GI Case Studies Dietetic Intern Practicum Learning Day Primary Care Dietitians Association May 27, 2021 Prepared by: Joanne Bak, RD - Primary Care ...

GI Case Studies
  Dietetic Intern Practicum Learning Day
   Primary Care Dietitians Association
              May 27, 2021
      Prepared by: Joanne Bak, RD

IBS Case Study
                        Mrs. A.R.
52 yr old from Yugoslavia, married, works as a cleaner 4/7

Reason for Referral: IBS-M
Patient concerns: abdo pain, sweets cravings, need for probiotic?
• HPI: IBS dx May 2018
     • stools hard to loose, maybe no BM for 3-4 days +/- abdo cramps
•   PMHx: GAD
•   Medications: Effexor
•   Recent Labs: Nov 2020 all WNL – CBC, lipids, A1C, TSH
•   Current Weight: 88.6 kg
     • Weight hx: gained 3 kg x 1 year eating sweets at night due to stress of pandemic
     • BMI: 30.3
• Food Allergies/Intolerances/Restrictions: none
     • MD advised low FODMAP diet but patient finds the diet hard to follow
• Supplements: none, hard time remembering to take
• Physical Activity: none outside of housecleaning

Mrs. A.R. – Diet History
• Breakfast:
    • Non-work days @ 10 am:
         •   hot water with lemon + eggs + white bread or cereal (Special K or Miniwheats) + 2% milk
    • Work days: no food until 3 pm
• Lunch: skips
• PM: pear or apple or banana
• Dinner @ 5 pm: examples
    • Homemade soups (chicken, egg noodles, lots of veg - carrots, celery, cauliflower etc) + entrée
         •   baked/roasted chicken/meat + potato + veg
         •   goulash or stuffed peppers or cabbage rolls + bread
    • Dessert: store bought or homemade – cookies/cake
• HS: chocolates, almonds – eats non-stop til 10 pm – can’t control self; no salty snacks
• Fluids: 1-1.5 L water/d + 2 c coffee with lots milk; no SSB; 2 beer on weekends

Nutrition Assessment: IBS - M
• Concern #1: What are the possible reasons for Mrs. A.R.’s bowel symptoms?

• Concern #2: Why do you think she is eating excessive sweets at night?

• Concern #3: Would you advise she start a probiotic supplement? Why?

Nutrition Plan: Mrs. A.R.
• Do you agree with her doctor to start her on a low FODMAP diet? Why?

• What diet recommendations would you make? Key points.

Celiac Case Study #1
                          T.K.
45 yr old teacher, sudden onset diarrhea/uticaria x 4 mos

Reason for Referral: diarrhea, uticaria, possible food allergies/gluten intolerance
 Patient concerns: hives, bowel changes & diet triggers
• Initial RD consult (Feb 26/21): patient reported the following:
   • Eliminated gluten, nuts, dairy x 1 week each last fall – no clear benefit
   • Gluten free x 6-8 weeks (before Xmas to late Jan 2021)
       • better stool consistency, abdo pain variable
   • Advised by allergist & family MD to have celiac screen, told ‘not to change her usual diet’.
       • Results from Jan 25/21 bloodwork: TTG IgA 0.5 U/mL IgA 3.07 (ref range 0.54-4.17)
       • Allergist dx: uticaria, gluten and dairy intolerance (limit amt daily) and strawberry allergy; assured
          patient she does not have celiac disease

Assessment
• Can celiac disease be ruled out based on this information? Why?

• What would you advise this patient? What are her options in this situation?

• What are the possible consequences of each option?

Celiac Case Study #2
M.T. is an 84 yr old woman recently diagnosed with celiac
              disease, lives with her daughter

Reason for Referral: new diagnosis celiac disease
 Patient concerns: diarrhea, weakness, loss of appetite, celiac diagnosis
• HPI:
    • July 2020: endoscopy --> small HH, villous atrophy duodenum, microscopic colitis
         o Meds started: Cholestyramine for diarrhea; Pantaprazole for reflux
         o Plan by GI specialist – confirm celiac dx by serology to r/o other possible causes
    • Dec 2020: family MD
         o 10 week increase in diarrhea requiring increase in cholestyramine from 2-3 pouches/day (helping), weakness
              ! ? related to celiac flare or diet " RD referral
         o Celiac serology: TTG IgA >250                   Other Labs: Vit B12 253 Hb 119 ferritin 134

• PMHx: osteoporosis, anemia
• Supplements: Vit D 1000 IU/d; Ca 500 mg OD; MV OD; B12 q mo IV; restarted Feramax (Jan 2021)
• Weight Hx: 50 kg reflecting 4 kg loss x 1 mo                           Current BMI: 21.9

Diet History              (Dec 2020)
• Food Intolerances: lactose, caffeine, spicy foods
• Breakfast:
   • Quaker Oats with berries + almond milk OR rye bread with cheese, jam +/- pb
• Lunch:
   • Homemade veg or lentil soup using bouillon cube as a base OR egg + fruit
• Dinner:                                                                        Where is the gluten?
   • Mediterranean style; stew with egg noodles
• Snacks:
   • cookies, croissant, bagels, Balkan LF yogurt, cheese
• Fluids:
   • Green tea or coffee 2c/d with almond milk
   • Ensure, hot chocolate - occasional
   • Water – not enough

Nutrition Assessment
• Patient’s questions/concerns:
   • Colitis – celiac – different parts of the bowel or same issue re: diet?
   • Dried fruit from Bulk Barn – safe?
   • Scared to buy root vegetables – cross contamination?
• What are the top 2 priorities from your perspective for today’s consult?
   • Gluten free diet education
   • Modifying fibre to reduce colitis diarrhea
   • High energy high protein diet for weight gain
   • Iron rich foods for anemia
   • Calcium rich foods for osteoporosis

Nutrition Monitoring: 1 mo later (Jan 2021)
• Progress with previous plan:
   • generally formed BM, less cholestyramine (2 pouches vs 3), eating more but no weight gain
• New concerns/questions:
   • Does gluten tolerance improve over time?
• Diet Changes:
   • Veg – cooked squash, zucchini – tolerating
   • No peanut butter or legumes still – misses - worried it will make colitis worse
   • GF pasta and GF oats +/- Ocean Spray dried cranberries
   • Dimpflmeier light rye bread – no gluten in list of ingredients – dislikes GF types plus $$
• Diet Assessment:
   • What changes has M.T. made that indicate better understanding of GF diet?
   • What knowledge gaps persist re: celiac disease and diet?

Nutrition Monitoring: 6 weeks later (Mar 4/21)
Progress with previous plan:
• occasional GI pain, bowels ok, less cholestyramine; appetite better, still no weight gain
• doing better with diet, reading info previously given by RD but had questions
    • stomach aches/pain - trying to follow diet 99% so not sure if colitis or celiac related
    • itchiness on her back - wonders if connected to celiac disease
    • read older adults with celiac takes 2 years to heal intestines - if untreated, severe health consequences
    • read that people with celiac at risk for: osteoporosis, iron deficiency, anemia - coffee ok? drinks 1c/d
Diet Changes/Concerns:
• Really misses rye bread
     • Found a lady who makes GF bread to supply to a commercial kitchen that she likes, has seeds, reminds her of
        rye bread
          • wonders if this is ok and/or if I have a recipe for bread machine GF bread?
   • Still hesitant re: legumes, peanut butter; having some Ensure, not daily
• Follow up: 2/12 - key points ?

Bowel Narrowing
           & Diet
R.Z. is a 25 yr old female with recent hospitalization for SBO

Reason for Referral: SBO with multiple adhesions, vegan & difficulty with low fibre diet
Patient concerns: fear of recurrent SBO, unwanted weight gain

 • HPI:
     • small bowel resection at age 16 for an AV malformation of the small intestine
     • Sep 9/20 admitted to hospital with SBO terminal ileum, had 2 laparotomies
     • during surgery found to have a large cluster of densely adherent, mangled small bowel – could not fix
     • put on bowel rest with NG tube and TPN ~ 2 mos
     • d/c early November 2020 on low fiber, low residue diet (saw RD in hospital)
     • Nov 20/20 – RD referral from family MD

Initial Nutrition Consult:
Feb 18/21 (declined earlier appointment, ‘wasn’t ready’)
• Patient Concerns:
   • struggling with diet and fear of recurrent SBO
   • vegan but now allowing dairy such as cheese/milk if it’s in a mixed food; no eggs
   • gaining too much weight since diet is all carbs, hungry all the time
• Labs: none available
• Meds: none – initially on stool softeners but advised not to take anymore by GI
• Weight Hx:
   • 61.4 kg Feb 18/21 with 10 lb gain in past 2 wks        UBW: 60 kg (BMI 22)
   • 54 kg Nov 20/20
   • 49.5 kg Oct 30/20 – lowest weight in hospital

Nutrition History
• Food Allergies/Intolerances: high fibre foods                        Diet History:
• Supplements: none                                                    Breakfast – none
• Knowledge/Beliefs:                                                   Lunch - 2 white Everything bagels + vegan butter
    • RD in hospital - no nuts, seeds, skins, legumes                  OR Sub s/w - white bread, lettuce, tomato, cucumber,
    • very scared to eat foods other than:                             onion + vinaigrette

         • white bread & white pasta (but prefers whole wheat pasta)   Dinner - white pasta w tomato sauce, onions/carrots
                                                                       or vegan organic soup w noodles, tofu, onions, carrots
         • tomatoes and onions - not taking out the seeds anymore
         • peeled cucumber, apples; occasional few blueberries         Snacks - mini cucumber with ranch dip; odd time
                                                                       blueberries; no ‘snack foods’
         • cut back on lettuce as not digesting well now
                                                                       Fluids – 1.5 L/d max
    • NOT willing to NOT be a vegetarian
                                                                       - 1 bottle water/d
• Preferences:                                                         - 1 c coffee/tea
    • used to eat hummus                                               - 1-2 boxes juice/d
                                                                       - 1 Gatorade +/- g’ale
    • dislikes pb - but would eat if advised to
                                                                       - no soy milk but likes
    • dislikes tomato / V8 juice / nutritional supplements

Nutrition Assessment
• What additional information do you need to assess diet tolerance?

• Is R.Z.’s risk for another SBO low, moderate or high? Why?

• What other nutritional concerns are there?

• Recommendations?

Nutrition Monitoring: 1 mo later
Progress with Previous Plan: feeling better overall, diet still limited but less afraid; gained another 2 lb
• Patient only had 20 minutes to talk – at work
Adherence to plan:
• Supplements – can’t find MV without gelatin
• Diet review – minimal change
    • Limits veg to one meal: occ m’ potato, cooked green beans/carrots; Sub s/w on white bun with bit of lettuce
    • Tomato sauce on pasta: too much fibre? - loose stools after
    • Fruit: watermelon, couple strawberries
    • Proteins:
         • some peanut butter but forgets; cream cheese on bagels; bit of hummus
         • some soy milk but using oat milk more often in coffee/tea, none to drink
         • afraid to have lentils
GI: BM’s q 2 d; not skinny (as when heading for SBO); no pain; bloated all the time; odd time gurgling/sloshing after a meal

                                   What has improved?           What concerns do you still have?

Nutrition Plan
What might motivate R.Z. to follow through with diet recommendations?

Is a vegan diet realistic for R.Z. given risk for recurrent SBO’s?

Contact

Joanne Bak, RD, CDE                  905-272-9900 ext 302
Summerville Family Health Team   @   jbak@summervillefht.com
101 Queensway W., 7th floor          Summervillefht.com
Mississauga, ON L5B 2P7