NHD clinical - case study
Dr Fred Pender is a dietitian with over thirty years
experience both as an academic and a practitioner. An
An extract from
by Dr Fred Pender
enthusiatic exponent of the case-based approach as
Clinical Cases in
Dietitian and Author
a method of teaching dietetics, he believes that it is an
important vehicle for bringing practice into the classroom.
Dietetics
Dairy allergy: ulcerative colitis, loop ileostomy
Study concepts: nutritional status parameters (anthropometry), therapeutic advice to achieve nutritional requirements, nutritional
goals for ileostomates, formulating dietary advice, managing disinterest in food
Study context: loop ileostomy and weight loss
Dominic Pruz is a 41-year-old Baptist minister who evangelises in a ileostomy and pouch. Use two columns to indicate both the dietary
small village church in rural England. He lives in the manse with his objective together with some reasoning.
wife and four children under the age of 10 years. He has a long history 2. Explain the relationship with anaemia and anorexia in a client of
of ulcerative colitis and this has been managed for some years with this type.
a combination of steroid therapy, anti-inflammatory drugs and diet. 3. The patient has lost interest (or faith) in food and is unconvinced
He reports that he has been ‘through the mill’ diet-wise, having been of the role that diet plays in quality of life. With this in mind, discuss
on a dairy-free diet, an elimination diet and endless combinations of the approach that may be taken to motivate the client to better
sip feeds. He enjoyed some long spells of remission, but his general place diet in the context of his health.
health has begun to deteriorate and his appetite has been poor. He
has lost faith in the positive effects of dietary management.
Commentaries
Dr Pruz has recently returned from a visit to his homeland in Zimba-
Traditionally it was thought that milk caused diarrhoea and some doctors
bwe where a pan-proctocolectomy was performed. He had a loop ileo-
get confused and may actually ask a patient to avoid dairy products. In ad-
stomy placed and stoma formed and has been described by his con-
dition, undiagnosed coeliac disease may occur and should be excluded
sultant as a ‘bag loser’, as effluent pours through his stoma. He has
as a possibility. There has been some work done to link food intolerance
been plagued with intermittent bowel symptoms ever since (abdominal
with inflammatory bowel disease, but there is currently no evidence of a
discomfort and pain, bloating and flatulence). He has lost about 16kg
role for diet in the management of ulcerative colitis.
over the past 18 months. His height is 1.74m and he currently weighs
On consideration of the blood test results, albumin concentration is low
73kg. He has nausea most of the time and has lost interest in food. He
and it may be useful to see the WCC and CRP levels to ascertain whether
is seen by his consultant. Routine blood work and nutritional assess-
the patient is malnourished or septic (the client is probably malnourished
ment reveals the following clinical information:
on consideration of MAMC and TSF data). Haemoglobin and folate con-
centrations are also low and suggest anaemia; a diet/fluid history may
Serum/plasma constituents/ Result Range
reveal a poor intake of macro- and micronutrients (intake is probably low).
parameters
Concentration of potassium is dangerously low and the cause needs to
Mid-arm muscle circumference 21.4 50th centile =
be ascertained; it may be potassium loss from the gastrointestinal tract,
(MAMC) (cm) (<50th centile) 22.0 the patient may not be eating or there may be a gastrointestinal bleed
Triceps skinfold thickness 22.1 50th centile =
(which needs to be corrected urgently). Sodium concentration is low, sug-
(TSF) (mm) (<50th centile) 23.0 gesting sodium depletion, but urinary electrolytes need to be checked to
Total protein (g/l) 67.3 60-80
confirm or otherwise. It may be useful to check magnesium and vitamin
D concentrations which may account for low levels of potassium. (In a pa-
Albumin (g/l) 31.0 35-45
tient with a high-output stoma, there may be huge gastrointestinal losses
Haemoglobin (g/dl) 8.9 11.5-15.5 (male)
of magnesium. Low magnesium concentrations result in reduced secre-
Folate (ng/ml) 3.9 >5 tion and function of PTH, further increasing renal losses of magnesium
Potassium (mmol/l) 2.2 3.5-5.0
and indirectly reducing levels of 1,25 dihydroxyvitamin D.)
Sodium (mmol/l) 130 135-150
The objectives for dietary management are to improve his fluid and
electrolyte balance (the main priority) and improve his nutritional status
(to meet his nutritional requirements more easily). The client needs to be
Questions to consider educated about a better dietary and fluid intake.
1. Investigate the rationale for the various dietary interventions experi- Nutritional requirements for this client should be calculated using
enced by Dr Pruz, including the dairy product-free diet and the elimi- predictive formulae. Energy requirements for a client aged 41 years:
nation diet. Consider also the weight of evidence supporting the use BMR (11.5 x 73) + 873 = 1,713kcal, and together with PAL (1.5 x 1,713)
of these in the conservative management of ulcerative colitis. = 2,570kcal/d. Protein requirements for the same client: N = 0.2 x 73 =
2. Consider the blood investigations and, taking each parameter in 14.6gN = (x 6.25) = 91g protein/d. The aim initially would be to establish a
turn, indicate the possible implications of these for baseline nutri- low fibre diet, restrict hypotonic fluids and offer sip feeds (polymeric) and
tional status and for future nutritional strategy. double strength Dioralyte (1 litre/d).
3. Discuss the objectives of dietary management and prioritise nutri- Monitoring may include dietary intake (food record charts), MAMC and
tional goals for Dr Pruz. fluid balance (ensure output is reduced and urinary output <1 litre/d). A
4. Calculate his main nutritional requirements and interpret these into priority for the client is to ensure that he understands that the more he
a practical plan of action for the client. drinks, the more his output will increase and the thirstier he will become. It
5. Discuss suitable monitoring arrangements to assist in determining may be useful to discuss the possibility that he may have bacterial over-
whether the client is achieving his goals. growth/pancreatic insufficiency or undiagnosed coeliac disease. If diar-
rhoea persists, then liaison with the pharmacist may be helpful to ensure
Study questions that loperamide and codeine are taken or offered at appropriate times for
1. Construct a simple, but explicit information sheet for a client with the client).
NHDmag.com Mar '10 - issue 52 25
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