Crohn's disease

Crohn's Disease

 

Definition

Crohn's disease is a type of inflammatory bowel disease (IBD), resulting in swelling and dysfunction of the intestinal tract.

Description

Crohn's disease involves inflammation of the intestine, especially the small intestine. Inflammation refers to swelling, redness, and loss of normal function. There is evidence that the inflammation is caused by various products of the immune system that attack the body itself instead of helpfully attacking a foreign invader (a virus or bacteria, for example). The inflammation of Crohn's disease most commonly affects the last part of the ileum (a section of the small intestine), and often includes the large intestine (the colon). However, inflammation may also occur in other areas of the gastrointestinal tract, affecting the mouth, esophagus, or stomach. Crohn's disease differs from ulcerative colitis, the other major type of IBD, in two important ways:

• 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.

Also, ulcerative colitis does not usually involve the small intestine; in rare cases, it involves the terminal ileum (so-called "backwash" ileitis).

In addition to inflammation, Crohn's disease causes ulcerations, or irritated pits in the intestinal wall. These pits occur because the inflammation has made areas of tissue shed.

Crohn's disease may be diagnosed at any age, although most diagnoses are made between the ages 15 to 35. About 0.02-0.04% of the population suffers from this disorder, with men and women having an equal chance of being stricken. Whites are more frequently affected than other racial groups, and people of Jewish origin are between three and six times more likely to suffer from IBD. IBD runs in families; an IBD patient has a 20% chance of having other relatives who are fellow sufferers.

Crohn's disease is a chronic disorder. While the symptoms can be improved, a patient will not be completely cured of the underlying disease.

Causes and symptoms

The cause of Crohn's disease is unknown. No infectious agent (virus, bacteria, or fungi) has been identified as the cause of Crohn's disease. Still, some researchers have theorized that some type of infection may have originally been responsible for triggering the immune system, resulting in the continuing and out-of-control cycle of inflammation that occurs in Crohn's disease. Other evidence for a disorder of the immune system includes the high incidence of other immune disorders that may occur along with Crohn's disease.

The first symptoms of Crohn's disease include diarrhea, fever, abdominal pain, inability to eat, weight loss, and fatigue. Some patients have severe pain that mimics appendicitis. It is rare, however, for patients to notice blood in their bowel movements. Because Crohn's disease severely limits the ability of the affected intestine to absorb the nutrients from food, a patient with Crohn's disease can have signs of malnutrition, depending on the amount of intestine affected and the duration of the disease.

The combination of severe inflammation, ulceration, and scarring that occurs in Crohn's disease can result in serious complications, including obstruction, abscess formation, and fistula formation.

An obstruction is a blockage in the intestine. This obstruction prevents the intestinal contents from passing beyond the point of the blockage. The intestinal contents "back up," resulting in constipation, vomiting, and intense pain. Although rare in Crohn's disease (because of the increased thickness of the intestinal wall due to swelling and scarring), a severe bowel obstruction can result in an intestinal wall perforation (a hole in the intestine). Such a hole in the intestinal wall would allow the intestinal contents, usually containing bacteria, to enter the abdomen. This complication could result in a severe, life-threatening infection.

Abcess formation is the development of a walled-off pocket of infection. A patient with an abscess will have bouts of fever, increased abdominal pain, and may have a lump or mass that can be felt through the wall of the abdomen.

Fistula formation is the formation of abnormal channels. These channels may connect one area of the intestine to another neighboring section of intestine. Fistulas may join an area of the intestine to the vagina or bladder, or they may drain an area of the intestine through the skin. Abscesses and fistulas commonly affect the area around the anus and rectum (the very last portions of the colon allowing waste to leave the body). These abnormal connections allow the bacteria that normally live in the intestine to enter other areas of the body, causing potentially serious infections.

Patients suffering from Crohn's disease also have a significant chance of experiencing other disorders. Some of these may relate specifically to the intestinal disease, and others appear to have some relationship to the imbalanced immune system. The faulty absorption state of the bowel can result in gallstones and kidney stones. Inflamed areas in the abdomen may press on the tube that drains urine from the kidney to the bladder (the ureter). Ureter compression can make urine back up into the kidney, enlarge the ureter and kidney, and can potentially lead to kidney damage. Patients with Crohn's disease also frequently suffer from:

• 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

The chance of developing cancer of the intestine is greater than normal among patients with Crohn's disease, although this chance is not as high as among those patients with ulcerative colitis.

Diagnosis

Diagnosis is first suspected based on a patient's symptoms. Blood tests may reveal an increase in certain types of white blood cells, an indication that some type of inflammation is occurring in the body. The blood tests may also reveal anemia and other signs of malnutrition due to malabsorption (low blood protein; variations in the amount of calcium, potassium, and magnesium present in the blood; changes in certain markers of liver function). Stool samples may be examined to make sure that no infectious agent is causing the diarrhea, and to see if the waste contains blood.

During an endoscopic exam, a doctor passes a flexible tube with a tiny, fiber-optic camera device through the rectum and into the colon. The doctor can then carefully examine the lining of the intestine for signs of inflammation and ulceration that might suggest Crohn's disease. A tiny sample (a biopsy) of the intestine can also be taken through the endoscope, and the tissue will be examined under a microscope for evidence of Crohn's disease.

X rays can be helpful for diagnosis, and also for determining how much of the intestine is involved in the disease. For these x rays, the patient must either drink a chalky solution containing barium, or receive a barium enema (a solution that is administered through the rectum). Barium helps to "light up" the intestine, allowing more detail to be seen on the resulting x rays.

While Crohn's disease and ulcerative colitis are similar, they are also very different. Although it can be difficult to determine whether a patient has Crohn's disease or ulcerative colitis, it is important to make every effort to distinguish between these two diseases. Because the long-term complications of the diseases are different, treatment will depend on careful diagnosis of the specific IBD present.

Treatment

Treatments for Crohn's disease try to reduce the underlying inflammation, the resulting malabsorption/malnutrition, the uncomfortable symptoms of crampy abdominal pain and diarrhea, and the possible complications (obstructions, abscesses, and fistulas).

Inflammation can be treated with a drug called sulfasalazine. Sulfasalazine is made up of two parts. One part is related to the sulfa antibiotics; the other part is a form of the anti-inflammatory chemical, salicylic acid (related to aspirin). Sulfasalazine is not well absorbed from the intestine, so it stays mostly within the intestine, where it is broken down into its components. It is believed that the salicylic acid component actively treats Crohn's disease by fighting inflammation. Some patients do not respond to sulfasalazine, and require steroid medications (such as prednisone). Steroids, however, must be used carefully to avoid the complications of these drugs, including increased risk of infection and weakening of bones (osteoporosis). Some very potent immunosuppressive drugs, which interfere with the products of the immune system and can hopefully decrease inflammation, may be used for those patients who do not improve on steroids.

A new drug called infliximab (Remicade) appears to be a powerful treatment for Crohn's disease, particularly for patients who have not responded well to other forms of treatment. Infliximab is administered through infusion, and consists of a monoclonal antibody that interferes with the inflammatory process mediated by tumor necrosis factor-alpha (TNF-a). Patients taking infliximab seem to be able to decrease their use of steroid medications, and require fewer surgical interventions. Furthermore, infliximab is the first medication approved for treating fistulas. Unfortunately, infliximab can only be used on a short-term basis, because its interference with TNF-a activity can also predispose patients to serious infection. More research is needed to try to harness the benefits of infliximab, while avoiding the potential complications.

Serious cases of malabsorption/malnutrition may need to be treated by providing nutritional supplements. These supplements must be in a form that can be absorbed from the damaged, inflamed intestine. Some patients find that certain foods are hard to digest, including milk, large quantities of fiber, and spicy foods. When patients are suffering from an obstruction, or during periods of time when symptoms of the disease are at their worst, they may need to drink specially formulated, high-calorie liquid supplements. Those patients who are severely ill may need to receive their nutrition through a needle inserted in a vein (intravenously), or even by a tiny tube (a catheter) inserted directly into a major vein in the chest.

A number of medications are available to help decrease the cramping and pain associated with Crohn's disease. These include loperamide, tincture of opium, and codeine. Some fiber preparations (methylcellulose or psyllium) may be helpful, although some patients do not tolerate them well.

The first step in treating an obstruction involves general attempts to decrease inflammation with sulfasalazine, steroids, or immunosuppressive drugs. A patient with a severe obstruction will have to stop taking all food and drink by mouth, allowing the bowel to "rest." Abscesses and other infections will require antibiotics. Surgery may be required to repair an obstruction that does not resolve on its own, to remove an abscess, or to repair a fistula. Such surgery may involve the removal of a section of the intestine. In extremely severe cases of Crohn's disease that do not respond to treatment, a patient may need to have the entire large intestine removed (an operation called a colectomy). In this case, a piece of the remaining small intestine is pulled through an opening in the abdomen. This bit of intestine is fashioned surgically to allow a special bag to be placed over it. This bag catches the body's waste, which no longer can be passed through the large intestine and out of the anus. This opening, which will remain in place for life, is called an ileostomy.

Prognosis

Crohn's disease is a life-long illness. The severity of the disease can vary, and a patient can experience periods of time when the disease is not active and he or she is symptom free. However, the complications and risks of Crohn's disease tend to increase over time. Well over 60% of all patients with Crohn's disease will require surgery, and about half of these patients will require more than one operation over time. About 5-10% of all Crohn's patients will die of their disease, primarily due to massive infection.

Key terms

Abscess — A walled-off pocket of pus caused by infection.

Endoscope — A medical instrument that can be passed into an area of the body (the bladder or intestine, for example) to allow examination of that area. The endoscope usually has a fiber-optic camera that allows a greatly magnified image to be shown on a television screen viewed by the operator. Many endoscopes also allow the operator to retrieve a small sample (biopsy) of the area being examined, to more closely view the tissue under a microscope.

Fistule — An abnormal channel that creates an open passageway between two structures that do not normally connect.

Gastrointestinal tract — The entire length of the digestive system, running from the stomach, through the small intestine, large intestine, and out the rectum and anus.

Immune system — The body system responsible for producing various cells and chemicals that fight infection by viruses, bacteria, fungi, and other foreign invaders. In autoimmune disease, these cells and chemicals turn against the body itself.

Inflammation — The result of the body's attempts to fight off and wall off an area that is infected. Inflammation results in the classic signs of redness, heat, swelling, and loss of function.

Obstruction — A blockage.

Ulceration — A pitted area or break in the continuity of a surface such as skin or mucous membrane.

Crohn's disease

 [krōnz]

inflammation of the gastrointestinal tract, usually the terminal portion of the ileum; called also Crohn's colitis, regional enteritis, and regional ileitis. The synonym “regional ileitis” is, however, misleading because Crohn's disease is not limited to the ileum.

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 disease

(krōnz)

n.

A form of inflammatory bowel disease that most commonly affects the ileum and colon, characterized by abdominal pain, diarrhea, and thickening of the bowel wall.

Crohn's disease

Granulomatous 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 disease

A 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)

Crohn’s Disease

DRG Category:	329
Mean LOS:	14.9 days
Description:	SURGICAL: Major Small and Large Bowel Procedures With Major CC
DRG Category:	386
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.

Causes

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.

Genetic considerations

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.

Assessment

History

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.

Physical examination

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.

Psychosocial

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.

Diagnostic highlights

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

Diagnosis

Alteration in nutrition: Less than body requirements related to anorexia, diarrhea, and decreased absorption of the intestines

Outcomes

Nutritional status: Food and fluid intake; Nutrient intake; Biochemical measures; Body mass; Energy; Bowel elimination; Endurance

Interventions

Nutrition 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

Collaborative

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.

Pharmacologic highlights

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.

Independent

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).

Documentation guidelines

• 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?

A. There are certain foods that will agrivate crohn's and trigger it into an active state. Foods that are difficult to digest, like corn, lettuce, veggies with skin, greasy foods etc... A person with crohns may become symptomatic after eating these types of foods. It is important to identify the foods that trigger flair ups and avoid those foods.

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?

A. Here's a pretty good article that covers symptoms of UC:

http://www.wearecrohns.org/ucers/articles/319