, Drug dependenceSyp. Duphalac 30ml At bedtime intestine through osmosis, that makes the stools soft andeasier to pass.Saazo 500Softovac powder2-0-2Works by blocking the action of certain chemicalmessengers that are responsible for inflammation.1 tsp. in 1 Works by increasing the quantity of water in the stoolglass of waterReduced blood platelets, Rash, Jointpain, Abdominal pain, Indigestion,Decreased white blood cell count,Diarrhoea, Decreased appetite.Stomach Cramping
DIETARY ASSESSMENT : 24Hr. Home diet recall
MenuIngredients AmountsTeaMilkSugarBrown BreadButterBrown Bread toastButterTheplaWheat flouroilSugarChundaKhakraVagharela BhaatPickle2 tbsp.1 tsp.1 tsp.3320100709:00am- BREAKFAST21.652500212.50.50010100452011:00am- .54:00pm- SNACK1.652001.250.251003345921205.68:00pm- DINNER2.50.51.652050.6810711522544CALORIE (Kcal)609101396PERCENT (%)57937Sev Tameta nu shaakTea30g5ml5g1/2 cup1 tsp.2 slices2 tsp.Fat (g)1:00pm- ad50ml5g40g10gHouseholdEnergy (Kcal) CHO (g) Protein (g)measuresJowar 5g50g5ml5g2 tbsp.1 tsp.1 big2 tsp.1 tsp.1 tsp.2 no.1/2 cup1 tsp.1no.2 tbsp.1/2 cup1 tsp.1 tsp.21KCal/Kg BW0.5g/Kg BWVit C(mg)Fe (mg)Na (mg)K 880.8714.42.350.517.51IF (g)SF (g)Calcium 21601.440.4357.20.960.27360113270
Nutritional calculation of home diet recall Energy: 1071Kcal (21Kcal/Kg BW) Interpretation of home diet recall: Proteins: 25g (0.5g/Kg BW) HBV: 4.95gThe recall indicates that the patient consumeslow calories than required. Carbohydrate: 152g (57% of TC) There is severe lack of protein in the diet. Fats: 44g (37% of TC) No cereal pulse combination recipes included. Calories to Nitrogen ratio: 268:1 The consumption of fruits and vegetables isalmost negligible. There is a regular consumption of pickle andpapad in the diet.
NUTRITION ASSESSMENT SUMMARY BMI 20.28 Kg/m2 which indicates that the patient is within the normal range of BMI.BMI(kg/m2)ClassificationPrincipal cut-off pointsNormal range18.50 - 24.99Additional cut-off points18.50 - 22.9923.00 - 24.99Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004. SGA Score –A (Well nourished) Low hemoglobin levels indicating the presence of Anemia. Hence, provide optimal iron through diet andnutrition supplement. Include source of Vitamin C in the diet to enhance the absorption of Iron.
MEDICAL NUTRITION THERAPYENERGY: Patient with a significant weight loss should be started on a refeeding calorie level (20–25 kcal/kg) andmonitored before advancing to a higher calorie goal.Suggested energy requirements for patients based on Body Mass Index (BMI).BMI(kg/m2)Energy Requirements(kcal/Kg/d) 1536–4515–1931–3520–2926–30 3015–25(Kelly Anne Eiden, M.S., R.D., CNSD; Nutritional Considerations in Inflammatory Bowel Disease; PRACTICAL GASTROENTEROLOGY MAY 2003)
PROTEIN: Patients with IBD may have increased protein needs due to losses from inflammation of the intestinal tract,catabolism when an infection is present (i.e. abscess) and possibly for healing if patient requires surgery.Protein needs are assessed based on disease status and body weight. The recommended daily allowance (RDA) for protein is 0.8g/kg actual weight. The majority of IBD patients free from renal disease require approximately 1.0–1.5g/kg body weight.Klein S; A Primer of Nutritional Support for Gastroenterologists. Gastroenterology, 2002GLUTAMINE: Glutamine has been studied in the treatment of IBD due to its role as a fuel for rapidly replicating cells suchas those lining the intestinal tract mucosa. In animal studies, glutamine has been found to improve gut mucosa and decrease damage after certain drugtreatments.Dieleman LA, Heizer WD. Nutritional issues in inflammatory bowel disease. Gastroenterol Clin N Am, 1998;27:435-451.
FODMAPS: FODMAPs are sugars (carbohydrates) in the foods that are poorly absorbed by the gut. The intestinal bacteria in the gut can react to these foods and cause abdominal pain, gas, bloating, diarrheaand/or constipation. Reducing intake of high FODMAP foods may also help decrease GI symptoms for patients with Crohn’sor Ulcerative Colitis (Inflammatory Bowel Diseases or IBD). FODMAP is an acronym for:o Fermentable (produces gas in the intestines)o Oligosaccharides (fructans and galactans/GOS)o Disaccharides (lactose)o Monosaccharides (excess fructose) Ando Polyols (sugar alcohols like sorbitol, maltitol, mannitol, xylitol and isomalt)
SHORT CHAIN FATTY ACIDS: They are mainly produced during fermentation of the soluble dietary fiber by beneficial large intestinalbacteria. SCFA are considered the main nutrients for the large intestinal lining cells; they also increase the blood flow,muscle activity and water absorption in the colon. SCFA are partly used as food for beneficial bacteria and partly they are absorbed and metabolized.(Graham TO, Kandil HM. Nutritional factors in inflammatory bowel disease. Gastroenterol Clin N Am, 2002;31:203-218. ) SCFA have immunomodulatory properties, they accelerate healing and regeneration processes of the intestinalepithelium, and they lower colonic pH thereby stimulating growth of the beneficial microflora and inhibitinggrowth of the pathogens.(Pituch-Zdanowska, A., Banaszkiewicz, A., & Albrecht, P. (2015). The role of dietary fibre in inflammatory bowel disease. Przegla̜dGastroenterologiczny, 10(3), 135–141.)
PROBIOTIC: Researchers have examined the effects of probiotic supplementation in UC patients. Probiotic bacteria may includeLactobacilli, Streptococci, Bifidobacteria, and certain E. coli subspecies. Probiotics may be effective in UC becauseof lactic acid production, which reduces luminal pH content, inhibiting growth harmful bacteria.(Silva M, Jacobus NV, Deneke C, Gorbach SL. Antimicrobial substance from a human Lactobacillus strain. Antimicrob Agents Chemother 1987;31:1231-1233.) Another possible explanation is bacteriocin production, resulting in a direct antibacterial action.(Atrih A, Rekhif N, Michel M, Lefebvre G. Detection of bacteriocins produced by Lactobacillus plantarum strains isolated from different foods.Microbios 1993; 75:117-123.)IRON: Blood losses, more prevalent in UC, can lead to iron deficiency anemia. This can be difficult to correct with dietalone. Iron supplements and iron rich foods may have enhanced absorption when a source of vitamin C is ingestedat the same time.(SturnioloGC, Tuccari G, D’Inca R, et al. Mucosal iron concentration and immunohistochemical evidence of iron-binding proteins in long-standing ulcerative colitis. Ital J Gastroenterol 1993;25: A68.)
CASE PROGRESSIONHemorrhoidectomy on 7/12/2016, Patient was NBM.Day 1Clear liquids at nightDay 2 – Day 3Full liquids Soft bland dietDay 4 - Day 5Soft bland dietDay 6Full bland diet
SHORT TERM GOALS OF MANAGEMENT To treat symptoms and prevent complications. To prevent the progression of the complications and manage them. Reduce intestinal inflammation and if possible heal the mucosa. Eliminate symptoms and minimize side effects and long-term adverse effects. To correct nutritional deficiency if any. Maintain a good nutritional status. To provide adequate nutrition to avoid macronutrient and micronutrient deficiencies. To provide adequate protein with high Biological
ULCERATIVE COLITIS Inflammatory bowel disease (IBD) encompasses both ulcerative colitis (UC) and Crohn’s disease (CD). Ulcerative colitis affects the colon and rectum and typically involves only the innermost lining or mucosa, manifesting as continuous areas of inflammation and ulceration. The different types of ulce
Ulcerative Colitis National Digestive Diseases Information Clearinghouse What is ulcerative colitis? Ulcerative colitis is a chronic, or long lasting, disease that causes inflammation—irritation . or swelling—and sores called ulcers on the inner lining of the large intestine. Ulcerative colitis is a chronic inflammatory
IBD include hemorrhoids, rectal fissures, fistulas, perirectal abscesses and colon cancer.3 Ulcerative colitis and Crohn’s disease are the two forms of IBD and differ in their pathophysiology and presentation. Ulcerative colitis is limited to the rectum and colon, and affe
Anatomy E1 Ulcerative Proctitis Limited to the rectum (15 cms), distal rectosigmoid junction E2 Left Colitis Colorectal distal to the splenic flexure E3 Extensive Colitis Extending proximal to the splenic flexure Table 3. Montreal classification: ulcerative colitis severity. Ulcerative Colitis Severity Definition S0 Clinical Remission Asymptomatic.
The two types of hemorrhoids are external and internal. How common are hemorrhoids? Hemorrhoids are common in both men and women1 and affect about 1 in 20 Americans.2 About half of adults older than age 50 have hemorrhoids.2 Who is more likely to get hemorrhoids? You are more likely to get
severely active ulcerative colitis who have had an inadequate response or intolerance to one or more TNF blockers. Limitations of Use: RINVOQ is not recommended for use in combination with other JAK inhibitors, biological therapies for ulcerative colitis, or with other potent immunosuppressants such as azathioprine and cyclosporine.
Americans have either Crohn's disease or ulcerative colitis. That number is almost evenly split between the two conditions. Here are some quick facts and figures: More than 1.6 million Americans have IBD. On average, people are more frequently diagnosed with Crohn's disease or ulcerative colitis between the ages of 15 and 35,
and ulcerative colitis, view our brochures at www.ccfa.org or call our Information Resource Center at 888.MY.GUT.PAIN (694.8872). When is surgery necessary? About 23 to 45 percent of people with ulcerative colitis and up to 75 percent of peo-ple with Crohn's disease will eventually require surgery. Some people with these conditions have the
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