Crohn’s disease is genetic chronic inflammatory disorder of the digestive system that affects any part of the digestive tract, with the ileum and proximal colon being affected the most. Crohn’s disease causes gastrointestinal symptoms ranging from diarrhea, blood in the stool, abdominal pain, loss of appetite, weight loss, and malnutrition. Liver disorder can also occur.
In some cases, parts of the digestive tract need removal. This client has had a small bowel resection, and it important to provide nutritional therapy to prevent malnutrition.
The small intestine is the site of absorption of carbohydrates, fats, proteins, calcium, magnesium, trace elements and vitamins. It is also in the small intestine that bile salts are recycled.
Removal of the ileum reduces the absorptive surface area of the small intestine. Bile acids cannot be absorbed. This causes fat maldigestion and malabsorption of fat-soluble vitamins. Bile acids also spill in the colon causing watery diarrhea. The watery diarrhea is usually present in the post-operative period, and oftentimes medications are prescribed to manage the symptoms. The watery diarrhea causes dehydration; therefore, it is important to support electrolyte and fluid balance.
If this patient is not a renal patient, I recommend liberal use of unrefined salt. I cannot stress enough the importance of hydration: this client should drink filtered or spring water, away from meals, as well as nourishing bone broths. He should also reduce caffeine, soda, and alcohol to a minimum, as these beverages are dehydrating as well as irritating to the digestive tract. Should this client also be a renal patient, I would work collaboratively with his renal nurse specialist to find the right sodium and water requirements.
The Importance Of Vitamin B 12 When the Ileum Is Removed
Vitamin B 12 is absorbed in the lower ileum; it is necessary for red blood cell formation, DNA synthesis, and nerve function. Removal of the ileum causes vitamin B12 deficiencies; therefore, it is necessary for this client to start supplementing vitamin B12 immediately. I would recommend vitamin B12 injections, which are more bioavailable as they bypass the digestive tract. It is important to monitor vitamin B 12 levels yearly and adjust supplement dosage accordingly.
Altered anatomy also leads to fat maldigestion and deficiencies of fat-soluble vitamins. Vitamin D is necessary for healthy bones, calcium metabolism and immune system function, and deficiency can cause bone disease and osteoporosis. Supplementation of vitamin D as well as sun therapy are very important. Vitamin K is important for blood clotting and bone structure; deficiency can cause bleeding and bruising. Vitamin K deficiency is rare because the flora of the large intestine manufactures most of the vitamin K our bodies need. Vitamin A deficiency can be present. This fat-soluble vitamin is important for eyesight as well as tissue growth and healing, and deficiencies can cause night blindness and infections. Vitamin A is stored exclusively in the liver, and serum levels may not be a good indicator of body reserves. Ancient Egyptians treated vitamin A deficiency with liver.
What Happens During The Post-Operative Period?
In the immediate post-operative period a low-residue diet is indicated to control diarrhea. In some cases, enteral nutrition is necessary.2
I recommend for this client a nutrient-dense diet, high in protein diet but moderate in fats. Carbohydrates should be easy to digest and void of fibers (no whole grains for now, focus on potatoes without the skin, bananas, white rice). The diet will be low in oxalates and low-residue, as fiber, and especially insoluble fiber, is hard to digest in the post-operative period. Small amounts of well cooked vegetables can be added if tolerated (starting with ½ cup). Raw vegetables need to be avoided at this time. I recommend excluding vegetables that cause intestinal gas and discomfort: onions and garlic, vegetables of the brassica family, and legumes.3
References:
1 Costantini A, Pala MI. Thiamine and fatigue in inflammatory bowel diseases: an open-label pilot study. Journal of Alternative and Complementary Medicine (New York, NY). 2013 Aug;19(8):704–8.
2 Boelens PG, Heesakkers FFBM, Luyer MDP, van Barneveld KWY, de Hingh IHJT, Nieuwenhuijzen GAP, et al. Reduction of Postoperative Ileus by Early Enteral Nutrition in Patients Undergoing Major Rectal Surgery: Prospective, Randomized, Controlled Trial. Annals of Surgery. 2014 Apr;259(4):649–655.
3 Nutrition Guidelines for People With Short Bowel Syndrome | Memorial Sloan Kettering Cancer Center [Internet]. [cited 2020 Oct 10]. Available from: https://www.mskcc.org/cancer-care/patient-education/nutrition-guidelines-patients-short-bowel-syndrome
Celiac disease is an autoimmune gastrointestinal condition that causes a variety of health issues including nutrient malabsorption and deficiencies, changes in bowel habits, anemia, bone diseases, and eczema. It is more prevalent in females, and it usually occurs early in life.
Celiac disease is caused by an immune response to gluten in genetically sensitive individuals. One of the main culprits is gliadin, a protein component of gluten found in wheat, barley, rye, oats, malt, spelt, triticale, semolina, and bulgur.
Celiac disease causes an immune-system mediated damage of the digestive tract. This is carried out mostly by T-cells that become activated when sensitive individuals are exposed to gluten. Ingestion of gluten causes the body to produce antibodies against it; the presence of antibodies causes a mucosal inflammatory response, which triggers the T-cells to come to the site of inflammation and infiltrate the intestinal mucosa. Over time, repetitive exposure to gluten, and consequent autoimmune response, causes intestinal damage. The duodenum is the part of the small intestine that is affected the most. The autoimmune response causes hyperplasia of the crypts of Lieberkuhn, and atrophy of the villi and microvilli. This greatly decreases the absorptive surface area of the lumen, causing the small intestine to lose its ability to absorb nutrients, which leads to a myriad of nutrient deficiencies and symptoms.
How Genetic Make-Up Plays A Role In Determining Who Expresses Celiac Disease
Genetics play a big role in the development of celiac disease. There is a 10-15% chance of suffering from this autoimmune condition if a first degree relative suffers from it; rates are considerably higher in identical twins. People suffering from other autoimmune conditions (Type-1 diabetes, Sjogren’s Syndrome, juvenile chronic arthritis) have increased risk of developing celiac disease. Among other genetic conditions that can increase risk of developing celiac disease are Down’s Syndrome, Turner Syndrome and William Syndrome.
Gastrointestinal symptoms include abdominal pain, diarrhea (chronic or recurrent), weight loss, and malabsorption. Distention, bloating and steatorrhea can also be present. Celiac disease is accompanied in 10-15% of cases by a painful skin condition called dermatitis herpetiformis. Dermatitis herpetiformis, also called celiac rash, causes intense pruritus and painful vesicles and papules, most often on forearms, buttocks, knees, and scalp. Other features of celiac disease include failure to thrive, osteoporosis and metabolic bone disease, anemia, idiopathic peripheral neuropathy, fatigue, headaches, infertility, dental enamel hypoplasia, and stomatitis.
Diagnosis involves testing to serum autoantibodies while the patient is on a gluten-containing diet, and small intestine biopsy that requires 4 to 6 samples. The biopsy looks for increased intraepithelial lymphocytes, villous atrophy, and crypt hyperplasia, all of which must be present to distinguish celiac disease from non-celiac gluten sensitivity.
Treatments For Celiac Disease
Treatment for celiac disease is a strict celiac disease diet: all foods containing gliadin and gluten must be removed and completely avoided. Even traces amounts can be deleterious, and, unfortunately, gluten is hidden in foods, medications, and even non-food stuff, from make-up to stamps, to play dough. People with celiac disease need be careful when eating out, as cross-contamination is unfortunately widespread even in restaurants with gluten free menus.
The good news is that when followed strictly, the diet reduces inflammation to the small intestine and individuals can see improvement of symptoms within 3 months. In the presence of severe nutritional deficiencies and anemia, it is important to supplement with multi vitamins and minerals as well with targeted nutrients. When the digestive system can’t handle vitamin pills, injections may be prescribed. In some cases, steroid medications can be prescribed to keep inflammation under control while the small intestine regenerates. Unfortunately, about 1 in 50 people affected by celiac disease suffer from refractory celiac disease. People affected by refractory disease show no improvement in malabsorption and villi atrophy 6 to 12 months after strict gluten free diet. There is currently no treatment for refractory celiac disease.
References:
Caio G, Volta U, Sapone A, Leffler DA, De Giorgio R, Catassi C, et al. Celiac disease: a comprehensive current review. BMC Medicine. 2019 Jul 23;17(1):142.
Autoimmune Disorders [Internet]. Celiac Disease Foundation. [cited 2020 Oct 7]. Available from: https://celiac.org/about-celiac-disease/related-conditions/autoimmune-disorders/
What Are the Different Types of T Cells? [Internet]. Celiac Kids Connection. 2018 [cited 2020 Oct 7]. Available from: https://www.celiackidsconnection.org/2018/05/06/what-are-the-different-types-of-t-cells/
Reunala T. Dermatitis herpetiformis: coeliac disease of the skin. Annals of Medicine. 1998 Oct;30(5):416–8.
Carbohydrates are an important class of organic molecules found in all organisms. They are synthesized from carbon, oxygen, and hydrogen atoms. They are a source of energy, a form of stored energy, and they can have structural roles.
Monosaccharides, also called sugars, are the simplest form of carbohydrates. They are soluble and sweet tasting. They have between 3 and 6 carbon atoms, and their general formula is (CH2O)n, They are named according to the number of carbon atoms (triose C3H6O3, tetros C4H8O4, pentose C5H10O5, hexose C6H12O6). Glucose, fructose and galactose are all hexoses; while they all have the same chemical formula, they are structurally and chemically different.
Understanding The Importance of Glucose
Glucose is the main source of energy in respiration, and it is the building block for larger carbohydrates. It is a small, soluble monosaccharide that is easily transported in and out of cells through carrier proteins. It is less reactive than other monosaccharides; therefore, its breakdown must be catalyzed by enzymes. There are two forms of glucose: alpha-glucose and ß-glucose, which differ by the position of the hydroxyl group. The presence of either one yields very different polysaccharides.
Monosaccharides are joined together via a condensation reaction to form disaccharides and polysaccharides. During a condensation reaction one oxygen and two hydrogen atoms are removed from monosaccharides forming water. The removal of water bonds the monosaccharides together by a covalent bond known as a glycosidic bond. The names of glycosidic bonds depend on the location of the carbon atoms between which they are formed. For example, a bond formed between carbon 1 and carbon 4 is called a 1,4 glycosidic bond (i.e. maltose). Conversely, disaccharides and polysaccharides can be broken down into monosaccharides through hydrolysis. Being the opposite of condensation, a hydrolysis reaction requires water.
Disaccharides, also called sugars, are sweet-tasting and soluble. Different combinations of monosaccharides will form different disaccharides. For example, two molecules of alpha-glucose form maltose; alpha-glucose and fructose combine to form sucrose; ß-glucose and galactose combine to form lactose. Sucrose is formed by alpha glucose and beta fructose.
The Structure Of Sugar
Polysaccharides are polymers of simple sugars bonded via condensation reactions. Unlike monosaccharides and disaccharides, polysaccharides are not sweet-tasting nor easily soluble; they are not sugars. There is a variety of polysaccharides, depending on which monomers bond together to form the polysaccharide and where the bond takes place. For example: a polymer of alpha-glucose monosaccharides creates amylose. A polymer of ß-glucose gives us cellulose. A 1,4 glycosidic bonding gives us amylose, while a 1,4 and 1,6 glycosidic bonding gives us amylopectin.
Polysaccharides are the main source of stored energy for both plants and animals; they can also have structural roles. They are very compact, allowing storage of a lot of energy in a small space. They are insoluble in water; therefore, they do not affect the osmotic balance of the cell. They are large molecules that do not diffuse in and out of the cells. Finally, they can be easily hydrolyzed in alpha-glucose when energy is needed. Cellulose, chitin, starch, and glycogen are all examples of important polysaccharides.
Cellulose consists in beta glucose units connected via 1,4 glycosidic bonds and is important for the overall structure of plants. Chitin is made of N-acetyl-D-glucosamine polymers and it has a similar structure to cellulose. It is present in some fungi and in the exoskeleton of arthropods providing structure and strength that protect these organisms from the outside world. Starch is made from alpha-glucose, and it is found in photosynthesizing cells in leaves and storage cells in seeds. Glycogen is an important form of energy storage in animals. It is made of alpha-glucose molecules joined together by 1,4 and 1,6 glycosidic bonds. In times of strenuous activities or in between meals enzymes break down some of this glycogen in individual glucose molecules. When in excess, other enzymes add glucose units back to the chain to store them for later use.
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