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- The inflammation of Crohn's disease may be discontinuous, meaning that areas of involvement in the intestine may be separated by normal, unaffected segments of intestine. The affected areas are called "regional enteritis," while the normal areas are called "skip areas."
- The inflammation of Crohn's disease affects all the layers of the intestinal wall, while ulcerative colitis affects only the lining of the intestine.
Causes and symptoms
- arthritis (inflammation of the joints)
- spondylitis (inflammation of the vertebrae, the bones of the spine)
- ulcers of the mouth and skin
- painful, red bumps on the skin
- inflammation of several eye areas
- inflammation of the liver, gallbladder, and/or the channels (ducts) that carry bile between and within the liver, gallbladder, and intestine
Because it bears many similarities to ulcerative colitis, Crohn's disease is sometimes considered as one manifestation of a disease entity called inflammatory bowel disease. Like ulcerative colitis, Crohn's disease is a chronic, relapsing inflammatory disease that produces bouts of diarrhea, cramping of the abdomen, and fever. It is believed to be a genetic disorder, and is related in some way to an abnormal immune response to an unidentified etiologic agent.
In contrast to ulcerative colitis, Crohn's disease only rarely is complicated by toxic megacolon and carcinoma of the colon. Rectal bleeding is not typically present in Crohn's disease, but abscesses, fistulas, perianal ulcerations, and narrowing of the intestinal lumen are common sequelae.
Treatment is symptomatic; the goals are maintenance of good nutrition and prevention of a secondary infection. Antibiotics may be prescribed to control infection and antiinflammatory agents given to promote healing. Surgical removal of the diseased portion of intestine is reserved for the cases most resistant to treatment, since half of those treated by surgery experience a recurrence of the disease in another segment of the intestine.Further information may be obtained by writing The Crohn's and Colitis Foundation of America Inc., 386 Park Avenue South, 17th floor, New York, NY 10016-8804, calling them at: 1-800-932-2423 or 1-212- 685-3440, or consulting their web site at http://www.ccfa.org.
Crohn's diseaseGranulomatous enteritis, regional enteritis, terminal ileitis GI disease A chronic recurring inflammatory disease with periods of remission and exacerbation, located primarily in the distal small and proximal large intestines, which may occur anyplace in the GI tract between mouth and anus Epidemiology CD is most common at ages 15-25 Clinical Recurrent abdominal pain, fever, N&V, weight loss, diarrhea–± bloody, possibly also, reddish tender skin nodules, inflammation of joints, eyes, liver Diagnosis Barium enema, colonoscopy, Bx confirmation Complications GI bleeding, fistulas, anal fissures, deep ulcers can puncture bowel wall, leading to peritonitis Management Anti-inflammatories, immune suppression–infliximab ↓ draining fistulas, corticosteroids, antibiotics, possibly, fish oil; if severe, surgery
Crohn's diseaseA persistent inflammatory disease affecting a segment towards the end of the small intestine (the ileum) or the beginning of the large intestine (colon), or both. The cause is unknown. Also called regional ileitis. Dietary treatment providing nitrogen in the form of free amino acids or short chain peptides have been found in some cases to compare well with corticosteroid treatment. (Burrill Bernard Crohn, 1884–1983, American gastroenterologist)
|Mean LOS:||14.9 days|
|Description:||SURGICAL: Major Small and Large Bowel Procedures With Major CC|
|Mean LOS:||5.1 days|
|Description:||MEDICAL: Inflammatory Bowel Disease With CC|
Crohn’s disease (CD), also known as granulomatous colitis or regional enteritis, is a chronic, nonspecific inflammatory disease of the bowel that occurs most commonly in the terminal ileum, jejunum, and the colon, although it may affect any part of the gastrointestinal (GI) system from the mouth to the anus. In the United States, the prevalence of CD is approximately 201 cases per 100,000 adults and 43 cases per 100,000 children, and the prevalence has steadily increased in recent decades. Like ulcerative colitis, CD is marked by remissions and exacerbations, but, unlike ulcerative colitis, it can affect any portion of the tubular GI tract.
The disease creates deep, longitudinal mucosal ulcerations and nodular submucosal thickenings called granulomas, which give the intestinal wall a cobblestone appearance and may alter its absorptive abilities. The inflamed and ulcerated areas occur only in segments of the bowel, and normal bowel tissue segments occur between the diseased segments. Eventually, thickening of the bowel wall, narrowing of the bowel lumen, and strictures of the bowel are common. Also, fistulae that connect to other tissue—such as the skin, bladder, rectum, and vagina—often occur.
Research has not established a specific cause for CD. Infectious agents such as a virus or bacterium, an autoimmune reaction, environmental factors such as geographic location, individual factors such as smoking and dietary exposure, and genetic factors are all being investigated. Researchers now believe that emotional stress and psychological changes are a result of the chronic and severe symptoms of CD rather than a cause. Some experts suggest that patients have an inherited susceptibility for an abnormal immunological response to one or more of the factors listed here.
There is no clear agreement on how genetic and environmental factors lead to the tissue damage in inflammatory bowel disease. A sibling of an affected person has a 30% higher risk of developing the disease than someone from the general population. Mutations in the gene encoding Nod2 (nucleotide-binding oligomerization domain protein 2) may result in CD by altering intestinal production of antimicrobial proteins. In addition, recent evidence indicates that the GLI1 gene, which has not been previously associated with immune modulation, appears to be important for an appropriate inflammatory response in both humans and mice. Studies are ongoing.
Gender, ethnic/racial, and life span considerations
CD may occur at any age in both men and women, with rates slightly higher in males; it is generally first diagnosed between the ages of 15 and 30. Reports indicate that the number being diagnosed at age 55 and older is growing; thus, the age distribution is bimodal (15 to 30 and 55 to 70). Two factors that may predispose the elderly to CD include an increased vulnerability to infection and a susceptibility to inadequate blood supply to the bowel because of the aging process. CD is more common in whites than in African Americans or Asian Americans, and there is a two- to four-fold increase in the prevalence of CD in the Jewish population in the United States and Europe as compared with other groups.
Global health considerations
Western developed countries seem to have a similar prevalence of CD. In Western Europe and North America, the more temperate the climate and the more urban the environment, the higher the rates of CD. Rates are lower in Asia and the Middle East as compared to North America and Western Europe.
Patients initially report insidious symptoms such as mild, non-bloody diarrhea (three to five semisoft stools per day); fatigue; anorexia; and vague, intermittent abdominal pain. As the disease progresses, they complain of more severe, constant abdominal pain that typically localizes in the right lower quadrant, weight loss, more severe fatigue, and moderate fever. Some patients may also report skin breakdown in the perineal and rectal areas.
Most common symptoms include low-grade fever, diarrhea with abdominal pain, weight loss, and fatigue. Because CD is a chronic disease that affects the GI system and causes anorexia and multiple episodes of diarrhea, common problems are malnutrition and dehydration. Inspect for hair loss, dry skin, dry and sticky mucous membranes, poor skin turgor, muscle weakness, and lethargy. Also, inspect the patient’s perianal area for signs of fistula formation.
Palpate the patient’s abdomen for pain, tenderness, or distention. Generally, pain localizes in the right lower quadrant, but note the location, intensity, type, and duration of discomfort. Auscultate the patient’s abdomen for bowel sounds. Often, hyperactive sounds will be noted during an acute inflammatory episode.
The effects of chronic illness and debilitating symptoms, along with frequent hospitalizations, often result in psychological problems and social isolation. Assess the coping mechanisms as well as the patient’s support system.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Upper GI and barium enema series||Normal upper and lower GI tract||To determine the location and extent of rectal involvement, including inflammation strictures, perianal disease, and fistulae||May help differentiate Crohn’s disease from ulcerative colitis; should not be undertaken during acute episodes of illness|
|Sigmoidoscopy or colonoscopy||Normal GI tract on direct visualization||To detect location of illness as well as early mucosal changes, inflammation, strictures, and fistulae||May help differentiate Crohn’s disease from ulcerative colitis|
|Imaging studies||Normal GI tract without bowel obstruction, inflammation, fibrosis, fistulae, abscesses||To determine the location and extent of rectal involvement, including inflammation strictures, perianal disease, and fistulae||To differentiate among pathologies and extent of disease|
Other Tests: Low-radiation protocols are used by many centers to reduce radiation exposure to younger patients and children. Complete blood count, serum albumin, cholesterol, electrolytes (particularly calcium and magnesium), C-reactive protein, orosomucoid (a globulin in blood plasma), sedimentation rate; culture of stool specimens for routine pathogens, ova, parasites, Clostridium difficile toxin; perinuclear antineutrophil cytoplasmic antibody (a myeloperoxidase antigen more commonly found in ulcerative colitis) and antibodies to the yeast Saccharomyces cerevisiae (anti–S. cerevisiae antibodies) are more commonly found in CD; ultrasound.
Primary nursing diagnosis
DiagnosisAlteration in nutrition: Less than body requirements related to anorexia, diarrhea, and decreased absorption of the intestines
OutcomesNutritional status: Food and fluid intake; Nutrient intake; Biochemical measures; Body mass; Energy; Bowel elimination; Endurance
InterventionsNutrition management; Nutrition therapy; Nutritional counseling and monitoring; Fluid and electrolyte management; Medication management; Enteral tube feeding; Intravenous therapy; Total parenteral nutrition administration
Planning and implementation
medical.Much of the medical management centers on medications. During acute exacerbations, bowel rest is important to promote healing; bowel rest can be achieved by placing the patient NPO with the administration of total parenteral nutrition to supply the required fluids, nutrients, and electrolytes. Once the acute episode has subsided and symptoms are relieved, a diet high in protein, vitamins, and calories is prescribed. The patient’s diet should be balanced, and supplements of fiber may be beneficial for colonic disease; a low-roughage diet is usually indicated for patients with obstructive symptoms. In addition, a low-residue, milk-free diet is generally well tolerated.
surgical.Surgery, although not a primary intervention, may be necessary for patients who develop complications such as bowel perforation, abscess, intestinal obstruction, fistulae, or hemorrhage and for those who do not respond to conservative management such as nutritional and drug therapy. Unfortunately, there is a 60% recurrence of the disease process after surgical intervention. Multiple resections also may lead to short-bowel syndrome, defined as malabsorption of fluids, electrolytes, and nutrients, which leads to nutritional deficiencies. The syndrome occurs when less than 150 cm of functional small bowel remains.
|Medication or Drug Class||Dosage||Description||Rationale|
|Mesalamine (5-ASA; see description) (Asacol, Pentasa)||800–1,600 mg PO tid||Anti-inflammatory agent, 5-ASA||5-ASA preparations such as mesalamine have become treatment of choice; can be used in people who cannot tolerate sulfasalazine|
|Biologic anti–tumor necrosis factor agents (infliximab, adalimumab, certolizumab pegol, natalizumab)||Varies with drug||Monoclonal antibodies||Improves likelihood of induction and maintenance of remission; used in severe disease unresponsive to other therapies|
|Other anti-inflammatories||Varies with drug; sulfasalazine: 0.5–1 g PO qid; prednisone: 10–40 mg PO tid; methylprednisolone: 20–40 mg IV q 12 hr; hydrocortisone: 100 mg IV q 6 hr||Sulfasalazine (Azulfidine) and corticosteroids||Slow the inflammatory process; sulfasalazine is not used in treatment of disease confined to small intestine; glucocorticoids such as prednisone are used in acute exacerbations. Agents are administered until clinical symptoms subside, at which time steroidal agents are tapered off|
|Antidiarrheal agents||Varies with drug||Example: loperamide (Imodium)||Alleviate symptoms of abdominal cramping and diarrhea in patients with mild symptoms or postresection diarrhea|
|Metronidazole (Flagyl)||250 mg PO tid||Antibacterial agent||Effective in colon disease; treats infections with fistulae and perianal skin breakdown; beneficial in patients who have not responded to other agents|
|Immunosuppressive agents||Varies with drug||Azathioprine (Imuran) 6-mercaptopurine||Decrease inflammation and symptoms if steroids fail or decrease steroid requirements|
Other Drugs: Abdominal cramps may be treated with propantheline, dicyclomine, or hyoscyamine, but these drugs should not be used if a bowel obstruction is possible. Some patients who are suffering with severe abdominal pain may require narcotic analgesics such as meperidine (Demerol). Also, patients who develop deficiencies because of problems of malabsorption may require vitamin B12 injections monthly or iron replacement therapy. Other nutritional supplements include calcium, magnesium, folate, and other micronutrients.
Nursing care focuses on supporting the patient through acute episodes of inflammation and teaching measures to prevent future inflammatory attacks. Maintaining patient fluid and electrolyte balance is particularly important. Encourage the patient to drink 3,000 mL of fluid per day, unless it is contraindicated. Implement measures to prevent skin breakdown in the perianal area.
Provide frequent rest periods. Maintain adequate nutritional status using calorie counts. Other measures include assisting the patient with frequent oral hygiene; providing small, frequent meals with rest periods interspersed throughout the day; monitoring intravenous fluids and total parenteral nutrition as prescribed; and noting the patient’s serum albumin levels.
Encourage patients to express their feelings and refer them for more extensive counseling as needed. Also, discuss measures to diminish stressful life situations with the patient and family.
Evidence-Based Practice and Health Policy
Ananthakrishnan, A.N., Khalili, H., Higuchi, L.M., Bao, Y., Korzenik, J.R., Giovannucci, E.L., …Chan, A.T. (2012). Higher predicted vitamin D status is associated with reduced risk of Crohn’s disease. Gastroenterology, 142(3), 482–489.
- Factors that influence immunity, such as vitamin D, may also have an effect on risks for autoimmune disorders, including CD.
- A prospective study of 72,719 women enrolled in the Nurses’ Health Study revealed 122 cases of CD, which were significantly associated with vitamin D status. Each 1-ng/mL increase in the plasma 25(OH)D level reduced the risk of CD by 6% (p = 0.03).
- Evidence of stability of vital signs, hydration status, bowel sounds, and electrolytes
- Response to medications; tolerance of foods; ability to eat and select a well-balanced diet and weight gains or losses
- Location, intensity, and frequency of pain; factors that relieve pain
- Number of diarrheal episodes and stool characteristics
- Presence of complications: Fistulae, skin breakdown, abscess formation, infection
Discharge and home healthcare guidelines
Emphasize measures that will help prevent future inflammatory episodes, such as getting plenty of rest and relaxation, reducing stress, and maintaining proper diet (high protein, low residue). Teach the patient to recognize the signs of incipient inflammatory attacks. Explain all the prescribed medications, including the actions, side effects, dosages, and routes. Be certain the patient understands signs of possible complications, such as an abscess, fistula, hemorrhage, or infection, and the need to seek medical attention if any of them occurs. Caution the patient to be vigilant with skin care, especially in the perianal area. Instruct the patient to assess frequently for breakdown in this area and seek medical attention if it should occur.
Patient discussion about Crohn's disease
Q. Is there a connection between eating Subway's and Crohn's Disease symptoms? I have a colleague who eats Subway and then has severe Crohn's Disease. Is this common? Is there a connection between sandwiches and irritated gastrointestinal issues?
Q. Multiple diseases how do i handle them?
Q. What are the symptoms of Ulcerative Colitis? I am 40 years old and suffer from a lot of stomach aches and diarrhea. Do I have Ulcerative Colitis? What are its symptoms?