The patient is a female whose age is 25 and undergoing medical treatment of Crohn's disease that is an inflammatory bowel disease after diagnosis of cryptogenic multifocal ulcerous enteritis and the nutrition team received the request to attempt high protein meal to improve hypoalbuminemia along protein-losing enteropathy.
The patient suffered from anemia continuously since when she was 4 years old, but could not find the specific reason for that, however, while implementing capsule endoscope to find the reason, the capsule was stuck at the upper part of ileum then the patient took small bowel resection. At that time, weight was normal by 49.4 kg (100% of IBW), but it decreased down to 37.0 kg (75% of IBW) by 25% for a year as weight loss continued, then reached the status of severe underweight at 33.3 kg (68% of IBW) at the time of hospitalization in 2010. She also suffered from ascites and subcutaneous edema with hypoalbuminemia (1.3 g/dL), however, abdominal discomfort and edema of face occurred from 2007 and diuretic was used to control ascites from 2009. She took the injection of albumin intermittently as the outpatient to improve hypoalbuminemia, but there was no effect.
The patient was in severe underweight that was included in 68% of IBW with 153 cm height and 33.3 kg body weight and in excessive malnutrition of protein-energy that marasmus was mixed at total protein by 2.7 g/dL and albumin by 1.3 g/dL from biochemical examination. Other blood test indices were 89 mg/dL for cholesterol, 7.5 for BUN, 0.28 Cr, 6.9 mg/dL for Ca, 33/19 IU/L for AST/ALT, 8.1 g/dL for hemoglobin, and 1.7 for CRP.
The foods for the patient were extremely restricted due to abdominal discomfort and the varieties were limited. In case of eating out, the symptoms of abdominal pain and diarrhea appeared and had meals at home most of the time. According to survey results of her dietary history, the patient consumed spinach and broccoli only after complete boiling and avoided the intake of other vegetables because she thought abdominal discomfort got worse if she had high-fiber foods. The patient appealed that abdominal discomfort occurred even when she consumed a bottle of vegetable juice little by little for a whole day. In case of ingesting fruits, she limited the quantity because she had burning feeling in her stomach because of sourness of the fruits. The patient also did not like the sweet taste of fruits, and there was nearly no intake of fruits. The patient had the meals mainly with rice and some fishes she could eat and intake of most nutrients such as calorie, carbohydrate, fat, protein, vitamin and minerals was very insufficient below 30-40% of required amount.
The foods the patient had were too limited considering her preference and abdominal discomfort. However, the motive and participation of the patient were willing to be induced to increase the intake by setting the goal of nutrition management so that she could minimize the supply of intravenous alimentation and increase oral feeding as much as possible considering that she was in the condition that could use gastrointestinal tract as an young female who were supposed to do social activities actively. First, low reside diet with low contents of dietary fiber was provided and supplementary snack was provided two or three times a day for the purpose of reducing discomfort and increase intake, although the amount was only slightly increased due to abdominal discomfort. Standard formula such as Ensure and Greenbia which have low contents of fiber as the nutritional supplementing beverage was recommended and tried, but the patient appealed the abdominal pain after ingesting them. And component nutrition solution (Monowell) that was produced for purpose of providing the nutrients to the patient of colitis was tried, but it could not be continued because she appealed abdominal discomfort. Despite the efforts of increasing oral feeding in various types, the intake was 800-900 kcal, 34 g protein (24-27 kcal/kg, 1 g/kg) a day falling into 40-50% of required intake, and it was insufficient to satisfy with the required intake though it increased comparing with the time of entering the hospital.
Because it was difficult to increase oral feeding, supplementation of calories and protein were required to increase the weight and improve hypoproteinemia. After discussion with the medical team, the use of protein supplement was suggested. The references of Umar & DiBaise [8
] and Braamskamp et al. [9
] that recommended 2.0-3.0 g protein/kg/day were referred for positive balance of protein in protein-losing enteropathy and the goal of nutrient supply was set to 40-50 kcal/kg and 2.5 g protein/kg considering the condition of excessive underweight. Nutrition intervention was implemented continuously to increase oral feeding by providing gruel or soup as the snack and insufficient protein from oral feeding was supplemented with protein supplement (Promax, >90% protein) ().
Amino acid profile in protein supplement
It was guided to take protein supplement with the meal by providing it twice a day for breakfast and dinner after discussion with the patient and instructed her to consume protein supplement with gruel, water and yogurt in the way that the patient could eat. Twenty g was provided a day when providing protein supplement at first, but actual intake stopped at degree of 1/2 and it was increased up to target goal 55 g slowly for about 2 weeks starting from intake of protein 10 g a day considering adaptability of the patient, and the adaptability was good for the period of increase without abdominal discomfort. Blood testing including BUN, Cr, and electrolytes was monitored monitored continuously to check load on kidney along intake of high protein meal (2.5 g protein/kg). The patient discharged from the hospital about 4 weeks after hospitalization, however, there was weight loss by 1.0 kg from 33.3 kg to 32.3 kg while ascites were controlled and stabilized after treatment and serum albumin was improved from 1.3 to 2.5. She discharged from the hospital in the condition without discomfort after increasing protein powder up to target amount.
After discharge, she visited the hospital regulary as the outpatient for about 10 months and was managed (total 8 times by every 2 weeks and one-two months after discharge). She kept 55 g (morning 30, lunch 5, dinner 20) of protein supplements for about 5 months and 35 g for about 2 months and 25 g along the improvement of the patient. Body weight increased gradually from 32.3 kg (65% of IBW) to 44.0 kg (89% of IBW) by about 36% for the period of continuous management () and serum albumin concentration was kept above 2.8 in average without the injection of albumin (). And, the performance status that the patient felt was improved from 4 points of 'very tired' to 2 points of 'a little tired' out of 5-points scale measurement and input of diuretic stopped owing to the improvement of edema and ascites from the time of 4th month after discharging from the hospital. During this period, the results of blood test such as BUN, Cr and electrolytes were within the normal range.
Body weight change during follow-up after admission.
Serum albumin change during follow-up after admission.