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Case Study #1

Enterocolitis, SMA syndrome and


Clostridium difficile infection

Sean Servalish
Andrews University
2016-2017
Introduction:
K.T. is a 65-year-old, white female admitted to the Lakeland Regional

Hospital in Saint Joseph Emergency Department on December 6th, 2016 with

reports of severe abdominal pain, chronic diarrhea, persisting emesis, poor

intake and severe weight loss over the past 2-3 months. Under pain

management therapy, patient K.T. was admitted to Lakeland hospital with a

C. diff infection, continued abdominal pain and possible SMA syndrome

(superior mesenteric artery) for further testing and treatment. She admission

weight was 37.6 kg (82 lbs, 14 oz) and height at 1.5 m (5) resulting in a BMI

of 17; classified as underweight. Patients ideal body weight for height and

gender is 100 lbs, making her only 85% of this weight. This patient was

chosen for a case study due to their severity of nutrition related symptoms,

her presence of infection and possible rare disease affecting intake and her

appropriateness to be treated with nutrition therapy interventions. The

purpose of this study is to examine the progression of a diet from NPO

through the various stages and the different nutrition interventions available

for each diet stage, to discover the various tests performed to diagnose

digestive system abnormalities and to explore the rare SMA syndrome. The

study began 12/6/16 and concluded on 12/11/16.

Social History:

The patient referred to as K.T. is a widowed woman living in a trailer

home with her grandson, her great granddaughter and her grandsons

girlfriend. Patient was previously a nurse but does not currently work and

relies on disability for financial support, receiving Medicare and Medicaid


insurances. Patient is otherwise self-sufficient at home, preparing her own

meals and cleaning at home. Patient describes her home life as stressful at

times when having to support her grandson and great granddaughter with

many family members dealing with drug addictions and influences. Patient is

a former smoker at a pack a day for 15 years with occasional medical

marijuana use. She also says that aside from recent illness and stressful

family issues at home, she tries to live a healthy lifestyle with her diet and

staying active as she is able for her age and condition. K.T. practices

Christianity and occasionally attends church on Sundays.

Normal Anatomy and Physiology of Body Functions Affected by

Enterocolitis caused by Clostridium difficile Infection:

In an individual with infectious colitis, caused by any number of

bacteria including C. diff, will experience inflammation of the colon due to a

bacterial overgrowth. Many complications may manifest from this state in the

digestive tract including severe abdominal pain, bleeding of the colitis,


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malabsorption, maldigestion and malnutrition. Many nutrients, vitamins and

water are absorbed and reabsorbed in the colon; an inflamed colon not only

affects absorption but intake as well due to symptoms of pain, diarrhea and

early satiety. Often, infectious colitis can take place in a patient who has had

previous or recent antibiotic therapy, which was the case with patient K.T.

whos healthy gut flora was reduced by this type of treatment from a recent

UTI and never adequately replenished, allowing the growth of infectious

bacterium to take place and rise to unsafe levels.


Past Medical History

K.T. has a history of many surgical procedure and medical conditions.

Her medical conditions noted include: anxiety, arthritis, carpal tunnel

syndrome, chronic pain syndrome, hypertension, multiple fractures due to a

falling accident 5 years prior, acute kidney injury, recurrent pancreatitis,

pericarditis and a history of seizures reported to be infrequent. Her surgical

procedure history includes: anterior/posterior combined fusion cervical spine

(usually to remove bone spurs and cysts), carpal tunnel release,

tonsillectomy, hysterectomy, appendectomy, cholecystectomy, multiple

cesarean sections, miscarriage, vertebroplasty (injected bone cement into

fracture for support back fracture from fall 5 years ago), ERCP with

sphincterotomy and balloon dilation (for bile duct leak) and an

esophagogastroduodenoscopy which took place during current admission to

determine blockages in upper GI tract.

Present Medical Status and Treatment:

Clostridium difficile infection is a leading cause of hospital- associated

gastrointestinal illness. a gram-positive, spore- forming bacterium usually

spread by the fecal-oral route. It is non-invasive and produces toxins A and B

that cause disease, ranging from asymptomatic carriage, to mild diarrhea, to

colitis. To be diagnosed with this infection, there must be an acute onset of

diarrhea with documented toxigenic C. difficile or its toxin and no other

documented cause for diarrhea. The two biggest risk factors for this infection

are exposure to antibiotics and exposure to the organism; others are


comorbid conditions, gastrointestinal tract surgery, and medications that

reduce gastric acid, including proton-pump inhibitors.2

Treatment of bacterial infections like C. difficile largely depends on

antimicrobial therapy, especially for mild cases where Flagyl (metronidazole)

is used and vancomycin for more severe cases. For patients with ileus, oral

vancomycin with IV metronidazole and injected vancomycin may be given.

Depending on the severity of disease, the further line of management may

include surgery, IV immunoglobulin treatment or high dose of vancomycin.

Other treatments and therapies are supplemented probiotics and prebiotics,

fecotherapy, adsorbents and immunoglobulin therapy.3

Upon admission on December 6th, patient complained of abdominal

pain as well as chronic back pain, loose stools, weight loss and persistent

emesis. Initial findings from stool sample indicated a C. difficile infection and

associated colitis with possible blockage due to SMA syndrome as initially

suspected by MD due to SMA compression after receiving initial CT scans and

X-Ray. Patient was also found to have a low potassium (hypokalemia).

Hypokalemia is common in patients experiencing diarrhea and emesis.1 Initial

plan was treat patient with Flagyl antibiotic for positive bacterial infection

treatment and with MS Contin for relief of the abdominal and back pain

experienced. To reduce inflammation the patient was placed on an NPO diet

with progression as tolerated.

On December 7th, after little improvement to symptoms, patient began

IV vancomycin to help treat the infection. To determine presence of an ileus,


a duodenal sweep scan was performed and analyzed by gastrointestinal

specialist to determine the presence of SMA syndrome. is a digestive

condition that occurs when the duodenum is compressed between two

arteries (the aorta and the superior mesenteric artery). This compression

causes partial or complete blockage of the duodenum. This can be a largely

contributing factor for emesis and abdominal pain. Findings from the scan did

indicate a slight compression in the duodenum with dilation following as well

as enterocolitis discovered. The most common cause of SMA syndrome is

weight loss, so the doctors decided to treat other oral intake inhibiting

illnesses to help increase her weight and relieve the compression.4 A severe

malnutrition diagnosis was given as well for this patient following the dietetic

interns assessment and nutrition focused physical exam and treatment will

be explained in corresponding section of this study.

Patient continued oral Flagyl and IV Vancomycin throughout her stay

until diarrhea symptoms improved and stool became uniform. Patient

showed improvements in pain level and the doctor discharged her on

December 11th to go home with PRN pain medications and continued oral

Flagyl.

Labs:

Lab: Admission Final Lab Normal


Lab values values on Range for
on 12/06/16: 12/10/16 Lab Value:
White Blood Cell 12.0 5.2 4.5 - 11
count
Red Blood Cell 5.08 3.77 4.0 - 5.2
count
Hemoglobin 16.6 12.2 12.0 -16.0
Hematocrit 48.1 36.0 35.0-47.0%
Mean Corpuscular 94.7 95.5 80 100 fL
Volume
MCH 32.7 32.4 26-34 pg/cell
MCHC 34.5 33.9 32-37 g/dL
RDW 12.8 12.6 11.5 14.5%
Platelets 320 238 140 440
Random Glucose 135 104 65-100 mg/dL
Blood Urea 19 5 6 24 mg/dL
Nitrogen
Creatinine 0.6 0.5 0.5 - 1.0 mg/dL
BUN/Creatinine 32 10 7-25
Ratio
eGFR >60 >60 >60 mL/min
Sodium 142 139 136 - 143
mmol/L
Potassium 4.0 3.3 3.6-5.0 mmol/L
Chloride 99 106 96 107
mmol/L
CO2 23 25 22-31 mmol/L
Total Calcium 10.5 8.7 8.4 10.2
mg/dL
Total Protein 9.1 5.6 6.4 -8.2 g/dL
Albumin 5.1 3.1 3.2 4.6 g/dL
AST 28 28 8-39 U/L
ALT 21 16 9-52 U/L
Alkaline 157 89 38-126 U/L
Phosphatase

Medications:

Drug/Nutrient
Medication Purpose Possible Side Effects
Interaction
PRN:
Dry mouth, anorexia,
Do not consume nausea, vomiting,
Fetanyl Pain relief
alcohol while taking abdominal pain, diarrhea,
constipation.
Decreased appetite and
Treats seizure weight, dry mouth, nausea,
Ativan Avoid alcohol
disorder vomiting, constipation,
abdominal pain.
Gas-X Relieve gas, Dont take with Belching
bloating and thyroid medications,
abdominal 4 hours apart
discomfort minimum
Frequent urination, SOB,
None, can cause
Toradol NSAID pain problems with vision, flu-
weight gain
like symptoms
ROUTINE:
To treat GERD,
Dizziness, seizures,
reduces acid in
Iron supplements and swelling, fever, cramps,
Protonix the stomach
diuretics nausea, vomiting, stomach
(proton pump
pain, diarrhea.
inhibitor)
Constipation, chest pain,
Do not take with drowsiness, bradycardia,
MS Contin Pain relief
alcohol. nausea, vomiting. Loss of
appetite.
Dizziness, fainting, pain,
Ciprofloxaci Do not take with only
Antibiotic itching, nausea, vomiting,
n a source of calcium
loss of appetite
Drowsiness, headache,
Take with food and
nausea, vomiting, stiffness
Flagyl Antibiotic avoid alcohol while
of the neck, loss of
taking this.
appetite.
Dry mouth, increased thirst,
Do not take with
Vancomycin Antibiotic fever, SOB, nausea,
alcohol.
vomiting, stomach pain.
IV Normal Can increase
Saline w/ Fluid, hydration potassium levels with Swelling on extremities
KCl KCl in fluid.
Vitamin K intake, has
sodium in it so
Chest pain, rapid breathing,
monitor intake of
Heparin Blood thinner severe headache, itching,
sodium, avoid alcohol
easy bruising
because it also thins
blood
Alcohol can increase Fainting, sweating, nausea,
Treats
damage to your liver vomiting, loss of appetite,
Ofirmev headaches and
while taking this stomach pain, unusual
reduces fever
medicine bleeding.
Desyrel Antidepressant Do not drink alcohol Weakness, itching, fever,
with this medicine restlessness, muscle
spasms, swelling in mouth
or throat, hallucinations,
trouble sleeping, nausea,
constipation, headache.

Procedures/Tests:

Chest XR Findings included mild hyperinflation but no evidence of any

active disease.

CT Scan Pelvic Abdomen Enterocolitis discovered. Possible compression of


superior mesenteric artery and aorta.

Ultrasound Abdomen - Monitoring the common bile duct for dilation post
cholecystectomy and source of pain. No abnormal findings.

ECG Normal rhythm. Low heart rate, bradycardia.

Allergy test: wheat Test negative for any intolerance or allergy to wheat.

Medical Nutrition Therapy:

K.T. was flagged as a high level nutritional risk due to her severe recent

weight loss, low weight and persisting poor appetite. The patient does most

of the cooking and cleaning at home and rarely goes out to eat due to poor

transportation resources. She has a friend who lives near help her get to

appointments and the grocery store to purchase her food. Although she has

had no appetite in months, she forces herself to eat 2-3 meals per day with

1-2 snacks per day as well. Below is an analysis of nutrients and calories

gathered from the patients 24-hour recall for a typical day of eating, of which

she states she rarely consumes 100%:


Protein Fat Sodium Calorie
Breakfast Carbs (g)
(g) (g) (mg) s
Whole Wheat Toast 12 3 1 127 71
Large Egg, Fried in butter 0 6 7 123 94
6 oz 2% Milk 9 6 4 86 92
Lunch
Triscuit Crackers (8-10) 24 4 2 232 130
Cheddar Cheese Slices 0 7 9 176 114
Snack
Peanut Butter Sandwich 37 13 16 447 337
Gatorade 20 oz 39 0 0 238 158
Dinner
Small Chicken Breast, Baked 0 23 3 370 120
Broccoli, Cooked 5 2 0 19 26
Total: 126 64 42 1,818 1,142

Using the actual body weight of the patient at 38.4 kg (84.5 lbs.),

estimated nutrition needs were as follows:

Calories: 1152 1344 kcals based on 30 35 kcal per kg


because of her low weight and need for weight gain.
Protein: 46 - 58 g based on 1.2 1.5 g per kg due to a
depleted, malnourished body mass.
Fluid: 960 1152 based on 25 30 ml per kg to meet
hydration needs for age.

Comparing her needs to an average day of intake (when she consumes

100% of meals, which patient claims is rare), K.T. is falling just short of her

calorie needs for weight maintenance. With contributing emesis and

diarrhea, this daily caloric intake will eventually lead to a malnourished state.

K.T. initially was placed on an NPO diet due to distress in her GI tract

from infection and a possible ileus, receiving intravenous fluids. At this stage,

the dietetic intern first had an encounter with the patient. Nutrition focused

physical exam findings revealed severe compromise of subcutaneous fat in


all areas paired with severe depletion of muscle wasting in multiple areas. A

nutrition diagnosis was assigned; it was as follows:

Malnutrition related to physiological causes inhibiting adequate


nutrition consumption and loss of appetite as evidenced by a BMI less than
18.5, overall fat and muscle wasting, weight loss greater than 10% in the
past 3 months and persistent emesis and abdominal pain.

A clinical nutritional goal of advancing to a PO diet was established by

the dietetic intern for K.T. At the time of this encounter the interventions that

took place immediately were:

Ordered Culturelle (probiotic) twice a day to replenish


depleted gut flora.
Recommend a liquid diet as tolerated with eventual
advancement to a soft, bland diet.

The rest of the interventions were pending until an advancement to a

PO diet. On 12/08 K.T met their initial clinical goal and was cleared to begin a

clear liquid diet. At this time the following nutrition interventions took place:

Ordered Boost Breeze (clear liquid supplements) on


breakfast and lunch trays.
Ordered Theragran multivitamin daily to help avoid and
correct any micronutrient deficiencies occurring from
recent poor intake.

On 12/08 in the evening, patient was able to progress to a full liquid diet with

tolerance to clear liquid diet. Upon this advancement, Boost Plus was ordered

in place of Boost Breeze due to a distaste for the Boost Breeze supplement.

While monitoring the weight, intake, labs and digestive system of

the patient, some responses to nutrition therapy were observed. The patients

diet advanced to a mechanical soft diet upon discharge on 12/11, intake

slowly progressed to >75% of meals from less than 25% upon admission and
the patients weight stabilized and K.T. even gained a little over a pound with

the aid of the nutritional supplements offering additional calories and protein

to her diet.

This dietetic intern returned to follow-up with the patient on 12/09

prior to her discharge and spoke with her about her progress. K.T. reported

much improved abdominal pain and a slight improvement in diarrhea

symptoms during her admission with a returning appetite. The patient

brought up a cooking method of air-frying, a low-fat way to prepare meats,

related to her gallbladder removal in the past. The dietetic intern provided an

education about a low fat diet and the benefit of small frequent meals

related to this change in the body as well as its benefits to multiple

symptoms she is experiencing at this time.

K.T. responded well to all nutritional interventions provided by

dietetic intern and following dietitians. She has a high motivation level and

her expected level of compliance is high as she plans to continue

supplementation at home to increase her weight and overall health. The

patient was discharged home on 12/11 in fair health with expectations of a

resolving colitis infection and improving weight.

Prognosis:

The patients prognosis is very good pending the effectiveness of

the oral antibiotics on the remaining infection and the patients effort to

replenish her GI tract with healthy bacteria to promote a properly functioning

digestive system, disallowing regrowth of the C dif. bacteria. 89% of


patients that develop this infection have taken antibiotics prior to the
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infection. However, we also treat the infection with more antibiotics,

therefore the use of probiotics and prebiotics, both supplemented and from

diet will be so important in her recover and determining the prognosis. A big

goal for this patient will be to gain weight by consuming 100%+ of her

recommended needs through diet and supplements that she chooses at the

store. Weight gain to a more normal weight for her age and height will

increase her strength and relieve the pressure of the compressed superior

mesenteric artery.

Unfortunately, this patient was readmitted three days post-

discharge for the same symptoms. The patient has been diagnosed with a

severe infection and will require another continued bout in the hospital and

increased antibiotics to help treat her infection.

Summary:

So this study taught me a several things: the progression of diet

through different steps and stage from initially unable to tolerate an oral

diet, NPO, what SMA syndrome is and its effect on the digestive system and

overall nutrition and the importance of probiotics and their benefit for a

patient taking antibiotics. Antibiotics can reduce both bad and healthy

bacteria colonies in the GI tract and replenishing them with health bacteria

from fermented foods, probiotics or even medical treatment like a fecal

transplant can help overall health by preventing growth of infection bacteria

like C. diff. An infection like this can cause severe abdominal pain, diarrhea
and poor intake which leads to hospitalization. In the hospital patients are

most often began as NPO until antibiotic therapy is begun. Once symptoms

are improving patient will progress to a clear liquid diet and the appropriate

supplements can begin to help with the weight loss and poor recent intake.

From clear, patients progress to full liquid where additional supplements can

be supplemented, Boost Plus in this study. When liquid meals are tolerated

by a patient and doesnt irritate the inflamed colon, soft foods can be

incorporated into the diet as happened with K.T. in this case study. The

digestive system is sensitive at times and requires slow transitioning to avoid

irritation and set-backs.

References:

1. Roth, S., Lacey, K., Sucher, K., Nelms, M. Nutrition Therapy and
Pathophysiology. 2nd edition. Brooks/Cole Cengage Learning,
Belmont, CA; 2011. Book.

2. Surawicz, C., Brandt, L., Binion, D., Anathakrishnan, A. et al.


Guidelines for Diagnosis, Treatment, and Prevention of
Clostridium difficile Infections. The American Journal of
Gastroenterology Vol. 108. (2013) Web.

3. Vaishnavi, C. Clostridium difficile infection: clinical spectrum


and approach to management. Indian Journal of Gastroenterology
(2011) 30: 245. Web.

4. Gebhart T. Superior Mesenteric Artery Syndrome.


Gastroenterology Nursing. May-June 2015; 38(3):189-93. Web.

5. Marts, BC., Longo, WE., Vernava, AM., Kennedy, DJ., Daniel, GL., Jones,
I. Patterns and prognosis of Clostridium difficile colitis. Diseases
of the colon and rectum. 37(8):837-45. NCBI Web.