65 year old male with Crohn’s disease, weight loss and diarrhea
Introduction
A 65 year old man with Crohn’s disease for 15 years, consults the outpatient clinic of the gastroenterologist on an annual basis. He is suffering from weight loss and increased (stinky and difficult to flush) diarrhea over the past 6 months. As a consequence, he is feeling weak, socially disabled and is restricted to staying home (around a toilet). The dietitian is consulted to determine and improve his nutritional status. The patient’s wishes are to make the diarrhea manageable and to gain weight and strength. The differential diagnosis of the gastroenterologist includes exacerbation of Crohn’s disease and/or malabsorption due to bacterial overgrowth. He prescribes a trial treatment with antibiotics and pancreas enzymes.
Diagnostics
Together with the gastroenterologist a diagnostic scheme is prepared including food diary, fecal collection and fecal analyses, laboratory assessment, anthropometrics, breath test and ‘beet-test’. There are no signs of Crohn’s exacerbation which is still in remission, and the glucose breath test suggests bacterial overgrowth is less pronounced. What is striking is a clear bile acid diarrhea, steatorrhea/ fat malabsorption and an increased gastrointestinal transit time. Subsequently nutritional status is checked including micronutrient status. This shows: fat soluble vitamin deficiencies as a consequence of the fat malabsorption. He is at risk of malnutrition due to involuntary weight loss, without inflammation, (wasting) due to a negative energy balance as a consequence of fecal losses, and with a reduced handgrip strength and fat free mass index (FFMI).
Somatic factors Collected data based on targeted diagnostics
65 yr, male
15 yr: Crohn’s disease terminal ileum, ileocecal resection (Montreal A3L1B1)
5 yr: Liver cirrhosis (Child-Pugh A) due to Azathioprine in past, portal hypertension, and porta thrombosis (OAS)
Normal appetite, no chewing and swallowing issues, N-, V-, distention, stinky and sticky feces, 6-8 bowel movements/d, abdominal cramps, flatulence, no blood or mucus in stools
Normal weight 83 kg
Current weight 75 kg, now BMI 22.2 kg/m2
Weight 1 month ago 77 kg
Weight loss 6 months 9.6%
MUST score 1
Rx:
Calcium/colecalciferol 500/400 (mg/IE/d)
Hydroxycobalamin 300 µg/2 mnd
Temazepam 10 mg (if necessary)
Ustekinumab 90 mg/ml
Anthropometrics:
Height 1.84 m,
Bioelectrical impedance analysis:
FFMI 18.4 kg/m2 (P25)
Resting energy expenditure (indirect calorimetry): 1850 kcal/d, RQ 0.85
(REE estimated WHO 1715 kcal/d)
Food intake: (4 day diary ) ca 2300 kcal, 75 g protein (1 gram/kg), 110 g fat, 255 g carbs, no alcohol
Laboratory test results:
Vit A 0.8 µmol/L (L) Vit B12 324 pmol/L (N)
Vit D 24 nmol/L (L) Vit B1 124 nmol/L (N)
Vit E 26 µmol/L (N) HB 7.9 g/dl (L)
Folic acid 18 nmol/L (N) Iron 7 µmol/L (L)
Gamma GT 92 (H) Albumin 31 g/L (L)
Ferritin 25 µg/L (N) CRP 8 g/dl (N)
Leuco 6.5 x106/L (N)
Fecal tests:
Calprotectin <10 µg/g (N)
Elastase 355 µg/g (N)
Volume 1180 g/d (H)
62 g/d fat (H) 44% absorption (L)
Nitrogen 3.5 g/d (H) 71% absorption (L)
Bile salts 4273 µmol/d (H)
Other:
Gastro intestinal transit-time (with corn): 90 min
Glucose hydrogen breath test: negative
CT pancreas: normal
Functional factors
Grip strength 46 kg (P15 = 43)
Less active pattern than desired due to GI complaints
Daily walk with dog
ADL independent
Psychological factors Social factors
Does not accept current health status
Frustrated about social disability
Good illness insight
Feeling of reduced quality of life
Feels supported and helped by (para)medical team
Married, concerned wife
Retired official
College education
Plane spotter
Voluntary work neighbourhood association
2 adult children living on their own, 3 grandsons
Dietetic diagnosis
65 year old man with Crohn’s disease (in remission) and liver cirrhosis (CP-A) is at risk of malnutrition, most likely type wasting due to a negative energy balance with normal appetite/intake, but severe malabsorption and steatorrhea due to bile acid diarrhea and increased gastro intestinal transit time, resulting in 10% weight loss in 6 months, normal BMI a decreased handgrip strength and FFMI and fat soluble vitamin deficiencies (A, D). He is retired, married, suffering from a decreased quality of life and social disabled (as a consequence of frequent stools). He is very cooperative with the goals of improving his weight, his GI symptoms and health status.
Treatment goals
- Weight gain of 1-2 kg/month until normal weight (83 kg) with a positive energy balance
- Energy goal including gaining weight and compensation for malabsorption: 3000-3500 kcal/d.
- Protein goal 1.5 g/kg/ actual bodyweight:110-115 g/d
- Normalizing stools and GI complaints to acceptable and manageable levels
Treatment plan
- Diet: Energy and protein enriched and low(er) fat diet
- Supplementation: start retinol 25.000-50.000 IE/d for short period and colecalciferol 25.000-50.000 IE/wk
- Medication: Start anti diarrheal medication and maximal dose bile salt binders
Evaluation
The initial proposed trial of treatment with antibiotics for alleged bacterial overgrowth (SIBO) and pancreas enzyme therapy for possible exocrine pancreas insufficiency, did not result in any effects on the symptoms, stools and bodyweight. This is not surprising since diagnostics did not show any signs of SIBO (breath test) or pancreas insufficiency (fecal elastase and CT imaging). Since dietetic intervention combined with adequate medical treatment, he is turning into an anabolic state (after 6 months weight 80 kg; + 5 kg, BMI 24.0 kg/m2), defecation frequency is normalized to 2-3 times a day and seems less stinky, loose and fat. He is confident that he will get his normal life back.
