4 crohns

subacute and chronic inflammation of the GI tract wall that extends through all layers (ie, transmural lesion).

Most commonly affected areas are the distal ileum and ascending colon.

Occurs frequently among 50 – 80 years old

Fistulas, fissures and abscesses form as inflammation extends into the peritoneum.

Periods of remission and exacerbation may occur

Bowel wall thickens and becomes fibrotic, and the intestinal lumen narrows.

Diseased bowel loops adhere to other loops surrounding them.

Cobblestone ulcerations form along the mucosal wall of the ileum, cecum and ascending colon which form scar tissue and inhibit food and water absorption.The disease process begins with edema and thickening of the mucosa. Ulcers begin to appear on the inflamed mucosa. These lesions are not in continuous contact with one another and are separated by normal tissue.

Genetic predisposition Autoimmune reaction Environmental factors

Unknown

Prominent right lower quadrant abdominal pain

diarrhea unrelieved by defecation

abdominal tenderness and spasm.

Crampy abdominal pains

Fever and leucocytosis

Weight loss, malnutrition, secondary anemia

The result is a person who is thin and emaciated from inadequate food intake and constant fluid loss.

A proctosigmoidoscopy is usually performed initially to determine whether the rectosigmoid area is inflamed.

A stool examination is

also performed; the result may

be positive for occult blood

and steatorrhea.

Endoscopy, colonoscopy, and intestinal biopsies may be used to confirm the diagnosis.

Albumin and protein levels may be decreased, indicating malnutrition.

CT scan may show bowel wall thickening and fistula formation.

Complete blood cell count to assess hematocrit and hemoglobin levels (usually decreased) as well as the white blood cell count (may be elevated)

The most conclusive diagnosticaid for Crohn’s disease is a barium study of the upper GItract that shows the classic “string sign” on an x-ray film of the terminal ileum, indicating the constriction of a segment of intestine.

A recurrent ulcerative and inflammatory disease of the mucosal and sub-mucosal layers of the colon and rectum.

It is typically accompanied by systemic complications and a high mortality rate.

It is characterized by:

multiple ulcerations,

diffuse inflammations,

desquamation of the colonic epithelium

alternating periods of remission and exacerbation

Edema of the mucous membrane of the colon leads to bleeding and shallow ulceration.

Abscess formation occurs; bowel wall shortens and becomes thin and fragile.

Approximately 5% of patients develop colon cancer

Emotional stress Autoimmune

response Genetic

predisposition Caucasian race Jewish heritage 30-50 years old

Diarrhea Passage of mucus and pus, Abdominal pain Intermittent tenesmus

(ineffective painful straining to empty the bowels in response to the desire to defecate, without producing a significant quantity of feces)

Ineffective straining at stool Anal fissure Haemorrhoids Hernia

Rebound tenderness may occur in the right lower quadrant

Rectal bleeding Anorexia Weight loss Low grade fever Vomiting Dehydration

Cramping and feeling of urgent need to defecate

Passing of liquid stools 10-20 times per day

Hypocalcemia Anemia

Stool exam to r/o dysentery Occult blood test Abdominal x-ray CT scan, MRI Sigmoidoscopy Barium Enema

The abdomen is examined for bowel sounds, distention, and tenderness. These findings assist in determining the severity of the disease.

Abdominal x-ray studies are useful for determining the cause of symptoms.

Elevated antineutrophil cytoplasmicantibody levels are common

The stool is positive for blood

Laboratory test reveal low hematocrit and hemoglobin levels, elevated white blood cell count, low albumin levels, and electrolyte imbalance.

Sigmoidoscopy or colonoscopyand barium enema are valuable in distinguishing ulcerative colitis from other diseases of the colon with similar symptoms.

CT scanning, MRI, and ultrasound studies can identify abscesses and perirectal involvement.

A barium enema may show:

mucosal irregularities, focal strictures or fistulas, shortening of the colon, dilation of bowel loops.  

o Reduce inflammationo Suppress inappropriate

immune responseo Provide rest to the diseased

bowel to promote healing

Goals:

• Low residue, high CHON, High calorie diet

• IV for electrolyte imbalance

• Avoid foods that exacerbate the condition (milk and cold foods)

• Parenteral nutrition as ordered

Sedative, tranquilizer or analgesic for pain

Antidiarrheal Antiperistaltic meds Antibiotics for secondary

infection

Sulfonamides: Sulfasalazine (azulfidine) or Sulfisoxazole (gantrisin) for inflammation

ACTH and Corticosteroids Aminosalicylates: Mesalamine

(asacol, pentasa) Immunomodulators:

Azathioprine (Imuran)

Determine stressors

Developing coping mechanisms

Resolving conflicts

Segmental Subtotal Total

COLECTOMY

Conventional ileostomy Ileoanal anastomosis Kock pouch (continent ileal

conduit) Proctocolectomy with

ileostomy (excision of colon, rectum and anus) if rectum is severely involved

Total Colectomy With Ileostomy

An ileostomy, the surgical creation of an opening into the ileum or small intestine (usually by means of an ileal stoma on the abdominal wall), is commonly performed after a total colectomy (ie, excision of the entire colon).

It allows for drainage of fecal matter (ie, effluent) from the ileum to the outside of the body. The drainage is liquid to unformed and occurs at frequent intervals.

Continent Ileostomy

Continent ileal reservoir (ie, Kock pouch) is done by diverting a portion of the distal ileum to the abdominal wall and creating a stoma.

This procedure eliminates the need for an external fecal collection bag.

Approximately 30 cm of the distal ileum is reconstructed to form a reservoir with a nipple valve that is created by pulling a portion of the terminal ileal loop back into the ileum.

GI effluent can accumulate in the pouch for several hours and then be removed by means of a catheter inserted through the nipple valve.

Restorative Proctocolectomy With IlealPouch Anal Anastomosis

the surgical procedure of choice in cases where the rectum can be preserved in that it eliminates the need for a permanent ileostomy.

It establishes an ileal reservoir that functions as a “new” rectum, and anal sphincter control of elimination is retained.

The procedure involves connecting the ileum to the anal pouch (made from a small intestine segment), and the surgeon connects the pouch to the anus in conjunction with removing the colon and the rectal mucosa (ie, total abdominal colectomy and mucosal proctectomy).

A temporary diverting loop ileostomy that promotes healing of the surgical anastomoses is constructed at the time of surgery and closed about 3 months later.

With IPAA or restorative proctocolectomy, the diseased colon and rectum are removed, voluntary defecation is maintained, and anal continence is preserved.

The ileal reservoir decreases the number of bowel movements by 50%, from approximately 14 to 20 per day to 7 to 10 per day.

Nighttime elimination is gradually reduced to one bowel movement.

Complications of ileoanal anastomosis include:

irritation of the perianal skin from leakage of fecal contents, stricture formation at the anastomosis site, “pouchitis” (inflammation of theileoanal pouch due to altered microbial levels).